Advanced Practice Nursing: Canadian Perspectives and Global Relevance

In this editorial, Advanced Practice Nursing (APN) will be explored as a practice model that could be implemented to strengthen health care systems globally. Canadian perspectives and the evolution of APN in Canada will be used as an example to identify potential opportunities for the conceptualization and implementation of advanced practice nursing that is both overarching and tailored to country, regional, and work-place needs.

Promotion of optimal health outcomes for patients and families remains central to nursing practice on a global scale. This unifying goal provides the scaffolding needed for nurses to explore and advance patient centered care through models of innovative collaboration and decision making. The art and science that nurse's practice and their advancing scope is internationally in high demand to address unmet population health needs and improve quality, efficiency and sustainability of health care services⁽¹⁾. As a result, APN has been heralded as integral to the provision of high quality, patient centred and cost-effective health care⁽²⁾. However, questions remain on an international scale as to what the APN role encompasses, scope of practice, educational and regulatory requirements⁽³⁾.

Collective efforts to unite and foster development of APNs formalized in 2000, with the launch of the International Nurse Practitioner/Advanced Practice Nurse Network, by the International Council of Nurses (ICN). Despite a plethora of literature exploring country specific APN roles and advancement, the Network recognized a global collective voice did not exist to draw commonality and cultivate communication among APNs⁽⁴⁾. For successful APN implementation on local and global scales, role clarity and articulation are essential⁽⁵⁾. In addition, variations around role definition, function and preparation create barriers that hamper adequate utilization of the APN role into health care reform and evolution⁽²⁾.

The ICN defines the APN as

a generalist or specialised nurse who has acquired, through additional graduate education (minimum of a master's degree), the expert knowledge base, complex decision-making skills and clinical competencies for Advanced Nursing Practice, the characteristics of which are shaped by the context in which they are credentialed to practice⁽⁶⁾.

Common themes that present in the above APN definition are supported by a wide range of nursing scholarly work, including an international concept analysis which, aimed to clarify what is meant by APN internationally and determined that advanced practice is beyond basic practice, within the clinical domain and can be distinguished by clinical expertise, leadership, autonomy and role development. Of particular interest is the concept of role extension included in this analysis, as inclusion of a role that was previously regarded as a role of another profession⁽⁷⁾.

Clinical Nurse Specialist (CNS), Nurse Practitioner (NP), Higher Level Practitioner, Nurse Consultant, Specialist Practitioner and Nurse Therapist are among the various titles used internationally to describe APN roles, where CNS and NP are used most commonly⁽⁶⁾. To clarify the breadth of role nomenclature in literature, APN is often used as an umbrella term to encompass both NP and CNS roles, where both NPs and CNSs are described quite differently. NP's provide assessment, diagnosis, diagnostic testing, formation of a management plan which may include the prescription of medicines. Conversely, the CNS provides ongoing improvement in patient care through management/case management of a particular patient group⁽⁷⁾.

Currently, nurses are practicing in advanced practice roles on each continent, where most countries started to develop the role at the turn of the century⁽⁴⁾. Like many countries, APNs emerged in Canada to improve access to health care, reduce wait times, support health care expenditures and maintain health among specific groups⁽⁵⁾. In the late 1990's early 2000's the Canadian government reorganized a new health care model for the population, where national efforts prioritized health promotion and interdisciplinary care toward models of advancing quality health care⁽⁸⁾. As such, primary health care investment led the way for the NP role to emerge, particularly expanding the scope of rural and remote nurses and University programs were established for more extensive nursing training⁽⁸⁾. NPs in Canada are Registered Nurses who have a university level education of four years, plus a Masters level qualification and NP licensing certification by exam. Through this education and certification, NPs are qualified to prescribe medications, give diagnosis, order certain diagnostic tests and admit and discharge patients⁽⁹⁾.

The NP role was born out of primary care and is seen as easier to implement in areas where there is more of a team approach and opportunity to share tasks⁽⁶⁾. Brazil has an impressive interprofessional Primary Health Care model where the NP role could be very promising. Internationally many NPs also work in Acute Care environments⁽³⁾. In Canada, the CNS role gradually emerged together with the Acute Care NP role to optimize care for patients in acute care settings⁽¹⁰⁾. The evolution of practice models according to context are promising initiatives to remain mindful of when aiming to optimize patient care in dynamic health care environments. With similar agility, APN speciality tracts were created to contribute to the number of providers required to deliver high quality, cost effective care⁽¹¹⁾. These APN specialty areas can include family, adult, geriatric, neonatal, pediatric, women's health/gender and mental health⁽²⁾.

