Advanced Nursing Practice

A National Framework

2008

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February 2008

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Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Evolution of Advanced Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Definition and Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Educational Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Competencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Clinical Competencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Research Competencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Leadership Competencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Consultation and Collaboration Competencies . . . . . . . . . . . . . . . . . . . . . . . 26
Impact of Advanced Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Support for Advanced Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Looking to the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Appendix A: PEPPA Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Appendix B: The Consultation Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Appendix C: Members of the National Working Group . . . . . . . . . . . . . . . . . . . . 44
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Advanced Nur sing Practice: A National Framework

Advanced nursing practice

is an umbrella term describing an
advanced level of clinical nursing
practice that maximizes the use of
graduate educational preparation,
in-depth nursing knowledge and
expertise in meeting the health needs
of individuals, families, groups, communities and populations. It involves
analyzing and synthesizing knowledge;
understanding, interpreting and applying
nursing theory and research; and developing and advancing nursing knowledge
and the profession as a whole.

Introduction

photo : Teckles Photography Inc

Society and its health-care needs are always

evolving. As a result, health care in Canada
today faces many challenges, including rising
costs, shortages of professionals, an aging
population, the introduction of new technology
and difficulties with access to care. The
demand for collaborative, innovative clinical
practitioners to act as leaders in health care
has never been stronger.

Advanced Nur sing Practice: A National Framework

Society and its health-care needs are always evolving. As a result, health care in
Canada today faces many challenges, including rising costs, shortages of professionals,
an aging population, the introduction of new technology and difficulties with access
to care. The demand for collaborative, innovative clinical practitioners to act as
leaders in health care has never been stronger. Nurses in advanced nursing practice
are well positioned to respond to the evolution of health care. In particular, advanced
nursing practice plays a key role in meeting the health needs of Canadians, by
building nursing knowledge, advancing the nursing profession and contributing
to a sustainable and effective health-care system.
The Board of Directors of the Canadian Nurses Association (CNA) approved the
key elements of a national framework for advanced nursing practice in June 1999.
The first edition of Advanced Nursing Practice: A National Framework was published
in May 2000. That document defined advanced nursing practice, identified its characteristics and competencies, 1 and described the necessary educational preparation,
the various domains of practice and potential roles, and its regulation. The framework was deliberately broad, in part to allow for variations among jurisdictions and
in part to allow for evolution of advanced nursing practice roles. In March 2002,
the CNA Board of Directors revised one of

...advanced nursing practice

the key elements of the framework by estab-

plays a key role in meeting the

lishing a graduate degree in nursing as the

health needs of Canadians,

minimum educational requirement for

by building nursing knowledge,

advanced nursing practice.

advancing the nursing profession

and contributing to a sustainable
and effective health-care system.

The overall objective of this national framework is to promote a common understanding

of advanced nursing practice in Canada and

Terms defined in the glossary are presented in italics on first appearance in the text.

Advanced Nur sing Practice: A National Framework

thereby to increase consistency in role definition,

curricula and competency development.

In March 2002, the CNA Board of

The framework has already been used for a variety

Directors revised one of the key

of purposes, including developing educational

courses, outlining concepts for research, shaping
government position statements and interpreting

elements of the framework by

establishing a graduate degree
in nursing as the minimum

advanced nursing practice for employers, the public,

other health-care workers and policy-makers.

educational requirement for

advanced nursing practice.

In 2005, CNA organized the Dialogue on

Advanced Nursing Practice to bring together
nursing stakeholders including educators, policy-makers, administrators and
representatives of nursing organizations to discuss what could be learned from
the existing advanced nursing practice roles, to identify what more could be done
to support the evolution of advanced nursing practice and to identify principles
and strategies that would promote the introduction of other advanced nursing
practice roles. Participants identified the national framework for advanced
nursing practice as a useful guide in the continued development of this form of
practice in Canada and recommended that it be updated periodically to respond
to the needs of its users and to reflect changes in health-care system environments.
The Canadian Nurse Practitioner Initiative, launched in 2004, helped in the development
of a framework for the integration and sustainability of the nurse practitioner role in
Canadas health-care system. Recommendations for practice, education, legislation
and regulation, and health human resources planning were considered in the current
revision of the advanced nursing practice framework.

Advanced Nur sing Practice: A National Framework

The advanced nursing practice framework contains the following key elements:
evolution of advanced nursing practice
definition and characteristics
educational preparation
roles
regulation
competencies
impact of advanced nursing practice
support for advanced nursing practice

Advanced Nur sing Practice: A National Framework

Evolution of Advanced
Nursing Practice

photo : Teckles Photography Inc

Advanced nursing practice has emerged

over the past decades as health-care systems
and governments around the world have come
to recognize that optimizing the nursing
contribution to health care through expanding
their role is an effective strategy for improving
health services (Schober & Affara, 2006, p. 2).

