Abstract

The Special Focus on Advanced Practice Nursing in Canada, published in the Canadian Journal of Nursing Leadership (http://www.longwoods.com/publications/nursing-leadership/24885), highlights the unique contributions that advanced practice nurses (APNs) have added to meet the demands of the evolving Canadian healthcare system. Drs. Martin-Misener and Bryant-Lukosius should be commended for their vision as editors of this Special Issue of CJNL, and profiling some excellent work that has occurred across the country in this field of research. In light of this Special Issue, this commentary is written to offer some reflections upon how APNs (i.e., nurse practitioners, clinical nurse specialists) have influenced the nursing profession more broadly within the Canadian context.

Clearly, the need for advance practice nursing roles in Canada is here. As the complexity of care has increased and in response to changing healthcare demands, the nursing profession needs to change as well. In fact, all nursing roles are expanding to meet these emerging needs within our healthcare system with expanded levels of autonomy and decision-making, including registered practical nurses/licensed practical nurses (RPNs/LPNs; Practical Nurses Canada 2017), registered nurses (RNs; CNA 2015), clinical nurse specialists (CNS; CNA 2017) and nurse practitioners (NPs; CNA 2012). In this manner, nurses at all levels have been able to advance their level of practice, with some nurses now able to prescribe medications (NPs, RN prescribers). This evolving nature of the nursing profession is to be expected in response to the evolving needs within the healthcare system.

However, with these changes comes uncertainty. Historically, many nurse leaders have claimed that the nursing profession was not ready for new advanced roles, as we had yet to articulate clearly the role of nursing in general (Kaasalainen et al. 2010; McTavish 1979). It is critical that we articulate clearly the current nursing roles within Canada, as there remains so much ambiguity among them, such as RNs, RPNs/LPNs, registered psychiatric nurses, CNSs and NPs. As these nursing roles continue to evolve and shift within the healthcare system, we need to be cognizant of the overlap among them and be constantly mindful of ways to best optimize each role to complement the others. Lowe et al. (2011) state that professional maturity and respect is required to accept that the various nursing roles complement each other, just as all nursing roles complement other health professional groups in the multidisciplinary team.

To perpetuate this ambiguity among nursing roles further, how they are implemented varies across sectors and regions, with some being limited in their scope of practice and others pushing to their full scope of practice. Bourgeault (2017) states that scopes of practice for nurses and models of care tend to be heavily influenced by tradition and politics, rather than the best evidence. Unfortunately, this variability in role implementation of different types of nurses across sectors and regions, irrelevant of their respective scopes of practice, adds further confusion with respect to their distinctness and overall contribution to the nursing profession (Donald et al. 2010).

There has been some concern over the impact of the NP role on the other main advanced practice role in Canada – the CNS. It was worrisome to read that there were few submissions to the Special Issue about CNSs, compared to those submitted about the NP role (Martin-Misener and Bryant-Lukosius, 2017). Gardner et al. (2007) contend that the title of APN is "losing its currency" as a consequence of longstanding confusion in nomenclature, practice inflation and the development of the NP role. Clearly, all nursing roles need to be better defined to keep our profession intact. Research is an important element to help define current nursing roles as well as the value that each adds within the larger system (Donald et al. 2010; Martin-Misener and Bryant-Lukosius 2017).

On the other hand, one could argue that the emergence of the NP role has greatly progressed the nursing profession in Canada. In fact, some have stated that we have challenged traditional and longstanding organizational and cultural limitations inherent in the nursing profession by advancing our professional autonomy (Lowe et al. 2011; Mantzoukas and Watkinson 2006). Despite many obstacles along the way, perseverance has paid off, as Pulcini et al. (2010) state that the growing NP movement has advanced the acceptance of the nursing profession.

Without question, APNs (i.e., NPs and CNSs) have contributed to building the overall capacity of the nursing profession in light of their advanced scopes of practice and education requirements. In addition, APNs can contribute to the optimization of other nursing roles as well, such as RNs or RPNs/LPNs, while addressing practice and patient care issues through collaboration to improve quality of care (Gardner et al. 2009; Kaasalainen et al. 2010; Sangster-Gormley et al. 2013). Moore and Prentice (2012) found that RNs and APNs sharing a similar philosophy of care, having mutual trust and respect for one another contributed to a more collaborative relationship. On the other hand, lack of clinical experience and lack of support from management discouraged collaboration (Moore and Prentice 2012). Ideally, the role of APNs should include supporting RNs and RPNs to work within their full scope of practice to fully optimize each other's role. Part of this will require APNs to educate other nurses on the APN roles while recognizing the value of the RN and RPN role as well within the larger model of nursing care.

It has been widely acknowledged that nurses, across all levels, need to optimize their scopes of practice to provide more efficient use of the health workforce. Bourgeault (2017) reports on a recent study that found 80% of nurses reported being over-skilled, mostly for Master's prepared nurses (OECD 2016). I would argue here that other types of nurses, including RNs and RPNs, need to fully optimize their scopes of practice as well to create even further efficiency in the healthcare system.