Advanced practice nursing is often discussed referring to the autonomy it affords nurses through expanded roles⁽¹²⁾. Autonomy however can take various forms dependent on worldview and circumstance in which roles are situated. For example, in Canada and the USA, prescribing is seen as a role only undertaken by APNs, while legislation in other countries may permit nurses with the appropriate training to prescribe while not necessarily being in an APN role. Nurse prescribing has been created as a strategy to support access to care and meet growing health needs identified by the user and populations⁽⁸⁾. Autonomous practice is grounded in the foundational training required to achieve and establish independent relationships with patients and other health care professionals⁽⁸⁾. This foundational training and expansion of this concept can be seen as one of the pillars to APN practice. Nurses cannot practice autonomously however, without recognizing their role, impact and value as a multidisciplinary team member. Considering this dynamic interplay, it is essential that interprofessional boundaries and the scope of role extension be clearly established to ultimately promote comprehensive healthcare to individuals and families⁽⁸⁾.

The variation of APN roles, titles, educational requirements, scope, and regulatory practices occurs in and across countries where APNs are situated. Although overarching international APN attributes have been identified, the role's complexity lends to difficulty identifying advanced practitioner's unique contribution. Some of this can be attributed to the lack of role clarity, impact on indirect rather than direct role on patient outcomes and the collaborative team environment that APNs are a part of⁽¹³⁾. Also of note are the publication dates in many scholarly works used to reference and clarify the APN role, where the debate continues for greater than twenty years.

APNs have been shown to improve patient health outcomes⁽¹⁴⁾ and establish high patient satisfaction with the care they provide⁽¹⁵⁾. NPs impact beyond the level of the patient and family, highlighting organizational effectiveness, service provision and mitigating acute care utilization⁽¹⁶⁾. MDs perspectives on the integration of APNs in practice identify challenges and positive attributes, however each hinge on specific practice environments and location specific health care reform⁽¹⁷⁾. To support evaluation of the long-term impact and sustainability of APN roles, an evaluation framework, titled PEPPA (Participatory Evidenced-Informed Patient Centred Process), was created in 2016 by global nursing leaders⁽¹⁸⁾. This framework is the first of its kind to evaluate different types of APN roles, in developed countries, as they evolve to meet population health needs, practice settings and health systems⁽¹⁷⁾. PEPPA uniquely fosters role clarity through consultation with stakeholders (patients, providers, administrators) who influence role design, implementation and evaluation, to support meaningful and policy relevant data to further integrate, advance and position APNs within the health care system⁽¹⁷⁾.

In Canada, for the past three decades, momentum to advance, develop and integrate APNs into a variety of clinical practice settings has continued at a steady pace. Health care services for an aging population, public demand for increased access and reduced wait times, utilization of various interprofessional practice models and development of professional practice organizations are among several reasons for the steadfast and growing network of APNs in Canada⁽¹⁰⁾. That said, professional clarity with the goal of professional unity takes a considerable amount of time on both local and global scales. While several nursing leaders continue to internationally collaborate and strive for a universal consensus to define and advance the APN role, APNs continue to intersect professional boundaries in country specific health care agendas and leverage how health services can be improved⁽⁷⁾. Ultimately, respecting how various nursing roles complement each other, will allow the unifying voice of nursing to advance the health and social well-being of patients, families, and communities.

In spite of the barriers to APN development and practice globally, the pandemic has amplified the critical role of nurses. As many countries are considering APN implementation, lessons from COVID 19 have changed the face of healthcare, and as a global health care workforce, nurses have been stretched to fill gaps and lead the health care profession. Stark realities of the inadequate supply of skilled of nurses are clear, further implicating training and retention of the nursing workforce⁽¹⁹⁾. There is need to recognize and promote the significant impact nurses' ability and knowledge has had toward changing the face of healthcare and the APN role situated and elevated firmly within.

The opportunities and issues highlighted above are points to examine and remain cognizant of as the APN role is being explored in Brazil and globally.

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Publication Dates

• Publication in this collection
  19 Nov 2021
• Date of issue
  2022