Advanced Nur sing Practice: A National Framework

Nurses can choose from

a variety of diverse and

Advanced nursing practice2 has emerged over the past

equally valuable practice

decades as health-care systems and governments around

opportunities, of which
advanced nursing practice

the world have come to recognize that optimizing the

nursing contribution to health care through expanding
their role is an effective strategy for improving health

is one.

services (Schober & Affara, 2006, p. 2). Despite the

common development of this realm of nursing practice,
the understanding of what constitutes advanced nursing practice varies from one country
to another and even within countries. Advanced practice nurses are viewed as experts in
their respective domains, engaged in activities that extend beyond the narrow application
of technically complex procedures. In particular, advanced nursing practice involves the
sophisticated use of knowledge and skills (Daly & Carnwell, 2003, p. 163).
Two advanced nursing practice roles are recognized in Canada today: the clinical nurse
specialist and the nurse practitioner. These two roles evolved from different roots. Clinical
nurse specialists first emerged in the 1970s as client care grew more complex. Their role
was to provide clinical guidance and leadership to nursing staff managing complex care,
to improve the quality of care and to promote evidence-based practice. Cutbacks in the
1980s and 1990s led to the elimination of many of these positions, but as concern over
the quality of care builds in the early 21st century, there is reason to believe that the clinical nurse specialist role will regain prominence.

In Canada, the origin of the nurse practitioner lies in the work of nurses who, decades ago,
provided care that was otherwise unavailable in rural and remote areas. Nurse practitioners
gained formal recognition in the 1970s, when this role was recommended by policy-makers
as a way of providing health care to isolated populations. Education programs were started,

Advanced nursing practice is used by CNA as the umbrella term for the advanced level of clinical practice described in
this framework; individuals in advanced nursing practice roles are referred to in this document as advanced practice nurses.
Nurses refers to registered nurses.

Advanced Nur sing Practice: A National Framework

Canadian advanced practice nurses have

but a perceived oversupply of
physicians, a lack of enabling
legislation and problems related
to remuneration caused interest
to wane. Interest was rekindled

the education, clinical expertise, leadership

skills and understanding of organizations,
health policy and decision-making to play
an important role in client and health-care
system outcomes now and in the future.

in the 1990s by health-care

reform, an increased demand for access to primary health care and the need for integrated
care. The Canadian Nurse Practitioner Initiative was launched in 2004 to develop a panCanadian framework to encourage full integration of nurse practitioners into Canadian
health care.

As demand, technology and knowledge change the ways in which health care is delivered,
interest in advanced nursing practice is on the rise. Trends in the delivery of health care
are providing opportunities for nurses to expand current roles and create new ones. Nurses
can choose from a variety of diverse and equally valuable practice opportunities, of which
advanced nursing practice is one. As nurses move along the continuum of experience and
education, they acquire additional competencies that become incorporated into their
practice. This evolution enables nurses to contribute to the health-care system in new ways.

Although all nurses contribute to the health-care system through their work in
clinical practice, education, administration, research and policy, advanced nursing
practice focuses on the clinical domain in a wide array of practice settings. Clinical
practice not only incorporates direct client care but also involves a supportive and
consultative role. Canadian advanced practice nurses have the education, clinical
expertise, leadership skills and understanding of organizations, health policy and decisionmaking to play an important role in client and health-care system outcomes now and
in the future.

Advanced Nur sing Practice: A National Framework

Advanced Nur sing Practice: A National Framework

Definition and
Characteristics
Definition

photo : Teckles Photography Inc

Advanced nursing practice is an umbrella term

describing an advanced level of clinical nursing
practice that maximizes the use of graduate educational
preparation, in-depth nursing knowledge and expertise
in meeting the health needs of individuals, families,
groups, communities and populations.

Advanced Nur sing Practice: A National Framework

Definition
Advanced nursing practice is an umbrella term describing an advanced level of clinical
nursing practice that maximizes the use of graduate educational preparation, in-depth
nursing knowledge and expertise in meeting the health needs of individuals, families,
groups, communities and populations. It involves:
analyzing and synthesizing knowledge;
understanding, interpreting and applying nursing theory and research; and
developing and advancing nursing knowledge and the profession as a whole.

Characteristics
In advanced nursing practice, nurses build on their expertise in a specialty area,
integrating and consistently displaying the following features and characteristics:
provision of effective and efficient care, delivered with a high degree of
autonomy, to an identified population;
demonstration of leadership and initiation of change to improve client,
organization and system outcomes;
deliberate, purposeful and integrated use of in-depth nursing knowledge,
research and clinical expertise, as well as integration of knowledge from
other disciplines;
depth and breadth of knowledge that draws on a wide range of strategies
to meet the needs of clients and to improve access to and quality of care;
ability to explain and apply the theoretical, empirical, ethical and experiential
foundations of nursing practice;

10

Advanced Nur sing Practice: A National Framework

 understanding, development and dissemination of evidence-based nursing

knowledge;
ability to initiate or participate in planning, coordinating, implementing
and evaluating programs to meet client needs and support nursing practice;
use of knowledge-transfer techniques to put research-based knowledge
into practice;
demonstration of advanced judgment and decision-making skills; and
critical analysis of and influence on health policy.