Another interesting phenomenon within the nursing profession is the idea of "transitioning" to different roles as nurses advance their education (eg., RPN to RN, RN to NP, RN to CNS). Barnes (2015) conducted a concept analysis on this topic and found that defining attributes of transition were: high personal development and new role learning, shift from being a provider to a prescriber of care (NPs), straddling two identities with "imposter syndrome" and many mixed emotions along the way (e.g., exciting, stressful, anxious, overwhelmed, frustrated, ambivalence, isolation, desire to return to prior role as an RN). Transitioning across roles within a profession is not unique to nursing because it happens within other professional groups as well (e.g., engineering) as individuals advance their education and skill set (e.g., complete a university degree as a college diploma graduate).

This type of career progression can not only contribute to role confusion and ambiguity but also strengthen the hierarchy that exists among roles within the same profession. By introducing a new nursing role (i.e., NP) into the mix, it causes a shift and can threaten traditional nursing roles (i.e., CNS, RN) within this hierarchy. As such, the socialization norms within the nursing profession may require re-shifting. It is worrisome though, in light of current trends within the larger context of the healthcare system, how this shifting within the nursing profession will affect the RN role as we see parallel movements at the other end of the spectrum with RPNs expanding their scope of practice. What will happen to the RN role if this shifting continues? Will the RN role continue to exist or will there just be further expansion of nursing roles upward?

The upward shifting of nursing roles has the potential to medicalize nursing if NPs move away from our "nursing roots" and assume more tasks traditionally performed by physicians (Brown 1974; Kaasalainen et al. 2010; MacDonald et al. 2005). This "scope creep" has led to the misconception that the NP role is focused on providing medically oriented care and the CNS, RN and RPN roles are focused on traditional nursing care. In fact, NPs have been termed "mini-doctors" by some. I believe this misconception is mostly because of the lack of understanding of the NP role by the public, healthcare administrators and other healthcare providers. While it is true that in some settings, NPs do practice in more of a medical role, this is likely because of the preferences and needs of the organization (Bourgeault 2017). If they are true to their training and scope of practice, their focus should maintain a more holisitic model of care, consistent with a nursing philosophy of care. Melanie Closs (1996) eloquently stated in a response letter over two decades ago, that "nurse practitioner care has diagnostic and prescriptive responsibilities that have traditionally been the domain of physicians, but the model of care is a nursing model, not a medical model … professional egos will be challenged as nurse practitioners become increasingly integrated into primary care settings, but NPs need to investigate how professional resistance is manifested and in what ways these role conflicts can be managed" (p. 6).

It would not be surprising to hear that some NPs prefer to be called "mini-doctors" and prefer to work within a medical model. For these NPs, they may have wanted to be a doctor early on in their education or nursing career but the opportunity never arose. My sense is that now that we have the physician assistant program in Canada, those individuals who prefer to work within a medical model can opt to become a physician assistant instead. This will only benefit the nursing profession such that those who choose the NP route are committed to working within the nursing model of care; one that is based on a holistic perspective, beyond the basic biomedical aspects of care.

One of the factors that has led to the confusion between the NP and physician roles, is that the large proportion of research that was conducted initially when NPs were first introduced in Canada, compared outcomes of NP practice to those of physician practice, in hopes to justify the effectiveness of the NP role (Kaasalainen et al. 2010). By comparing the two roles, it seems to me that we are positioning them one against the other, which is prone to dispute and threatens the physician role. To offset this, it is important that we position NPs as a distinct role in research studies, having simply standard practice as the comparator, not physician-focused practice. In doing so, outcomes used in the evaluation can focus on NP-outcomes, sensitive to their own scope of practice as opposed to "a replacement model" (Martin-Misener and Bryant-Lukosius 2017: 8).

From a research perspective, excellent work has been conducted to understand and make recommendations to improve the integration of APN roles in Canada (DiCenso et al. 2010), in specific settings such as primary care (DiCenso et al. 2003), acute care (Griffiths 2006; Sidani and Irvine 1999; Sidani et al. 2000) and long-term care (Donald et al. 2013; Kaasalainen et al. 2007; Martin-Misener et al. 2015). Research about the effectiveness of APN roles, including its cost-effectiveness, must continue in order to legitimize the NP role and build a strong evidence base to substantiate this emerging nursing role within the healthcare system (Lopatino et al. 2017). Martin-Misener and Bryant-Lukosius (2017) argue that the focus of APN research should address the "value-add" of APN roles compared to other nursing roles.

In addition to legitimizing nursing roles, including new ones, within our healthcare system, there is also a need to focus on how to best integrate them into various sectors within a thoughtful, well-planned approach. This was not the case back in the 2000s when NPs were quickly injected into the system without much forethought or communication with other healthcare providers. Lack of role clarity or role ambiguity was identified as the most important factor that influenced the implementation of the NP role in a systematic review (Lloyd Jones 2005) and it can influence acceptance and integration of the NP role in practice (Donald et al. 2010). In fact, Donald et al. (2010) recommend that a communication strategy be developed to educate healthcare professionals and that attention be given to interprofessional team dynamics during the introduction of the NP role in a particular setting. Focusing on how APNs can work collaboratively with other types of nurses within the Canadian context to advance the nursing profession forward should be our top priority.

About the Author

Sharon Kaasalainen, RN, PhD, Associate Professor, School of Nursing, McMaster University, Hamilton, ON

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