Nursing Leadership

Nursing Leadership 23(Special Issue) December 2010 : 1-4.doi:10.12927/cjnl.2010.22264

From the Guest Editor

Dorothy Pringle

As an innovation evolves, it reaches a point when there is enough experience among enough informed people to step back and reflect broadly on the progress made and seek views on its progress from those who have been instrumental in it. Questions to be asked include where has adoption of the innovation been robust, and where is it lagging or absent; what challenges have been encountered and overcome, and where have forces been strong enough to forestall further development; what is the potential for increased adoption of the innovation, or where is a loss of momentum likely, and how may these trajectories play out? Furthermore, it is important to seek explanations for the various outcomes that have resulted.

Special Issue On Advanced Practice Nursing In Canada

As an innovation evolves, it reaches a point when there is enough experience among enough informed people to step back and reflect broadly on the progress made and seek views on its progress from those who have been instrumental in it. Questions to be asked include where has adoption of the innovation been robust, and where is it lagging or absent; what challenges have been encountered and overcome, and where have forces been strong enough to forestall further development; what is the potential for increased adoption of the innovation, or where is a loss of momentum likely, and how may these trajectories play out? Furthermore, it is important to seek explanations for the various outcomes that have resulted.

Advanced practice nursing in Canada is at this point. Nurse practitioners (NPs) in Canada, including primary healthcare NPs, acute care NPs and a blended CNS/NP role, have been in the healthcare environment for more than 40 years; clinical nurse specialists (CNSs) for only slightly less time. Their evolutionary paths have been different and been influenced by different forces, and they are facing quite different challenges in the twenty-first century. Now is the right time to step back and get answers to important questions about how these two types of nursing practice are faring and why. This special issue does that.

Over the time that NPs and CNSs have been prepared and have practised in Canada, considerable research has been undertaken to inform the current picture of their status. When this research is combined with the experience of practitioners, policy makers and nursing leaders who have had direct experience with the two roles, it is possible to provide a comprehensive, substantial and informed assessment. For nurse practitioners, this is aided by data on the numbers of NPs across each province provided by the Canadian Institute of Health Information. As well, all provinces and territories have now passed legislation to regulate NP practice. This is not true of CNSs, and one of the salient questions requiring exploration is, why?

Dr. Alba DiCenso, who holds the CHSRF/CIHR Chair in Advanced Practice Nursing at McMaster University, was the obvious choice to lead a team to undertake this study. She has conducted more research on the topic of advanced practice nursing than any other Canadian researcher. This has included evaluations of the first neonatal nurse practitioner program in Canada and the Council of Ontario University Consortium Program to prepare primary care nurse practitioners. One of the objectives of her chair is to increase the number and expertise of researchers in Canada to conduct high-quality and policy-relevant health services research in the field of advanced practice nursing. The success of her capacity building is reflected in the team of authors of this special issue, a team that consists of senior and junior faculty, postdoctoral fellows, doctoral students and staff affiliated with the Chair Program.

A core team of eight investigators (DiCenso, Martin-Misener, Donald, Bryant-Lukosius, Kaasalainen, Kilpatrick, Carter and Harbman) was involved with all components of the study, and one of this group took the lead in writing the article for each component, describing the findings and discussion; however, the whole team contributed to developing the outline for the article, reviewing and rewriting elements, and editing it. The team for some sections was augmented by additional individuals who had made specific contributions to that section. The contributing authors are listed for each article.

The decision support synthesis, which included a scoping review, and interviews and focus groups with decision makers and practitioners across the country, provided a rich reservoir of material on the historic and current status of advanced practice nursing in Canada. The result is the most comprehensive picture of the state of advanced practice nursing available to date. Readers may approach this issue as a digest of the history and current status of advanced practice nurses (APNs) in Canada and choose to read through all the articles. Alternatively, they may selectively read articles of particular interest to them.