Advanced Nur sing Practice: A National Framework

11

12

Advanced Nur sing Practice: A National Framework

Educational Preparation

photo : Comstock

The minimum educational preparation for

advanced nursing practice is a graduate degree
in nursing. A nurse with this type of graduate
preparation has a thorough grounding in the
theoretical foundation of nursing and can
promote nursing research, generate new
knowledge and use academic preparation,
synthesis and knowledge-transfer skills to
interpret and incorporate new knowledge
into clinical practice.

Advanced Nur sing Practice: A National Framework

13

The minimum educational preparation for advanced nursing practice is a graduate

degree in nursing. A nurse with this type of graduate preparation has a thorough
grounding in the theoretical foundation of nursing and can promote nursing research,
generate new knowledge and use academic preparation, synthesis and knowledgetransfer skills to interpret and incorporate new knowledge into clinical practice.
Although a graduate degree is essential for advanced nursing practice, nurses who have
completed one or more graduate degrees cannot assume that their practice is at an
advanced level on the basis of these educational credentials alone. It is the combination
of graduate education and clinical experience that allows nurses to develop the competencies required in advanced nursing practice.
Like all nurses, advanced practice nurses are committed to lifelong learning. In addition
to pursuing such learning for themselves, they are committed to promoting, leading and
contributing to the lifelong learning of others.

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Advanced Nur sing Practice: A National Framework

Roles

photo : Corbis

Advanced nursing practice focuses on clinical

practice, whether through a direct relationship
with clients or through a supportive and
consultative role. Nurse educators, researchers
and administrators must demonstrate competencies in advanced nursing practice and
must have clinical practice as a significant part
of their role if they are to be considered as
functioning within advanced nursing practice.

Advanced Nur sing Practice: A National Framework

15

Advanced nursing practice focuses on clinical practice, whether through a direct relationship with clients or through a supportive and consultative role. Nurse educators,
researchers and administrators must demonstrate competencies in advanced nursing
practice and must have clinical practice as a significant part of their role if they are to
be considered as functioning within advanced nursing practice.
Only two advanced nursing practice roles are recognized in Canada today: the clinical
nurse specialist and the nurse practitioner. These two roles are fundamentally different.
Clinical nurse specialists provide expert nursing care for specialized client populations.
They play a leading role in the development of clinical guidelines and protocols,
promote the use of evidence, provide expert support and consultation, and facilitate
system change (Association of Registered Nurses of Newfoundland and Labrador,
2007). In contrast, nurse practitioners provide direct care focusing on health promotion and the treatment and management of health conditions. They are registered
nurses with additional educational preparation and experience who possess and
demonstrate the competencies to autonomously diagnose, order and interpret
diagnostic tests, prescribe pharmaceuticals and perform specific procedures within
their legislated scope of practice (CNA, 2006a).

With a focus on health promotion and disease

prevention, both the clinical nurse specialist
and the nurse practitioner enhance the provision
of timely, accessible, cost-effective and quality
health care for all Canadians
(CNA, 2006b, p. 3).

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Advanced Nur sing Practice: A National Framework

The clinical nurse specialist plays

Clinical nurse specialists and nurse practitioners
spend different amounts of time providing direct

a pivotal role in the provision of

safe, effective, evidence-based

clinical care, but both roles incorporate education,

care, supporting nurses to ensure

research, consultation and leadership components.

that they maximize their skills

Client, organization and system needs will help to

and abilities.

shape and determine the role of individual clinical

Bernadine Wallis, clinical nurse specialist

nurse specialists and nurse practitioners.

Winnipeg, Manitoba

With a focus on health promotion and disease

prevention, both the clinical nurse specialist and
the nurse practitioner enhance the provision of
timely, accessible, cost-effective and quality health
care for all Canadians (CNA, 2006b, p. 3). It is
anticipated that new advanced nursing practice
roles will develop to meet the existing and emerging
health-care needs of Canadians. For example, several
jurisdictions are exploring an advanced nursing

A nurse practitioner complements

rather than replaces other healthcare providers, bridges the gap
in service delivery for patients,

practice role within anesthesia care.

expands care options, and supports

a shift to wellness-based care.
Mary Nugent, nurse practitioner
Taber, Alberta

Advanced Nur sing Practice: A National Framework

17

18

Advanced Nur sing Practice: A National Framework

Regulation

photo : Eyewire / Getty Images

A framework describing advanced nursing

practice allows for a coordinated national
approach, permits flexibility among provinces
and territories, and allows new roles to develop.
Such a coordinated approach is necessary to
ensure that the public has access to consistent,
high-quality nursing services across the country.
It will also facilitate labour mobility for
advanced practice nurses who are subject to
specific provincial or territorial legislation.

