This timely paper provides a thought-provoking analysis of current advanced practice nursing education in Canada. It comes at a critical juncture in the evolution of Canadian healthcare services and the redefinition of nursing roles. Increasingly, multiple sectors of society are calling for more nurses with advanced practice preparation and for a wider range of advanced practice nursing specialties. Advanced practice nurses (APNs) are being proposed as a solution to a financially overburdened national healthcare system, the increasing complexity of healthcare services, and a crisis in access to primary healthcare. Thus, governments seeking greater fiscal efficiency, medical specialists needing sophisticated collaborative support, and healthcare consumers see APNs as the way forward.

As is often the case with social change, and as the authors of the article demonstrate, there was no master professional plan underpinning the introduction of advanced nursing practice or education. There was also no overarching professional vision of how responsibilities associated with advanced practice nursing should be organized into subgroups. Instead, the historical analysis demonstrates that educational programs were developed ad hoc by individual schools or a consortium of schools in response to specific health needs of service institutions or regional communities, typically at the request of government and often before the roles had been created in the healthcare system. Thus, the curricula and program goals were introduced in an ad hoc fashion across the country to address local or regional health service needs rather than to prepare learners for professional practice as defined by the profession or its representative associations.

Given the discursive path of the introduction of advanced practice nursing, as well as the provincial/territorial control of health and education, it is not surprising that Canada lacked nationwide standards for both nurse practitioner and clinical nurse specialist roles However, two significant advances have addressed this issue. The authors point out the importance of the publication of the Canadian Nurse Practitioner Core Competency Framework (Canadian Nurses Association [CNA] 2005) and Advanced Nursing Practice: A National Framework (CNA 2008). These documents provide a national consensus on APNs' roles and responsibilities. Additionally, the authors note that many provincial regulatory bodies now include the Canadian national entry to practice exam for nurse practitioners in their licensing processes. This exam follows the National Framework of Nurse Practitioner roles and encompasses family/all ages (primary healthcare), adults, paediatrics and neonatal. Thus, the profession has moved forward to a national conceptualisation and classification of advanced practice roles, and a national articulation of nurse practitioner competencies.

It is also not surprising that educational requirements for nurse practitioners are inconsistent from one jurisdiction to another. While commonalities exist in the curricula across the country, standards vary. The authors identify major discrepancies in the level of preparation required, particularly in primary healthcare nurse practitioner programs. To some extent this is related to the ad hoc introduction of the programs. The initial demand for nurse practitioners coincided with a dearth of physicians in remote rural areas of the North. To fill the gap, nurses were provided with additional post-registration or post-baccalaureate training to work more autonomously. In southern Canada, with an oversupply of physicians at the time, the situation was different. Acute care nurse practitioner programs at the master's level were established in the eighties and nineties to prepare practitioners for work in high-tech institutions in urban centres, where clinical nurse specialists were already employed and required a master's degree. The overwhelming perception in the literature reviewed by the authors is that all advanced practice nursing education should be at the master's level in Canada.

In contrast with nurse practitioners, the clinical nurse specialist has required a master's degree since the inception of the role. There are no CNS titled programs, however, and a lack of clarity regarding what type of master's degree programs prepares one for the CNS role. In fact, holding a master's or doctoral degree in nursing is part of the CNA definition of what a clinical nurse specialist is.

The article demonstrates a significant need for national educational requirements and quality indicators for advanced nursing educational programs in this country. With the recent pan-Canadian articulation of advanced professional practice, the resurgence of the CNS role in the United States, regulatory approval of nurse practitioner programs and a national entry to practice examination, a solid foundation is in place for the elaboration of national educational standards. It is clearly the moment in the evolution of Canadian advanced practice nursing to develop a national educational framework that is aligned with, and reflective of, the national vision for nurse practitioners and clinical nurse specialists.

The authors challenge the Canadian Association of Schools of Nurses (CASN) to take the lead in advancing this educational agenda in partnership with organizations such as the Canadian Association of Advanced Practice Nurses (CAAPN), the CNA and provincial/territorial regulatory bodies. CASN is strongly committed to advancing the quality of educational programs for APNs across the country. As a first step, following the approach of our sister organization the American Association of Colleges of Nursing, a national task force with broad representation is being set up to delineate the essential components of nurse practitioner education in Canada for primary healthcare, adult, pediatric and neonatal programs. It is important that a similar initiative follows with respect to the educational preparation of clinical nurse specialists.

The successful development of educational and practice standards involves the engagement of professional associations, practice leaders and educators in a complex, interactive, iterative and multilinear process. Despite the educational inconsistencies identified in the article, this process has begun for advanced practice nursing education in Canada. CASN's aim, as the national voice of nursing education, is to generate further momentum and take the process forward.

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