The issue begins with an overview paper (DiCenso) that provides a detailed discussion of the rationale and objectives for the decision support synthesis and details of the methods used in the scoping review, interviews and focus groups. Each of the other nine articles provides a brief overview of the methods used for that component of the study so that they can be read as standalone articles, without reference to the overview article. The second article is a detailed description of the historical development of advanced practice nursing roles in Canada (Kaasalainen). This is followed by an analysis of the education of APNs (Martin-Misener), including the different provincial educational requirements, how the education of APNs differs from CNSs, and the challenges confronting CNS preparation at this time.

The next three articles provide comprehensive analyses of the roles of the different types of APNs – the primary healthcare NP role (Donald), the acute care NP role (Kilpatrick and Harbman) and the CNS role (Bryant-Lukosius). The last four papers build on this background. Donald describes the differing ways in which NPs and CNSs are treated in terms of such issues as title protection and the overlap in role competencies and the difficulties this creates for employers and policy makers. The article on the role of leadership (Carter) describes the importance of leaders in contributing to the success of both NPs and CNSs in fulfilling their roles, including experiences of nurse leaders and the successful strategies they have used. The article on enabling role integration of APNs (DiCenso) summarizes factors found across all the study components that contribute to the integration of both NPs and CNSs into the healthcare system at the national and local levels. The final article (DiCenso) focuses on two examples – NPs in fee-for-service practices in British Columbia and NP-led practices in Ontario – that demonstrate how NPs have successfully expanded access to primary care.

All the papers in this special issue were peer reviewed and revised based on the reviewers' input. The reviewers represented a broad spectrum of Canadian educators, administrators, researchers and policy advisors. We solicited commentaries for two articles: the education of APNs and the role of nursing leadership in integrating APNs into the healthcare system. Both education and leadership play critical roles in the preparation and implementation of advanced practice roles. Dr. Cynthia Baker, the executive director of the Canadian Association of Schools of Nursing and the former associate dean, nursing at Queen's University, wrote the commentary on education; and Pamela Hubley, a nurse practitioner and the associate chief of nursing practice at The Hospital for Sick Children, an organization that employs over 75 APNs, wrote the commentary on the role of leadership.

The Office of Nursing Policy of the Strategic Policy Branch, Health Canada, the Canadian Health Services Research Foundation (CHSRF) and the Canadian Institutes of Health Research (CIHR), Knowledge Translation (KT) branch co-funded this special issue. These organizations have been enormously supportive of the development of APNs and have played complementary roles in advancing their cause. The Office of Nursing Policy has funded studies, symposia and meetings that allowed investigators, practitioners and administrators to sort through and reach consensus on how to move the roles of APNs forward. CHSRF has funded much of the research into APNs, and the KT branch of CIHR has enthusiastically supported the translation of APN research into policy. The Canadian Nurses Association (CNA) took the lead in developing the Advanced Nursing Practice Framework and spearheaded the Canadian Nurse Practitioner Initiative. Given this demonstrated commitment, we invited Rachel Bard, chief executive officer of the CNA, and Sandra MacDonald-Rencz, Director of the Office of Nursing Policy, to co-author the introduction to the issue, and Jennifer Ellis and Erin Morrison of CHSRF to write an introduction to the overview article by Alba DiCenso that leads off the issue.

CHSRF's vision is "Timely, appropriate and high-quality services that improve the health of all Canadians." There are a number of ways that CHSRF works to realize this vision that are directly related to advanced practice nursing including commissioning research and promoting dialogue on key healthcare policy issues, and by gathering and sharing information about innovative and effective healthcare practices. The progress in research and health policy regarding the education and deployment of APNs is an excellent example of CHSRF's goals being realized. CHSRF's EXTRA (Executive Training for Research Application) program is another way that advanced practice nursing can benefit by training leaders including nurse leaders to use research to advocate for and introduce innovations such as APNs into health care delivery. We would like to congratulate the team of researchers who developed this special issue – we believe it will make a valuable contribution to the public dialogue on the role of advanced practice nursing in Canada.



 

Dorothy Pringle, OC, RN, PhD, FCAHS
Editor, Special Issue

About the Author

Dorothy Pringle, OC, RN, PhD, FCAHS, Editor, Special Issue

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