Advanced Nur sing Practice: A National Framework

19

A framework describing advanced nursing practice allows for a coordinated national

approach, permits flexibility among provinces and territories, and allows new roles to
develop. Such a coordinated approach is necessary to ensure that the public has access
to consistent, high-quality nursing services across the country. It will also facilitate
labour mobility for advanced practice nurses who are subject to specific provincial or
territorial legislation.
Advanced practice nurses are registered nurses who are licensed by and accountable to
the registered nursing regulatory body established by legislation in each province and
territory. For many advanced practice nurses, additional regulation and standards are not
required because they practise within the scope of registered nursing in their respective
jurisdictions. In some cases, the scope of practice includes additional responsibilities,
such as prescriptive authority, that may require additional regulatory authority, but these
additional authorities are all within the scope of practice of nursing.
The regulation of nursing practice is intended to safeguard the public by ensuring that
nurses meet standard levels of knowledge and education. In Canada, regulatory titles,
including registered nurse and RN, are protected, but other titles, such as nurse,
nurse practitioner and NP, may or may not be protected according to the legislation
of specific jurisdictions.
Currently, the only advanced nursing practice

A framework describing advanced

role with additional regulation and title protection

nursing practice allows for a

in Canada is the nurse practitioner, although the

coordinated national approach,

specific title used varies among the provinces and

permits flexibility among provinces

territories. As new roles in advanced nursing

and territories, and allows new

practice emerge, they may or may not require

roles to develop.

additional legislation and regulation.

20

Advanced Nur sing Practice: A National Framework

Competencies

photo : Teckles Photography Inc

Competencies are the specific knowledge, skills,

judgment and personal attributes required for a
registered nurse to practise safely and ethically in
a designated role and setting (CNA, 2005). Core
competencies for advanced nursing practice are
based on an appropriate depth, breadth and range of
nursing knowledge, theory and research, enhanced
by clinical experience.

Advanced Nur sing Practice: A National Framework

21

Competencies are the specific knowledge, skills, judgment and personal attributes required
for a registered nurse to practise safely and ethically in a designated role and setting
(CNA, 2005). Core competencies for advanced nursing practice are based on an appropriate
depth, breadth and range of nursing knowledge, theory and research, enhanced by clinical
experience.3 They cut across specialty lines and are exhibited by all advanced practice nurses.
This framework separates competencies into four categories: clinical, research, leadership,
and consultation and collaboration. However, it is the effective and simultaneous interaction,
blending and execution of knowledge, skills, judgment and personal attributes in a wide
variety of practice environments that characterizes advanced nursing practice.

Clinical Competencies
The cornerstone of advanced nursing practice is expertise in a specialized area of nursing.
Through a holistic and integrated approach, the nurse works in partnership with the client
and other members of the health-care team in the provision of comprehensive care.
An advanced practice nurse integrates extensive clinical experience with theory, research
and in-depth nursing and related knowledge to:
develop multiple advanced assessment and intervention strategies within a
client-centred framework for individual clients, communities and populations;
use qualitative and quantitative data from multiple sources, often in ambiguous
and complex situations, when making clinical decisions and initiating and
managing change;
analyze the complex interaction of sociological, psychological and physiological
processes, determinants of health and clients lived experience;

Competencies specific to the nurse practitioner role and responsibilities are identified in Canadian Nurse Practitioner:
Core Competency Framework (CNA, 2005).

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Advanced Nur sing Practice: A National Framework

 anticipate and explain the wide range of client responses to actual or

potential health problems and recommend action;
guide decision-making in complex clinical situations;
engage clients and other team members in resolving issues at the individual,
organizational and health-care system levels;
identify and assess trends or patterns that have health implications for
individuals, families, groups or communities;
generate and incorporate new nursing knowledge and develop new standards
of care, programs and policies;
plan, initiate, coordinate and conduct educational programs based on
needs, priorities and organizational resources; and
manage a wide range of patient responses to actual and potential health
problems.

Research Competencies
Generating, synthesizing and using research evidence is central to advanced
nursing practice.
An advanced practice nurse is able to:
identify and implement research-based innovations for improving client
care, organizations or systems;
as either primary investigator or collaborator with other members of the
health-care team or community, identify, conduct and support research
that enhances or benefits nursing practice;

Advanced Nur sing Practice: A National Framework

23

Advanced practice
nurses are leaders in

evaluate current practice at individual and system levels in

light of research findings;

the organizations and

communities where

collect data on, and evaluate the outcomes of, advanced

nursing practice for clients, the nursing profession and the

they work.

health-care system;
critique, interpret, apply and disseminate evidence-based findings; and
contribute to nursing and the health-care system by disseminating new
knowledge through formal and informal channels, including presentation
and publication at the local, regional, national and international levels.

Leadership Competencies
Advanced practice nurses are leaders in the organizations and communities where they
work. They are agents of change, consistently seeking effective new ways to practise, to
improve the delivery of care, to shape their organizations, to benefit the public and to
influence health policy.
An advanced practice nurse demonstrates leadership by:
advocating for individuals, families, groups and communities in relation to
treatment, the health-care system and policy decisions that affect health and
quality of life;
identifying the learning needs of nurses and other members of the health-care
team and finding or developing programs and resources to meet those needs;
mentoring and coaching nursing colleagues, other members of the healthcare team, and students;
advocating for and promoting the importance of health-care access and
advanced nursing practice to nurses and other health professionals, the
public, legislators and policy-makers;

24

Advanced Nur sing Practice: A National Framework

 contributing to and advocating for an organizational culture that supports

professional growth, continuous learning and collaborative practice;
evaluating programs in the organization and the community and developing
innovative approaches to complex issues;
understanding and integrating the principles of resource allocation and
cost-effectiveness in organizational and system-level decision-making;
identifying gaps in the health-care system and developing partnerships to
facilitate and manage change;
developing and clearly articulating a vision for nursing practice, influencing
and contributing to the organizations and the health-care systems vision
and implementing approaches to realize that vision;
advising clients, colleagues, the community, health-care institutions and
policy-makers on issues related to nursing, health and health care;
identifying problems and initiating change to address challenges at the
individual, organizational or system level; and
understanding legislative and socio-political issues that influence health
policy, and building strategies to improve health, health-care access and
healthy public policy.

Advanced Nur sing Practice: A National Framework

25

Consultation and Collaboration

Competencies
Effective collaboration and communication with clients and others on the health-care
team represent important aspects of any nursing practice. The ability to consult and
collaborate with colleagues across sectors and at the organizational, provincial, national
and international level is a characteristic of nurses in advanced practice.
A nurse in advanced practice is able to:
initiate timely and appropriate consultation, referrals and collaboration with
other health-care providers;
consult and collaborate with members of the health-care team to develop
quality-improvement and risk-management strategies;
work with others to gather and synthesize qualitative and quantitative
information on determinants of health from a variety of sources;
practise collaboratively and build effective coalitions;
apply theories related to group dynamics, roles and organizations;

Collaboration is a complex process requiring knowledge

sharing and joint responsibility for patient care,
management and outcomes.
Sandra Duke, nurse practitioner
Halifax, Nova Scotia

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Advanced Nur sing Practice: A National Framework

 demonstrate knowledge and skill in communication, negotiation and conflict

resolution, including the ability to analyze, manage and negotiate conflict;
clearly articulate the contribution of advanced nursing practice within
the interprofessional health-care team;
participate in collaborative projects with academic institutions and maintain
cross-appointments; and
advocate for changes in health policy by participating on regional, provincial/
territorial, and federal committees that influence decision-making at
those levels.

Advanced Nur sing Practice: A National Framework

27

28

Advanced Nur sing Practice: A National Framework

Impact of Advanced
Nursing Practice

photo : Eyewire / Getty Images

Advanced nursing practice has evolved to meet

the demands of modern health care through
increasingly advanced knowledge and skills.
It is not merely technical and educational
progress that has driven the development of
advanced nursing practice; the health needs
of clients and the growing complexity of care
have also contributed.

Advanced Nur sing Practice: A National Framework

29

Advanced practice nurses

have used their experience
Advanced nursing practice has evolved to meet the

and education to take nursing practice to new levels,

demands of modern health care through increasingly

advanced knowledge and skills. It is not merely technical

as they have moved from a

and educational progress that has driven the development

supportive to a leading

of advanced nursing practice; the health needs of

role in client care.

clients and the growing complexity of care have also

contributed. Advanced practice nurses have used their

experience and education to take nursing practice to new levels, as they have moved
from a supportive to a leading role in client care.
Evidence about the benefits of advanced nursing practice is now building. Cunningham
(2004, p. 219) has stated that nurses in advanced nursing practice enrich health care by
adding value to the delivery of health-care services. Bryant-Lukosius, DiCenso, Browne
and Pinelli (2004, p. 526) found that advanced practice nurses may improve client and
health-care system outcomes related to health status, functional status, quality of life,
satisfaction with care and cost efficiency. DeGrasse and Nicklin (2001, p. 8) reported
that the use of advanced practice nurses decreased
the number of hospital admissions and emergency

Clinical nurse specialists, with

their focus on patient care from a
nursing perspective, can advance
nursing practice through education,

department visits, shortened lengths of stay and

resulted in cost savings for the institutions where
they were employed. Other outcomes that improved
with advanced nursing practice included fewer
readmissions for heart failure, shorter lengths of

research and the development of

systems that meet patient and
family needs.

30

stay when patients were readmitted and lower rates

of urinary tract infections, skin breakdown and
pneumonia (Kleinpell, 2007, p. 20). Kleinpell also

Erlene Seaborne, clinical nurse specialist

reported that advanced nursing practice helped

Hamilton, Ontario

promote evidence-based care, improved patients

Advanced Nur sing Practice: A National Framework

Clinical nurse specialists support and

teach other health-care providers and
adherence to health promotion and built the

can influence and improve health care

evidence base of nursing. Advanced nursing

at the individual and the system level.

practice is an innovative and exciting development that provides nurses with an opportunity

Linda Read Paul, clinical nurse specialist

Calgary, Alberta

to work at an advanced level of clinical practice

(Furlong & Smith, 2005, p. 1062).
The role of the nurse practitioner has been studied for many years. In a literature
review commissioned by the College of Registered Nurses of Nova Scotia and released in
June 2007, Sangster-Gormley reported that client satisfaction and education are the most
commonly researched outcomes of nurse practitioner care. However, the author went
on to describe solid evidence for many other benefits to care: nurse practitioners are
more likely to follow practice guidelines, and their patients have shorter stays, fewer
readmissions and other successful outcomes.
The body of research on advanced nursing practice is smaller than is the case for many
other topics in nursing. In another review of recent research, Oerman and Floyd
(2002, p. 140) identified and described this lack of evidence. They found that research
on outcomes has focused too much on cost savings, ignoring important aspects of the
work of advanced practice nurses such as resolution of symptoms, enhancement of
clients quality of life and improvements in knowledge among patients and families.
They called for advanced practice nurses to lead more research on the results of specific
nursing interventions.
For their annotated bibliography, published in 2004, Fulton and Baldwin reviewed
70 research papers that had been written by nurses or had examined the impact of
clinical nurse specialists. Fulton and Baldwin identified many ways in which clinical
nurse specialists improved care, such as reducing the number of visits to emergency
departments by clients with asthma and improving prenatal care of and generating

Advanced Nur sing Practice: A National Framework

31

better outcomes for very low birth weight babies; they also found that cancer
patients whose care team included a clinical nurse specialist had fewer complications.
Perhaps the most important aspect of the article was the scope of information it
covered: in addition to the research pieces, the authors reviewed 31 publications about
program development and evaluation and 25 anecdotal accounts. These numbers are
a sign that the knowledge base for advanced nursing practice is building, but Fulton
and Baldwin (2004, p. 22) warned that although the number of articles had drastically
increased, the scope of everyday [clinical nurse specialist] accomplishments is not
completely captured in published work. [Clinical nurse specialists] improve care
practice on a daily basis.

32

Advanced Nur sing Practice: A National Framework

Support for Advanced

Nursing Practice

photo : Teckles Photography Inc

Advanced nursing practice must be supported

at many levels if it is to operate effectively and
provide a full range of benefits to clients, other
members of the health team, organizations and
the community as a whole.

Advanced Nur sing Practice: A National Framework

33

Advanced nursing practice must be supported at many levels if it is to operate effectively

and provide a full range of benefits to clients, other members of the health team, organizations and the community as a whole. The University Health Network Framework for
Advanced Nursing Practice states that significant challenges have emerged in role implementation and development, as a result of inconsistent professional and organizational
support for [advanced nursing practice]. Role clarity, demonstrated value and consistent
support have been identified in the literature as keys to successful role implementation
(Micevski et al., 2004, p. 53).
To flourish, advanced nursing practice needs:
leadership by CNA, other nursing organizations and governments to encourage
creation of positions for nurses in this type of practice;
leadership by CNA and other nursing organizations to identify opportunities
for the introduction of future advanced nursing practice roles that align with
current and emerging population health and system needs;
health human resources planning that takes a pan-Canadian, interprofessional
approach and that is based on a conceptual framework;
organizational and administrative support and resources to implement, develop
and sustain various aspects of advanced nursing practice;
communication and education tools to inform the public, policy-makers, administrators and other professions about the contributions of advanced nursing practice;
human resources policies that allow nurses to pursue graduate education;
specially designed graduate curricula based on the characteristics and
competencies of advanced nursing practice;
flexible pathways to graduate nursing education;

34

Advanced Nur sing Practice: A National Framework

 support for professional development and lifelong learning;

funding for research about and by nurses in advanced nursing practice;
interprofessional education and organizations that foster team work;
resources to put in place the positions, technology, administrative infrastructure
and culture for advanced practice nurses to work most effectively; and
policy processes that promote advanced nursing practice and are shaped by the
expertise of advanced practice nurses.

Advanced Nur sing Practice: A National Framework

35

36

Advanced Nur sing Practice: A National Framework

Looking to the Future

photo : Corbis

Canadas health-care needs are growing

with the aging of the population, continued
shortages in the supply of health human
resources, increasing complexity of the healthcare system and mounting pressure to contain
costs. Advanced nursing practice is helping
to meet these growing needs. To have a farreaching impact, however, advanced nursing
practice must be promoted and sustained.

Advanced Nur sing Practice: A National Framework

37

Canadas health-care needs are growing with the aging of the population, continued
shortages in the supply of health human resources, increasing complexity of the health-care
system and mounting pressure to contain costs. Advanced nursing practice is helping to
meet these growing needs. To have a far-reaching impact, however, advanced nursing
practice must be promoted and sustained.
New advanced nursing practice roles should be introduced only in response to the healthcare needs of Canadians and must be based on solid evidence of those needs. CNAs position
statement National Planning for Human Resources in the Health Sector states that needs-based
planning anticipates health needs on the basis of demographic, epidemiological, and cultural
factors and includes benchmarking for regional variation and review of specialty mix within
and between disciplines (CNA, 2006c).

New approaches to health

Progress has been made in providing guidelines for the

care, based on strategies

introduction and evaluation of advanced nursing practice

that will enhance access

roles (Bryant-Lukosius & DiCenso, 2004, p. 531; Winnipeg

to service delivery while

Regional Health Authority, 2005, 2006). In particular, Bryant-

improving the health of

the population, must be

Lukosius and DiCenso (2004, p. 532) presented the PEPPA

framework, a participatory, evidence-based, patient-centred
process for [advanced nursing practice] role development,

developed collaboratively.

implementation and evaluation, which set out nine steps for

determining whether a new advanced nursing practice role is

needed and whether it will be effective. These steps include defining the patient population,
defining new models of care and the place of the advanced practice nurse within them,
implementing the new models of care and long-term monitoring.
The Canadian Nurse Practitioner Initiative includes an implementation and evaluation
toolkit, which serves as a practical guide to assessing the need and readiness for the nurse
practitioner role. In addition, the toolkit identifies key steps and factors to support the
implementation of this role and ongoing monitoring of its effectiveness through a

38

Advanced Nur sing Practice: A National Framework

structured, forward-looking evaluative approach. In particular, the toolkit offers guidance on

tailoring the planning, implementation and evaluation of the nurse practitioner role to the
unique requirements of specific practice settings. The design of the toolkit was based on the
PEPPA framework, extensive literature review and experimental research, key stakeholder consultation and a review of best practices (CNA, 2006d). In addition, a needs-based simulation
model for health human resources planning was developed in conjunction with the Canadian
Nurse Practitioner Initiative; this model is applicable to primary health care nurse practitioners
across all jurisdictions in Canada. It goes beyond the traditional planning models, which are
based on supply and projected population-to-provider ratios, to consider population health
needs and the level of services required to meet those needs (CNA, 2006e).
Coordination of the preparation and roles for advanced nursing practice is another necessary
step. The development of educational and experiential goals and programs for advanced practice nurses should be aligned across the provinces and territories, to reinforce their place in
health care overall and to permit labour mobility. The goal must be to ensure that all
Canadians have access to similar types of expertise.
To effectively develop and sustain the health-care system, the roles of health-care providers,
including advanced practice nurses, must be optimized. Canadians can anticipate many new challenges to their health-care system, including increases in chronic diseases such as diabetes mellitus
and arthritis. Nonetheless, a shift in focus from illness to health is expected, whereby clients will
become more educated and more strongly engaged and will participate more actively in developing
and maintaining their own health (Villeneuve & MacDonald, 2006). Advanced practice nurses
must be part of the solution to these health-care challenges and the changes that lie ahead.
New approaches to health care, based on strategies that will enhance access to service delivery
while improving the health of the population, must be developed collaboratively. With commitment and an understanding of its importance at all levels of health care, advanced nursing
practice can play a key role in meeting the health needs of Canadians, building nursing
knowledge and contributing to a sustainable and effective health-care system.

Advanced Nur sing Practice: A National Framework

39

Glossary
Advanced nursing practice
Umbrella term for an advanced level of clinical nursing practice that maximizes the use of
graduate educational preparation, in-depth nursing knowledge and expertise in meeting the
health needs of individuals, families, groups, communities and populations. It involves:
analyzing and synthesizing knowledge;
understanding, interpreting and applying nursing theory and research; and
developing and advancing nursing knowledge and the profession as a whole.

Client

The beneficiary of care; may be an individual, family, group, population or entire

community

Client-centred care
Nurses achieve client-centred care by actively including the client and significant others
as partners in the care, [and by] identifying the clients goals, wishes and preferences
and making these the basis of the plan of care... (College of Nurses of Ontario, 2006)

Clinical nurse specialist

A registered nurse who holds a masters or doctoral degree in nursing with expertise in
a clinical nursing specialty; uses in-depth knowledge and skills, advanced judgment and
clinical experience in a nursing specialty to assist in providing solutions for complex
health-care issues

Competencies

Integrated knowledge, skills, judgment and personal attributes required of a registered

nurse to practise safely and ethically in a designated role and setting (CNA, 2005)

Credentials

Marks or stamps of quality and achievement communicating to employers, payers and

consumers what to expect from a credentialed nurse, specialist course or program of
study, institution of higher education, hospital or health service, or health-care product,
technology or device

40

Advanced Nur sing Practice: A National Framework

Graduate education
Education beyond the baccalaureate level, including masters, doctoral and postdoctoral
levels (Field, Stinson & Thibaudeau, 1992)

Mentoring

A voluntary, mutually beneficial, long-term relationship in which an experienced and

knowledgeable leader (the mentor) supports the maturation of a less experienced nurse
with leadership potential (the mentee)

Nurse practitioner
A registered nurse with additional educational preparation and experience who possesses
and demonstrates the competencies to autonomously diagnose, order and interpret
diagnostic tests, prescribe pharmaceuticals and perform specific procedures within the
legislated scope of practice (CNA, 2006a)

Regulation

All of those legitimate and appropriate means governmental, professional, private and
individual whereby order, identity, consistency and control are brought to the profession;
through regulation, the profession and its members are defined, the scope of practice is
determined, standards of education and of ethical and competent practice are set and
systems of accountability are established (Styles & Affara, 1997)

Scope of nursing practice

The activities that nurses are educated and authorized to perform, as established through
legislated definitions of nursing practice, complemented by standards, guidelines and
policy positions issued by professional nursing bodies (CNA, 2005)

Specialized practice
Practice that concentrates on a particular aspect of nursing, related to the clients age
(e.g., pediatrics, gerontology), the clients problem (e.g., pain management, bereavement),
the diagnostic group (e.g., orthopedics, vascular surgery), the practice setting (e.g., home
care, emergency) or the type of care (e.g., primary health care, palliative care, critical care)

Advanced Nur sing Practice: A National Framework

41

Appendix A
PEPPA Framework
Participatory, evidence-based, patient-centred process for advanced practice
nurse [APN] role development, implementation and evaluation

From: Bryant-Lukosius, D., & DiCenso, A. (2004). A framework for the introduction of an evaluation of advanced practice
nursing roles. Journal of Advanced Nursing, 48 (5), 530-540. Reprinted with the permission of Blackwell Publishing.

42

Advanced Nur sing Practice: A National Framework

Appendix B
The Consultation Process
The Board of Directors of the Canadian Nurses Association (CNA) approved the key
elements of a national framework for advanced nursing practice in June 1999. The
framework was first published in May 2000 in Advanced Nursing Practice: A National
Framework. In March 2002, the CNA Board of Directors revised one of the key elements
of the framework by establishing a graduate degree in nursing as the minimum educational requirement for advanced nursing practice
Changes in practice that emerged during CNAs 2005 Dialogue on Advanced Nursing
Practice and the Canadian Nurse Practitioner Initiative (2004-06) signalled the need
to update CNAs framework on advanced nursing practice.
In 2006, the CNA Board of Directors created a national working group to guide revision
of the framework. Its consultations involved one face-to-face meeting, numerous teleconferences and circulation of several draft documents among member jurisdictions
and national nursing and other health-care organizations. In addition, a discussion of
the draft framework by the CNA Board of Directors helped to guide the final version.
Feedback from the consultation process was extensive. Hundreds of responses were
received from associations, organizations and individual nurses. Although views on specific
aspects of the framework differed, there was strong consensus on the key concepts for
advanced nursing practice. Taking into consideration the feedback received and the consensus recommendations from the national working group, the CNA Board of Directors
approved the updated framework for advanced nursing practice in November 2007.

Advanced Nur sing Practice: A National Framework

43

Appendix C
Members of the National Working Group
Co-Chairs
Christine Rieck Buckley
Debbie Philipchuk

Canadian Nurses Association

College & Association of Registered Nurses of Alberta

Members
Karen Antoni
Gail Beatty

Registered Nurses Association of Ontario

Michle Brennan

College of Registered Nurses of Nova Scotia

Suzanne Durand

Ordre des infirmires et infirmiers du Qubec

Stephen Leck
Francis Loos

Registered Nurses Association of Northwest Territories and Nunavut

Saskatchewan Registered Nurses Association

Betty Lundrigan

Association of Registered Nurses of Newfoundland and Labrador

Patricia McGarr

Yukon Registered Nurses Association

Blake Parkin

Association of Registered Nurses of Prince Edward Island

Cheri Vigar

College of Nurses of Ontario

Barb Waters

Nurse Practitioner Council of Canada

Jo Wearing

44

Canadian Association of Advanced Practice Nurses

College of Registered Nurses of British Columbia

Doug Wheeler

Nurses Association of New Brunswick

Joanne Winsor

College of Registered Nurses of Manitoba

Advanced Nur sing Practice: A National Framework

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www.cna-aiic.ca