Graduate Course Syllabus ADVANCED NURSING PRACTICE

Delivery mode Credits Prere% isite Co rse Coordi"ator I"trod ctio": Students review the characteristics and competencies of advanced nursing practice and examine issues related to the development of the role of an advanced practice nurse. Students build on their understanding of the competencies of advanced nursing practice to develop a vision of a future role in advanced nursing practice. As well, students develop a funding proposal for a project related to advanced nursing practice. Finally, students consider various futures scenarios that may shape their advanced nursing practice. Co rse Goals : Paced/home-st dy! lect re! disc ssio" : # c$ : : N rsalam

After completing this course, students should be able to:

1. Discuss the characteristics and competencies of advanced nursing practice !. "valuate application of the competencies of advanced nursing practice in their own practice #. Discuss issues related to implementation of advanced nursing practice roles, in particular the role of the nurse practitioner $. Develop awareness of how advanced nursing practice %particularly the role of the nurse practitioner& is regulated in his'her province'territory (. Analy)e current issues influencing advanced nursing practice, with particular reference to the role of the nurse practitioner *. "xplore various future scenarios for advanced nursing practice +. ,rovide evidence-based clinical services to well clients of all ages and to those presenting with acute and chronic health concerns, at a level appropriate to a beginning practitioner, including.
a. b. c. d. e. f. health history and physical examination clinical decision ma/ing ordering of laboratory and diagnostic tests prescription of medications therapeutic communication collaborative relationships

0. 1efer, to other health professionals, clients with health concerns that exceed the scope of practice of a beginning practitioner offering clinical services 2. Demonstrate integration of medical and nursing management of health concerns of clients Co rse & tli"e 3his course consists of the following units. Unit 1 - Competencies of Advanced Nursing Practice I 4n this unit students review the characteristics of advanced nursing practice as identified by the 5anadian 6urses Association and consider the extent to which they are able to evidence these. Students then study the competencies of advanced nursing practice, reflecting on how the Advanced 6ursing ,ractice program has prepared them in these areas. 4t should be focused on. 7 Develop multiple advanced assessment and intervention strategies within a client-centered framewor/ for individual clients, communities and populations

7 8se 9ualitative and 9uantitative data from multiple sources, often in ambiguous and complex situations, when ma/ing clinical decisions and initiating and managing change 7 Analy)e the complex interaction of sociological, psychological and physiological processes, determinants of health and clients: lived experience anticipate and explain the wide range of client responses to actual or potential health problems and recommend action Unit 2 - Competencies of Advanced Nursing Practice 2 4n this unit students review the characteristics of advanced nursing practice as identified by the 5anadian 6urses Association and consider the extent to which they are able to evidence these. Students then study the competencies of advanced nursing practice, reflecting on how the Advanced 6ursing ,ractice program has prepared them in these areas. 4t should be focused on. 7 ;uide decision-ma/ing in complex clinical situations 7 "ngage clients and other team members in resolving issues at the individual, organi)ational and health-care system levels 7 4dentify and assess trends or patterns that have health implications for individuals, families, groups or communities Unit - Competencies of Advanced Nursing Practice 4n this unit students review the characteristics of advanced nursing practice as identified by the 5anadian 6urses Association and consider the extent to which they are able to evidence these. Students then study the competencies of advanced nursing practice, reflecting on how the Advanced 6ursing ,ractice program has prepared them in these areas. 4t should be focused on. 7 ;enerate and incorporate new nursing /nowledge and develop new standards of care, programs and policies 7 ,lan, initiate, coordinate and conduct educational programs based on needs, priorities and organi)ational resources and 7 <anage a wide range of patient responses to actual and potential health problems. Unit ! - Advanced Nursing Practice "ole Implementation 1 4n this unit students study issues related to implementation of advanced nursing practice, including phases of role development, administrative support for advanced nursing practice, and evaluation of advanced nursing practice. 4ssues related to entrepreneurial opportunities and regulation of practice are explored. 3he unit closes with a loo/ at issues that may influence the future of advanced nursing practice. Unit # - Advanced Nursing Practice "ole Implementation 2 4n this unit students study issues related to legal practice certainty from the government. 4ssues related to Nursing $ill %raft are explored. 3he unit closes with a loo/ at issues that may influence the future of advanced nursing practice. Unit & - "esearc' in Advanced Nursing Practice 1esearch s/ills are an integral competency of advanced nursing practice and advanced practice nurses will be expected to critically review research and utili)e research findings. As well, it is li/ely that advanced practice nurses will be expected to identify the need for and facilitate the development of research-based projects in their wor/ settings. Unit ( ) *ealt' "esearc' +et'ods 4ntroduction to the scientific method, experimental, 9uasi-experimental, descriptive and epidemiological research. <easurement issues. 9uestionnaire development, reliability and validity of data, issues of sampling and sample si)e. "thics inresearch. Descriptive statistics, estimation and confidence intervals, inferential statistical tests. 8se of S,SS statistical software. "lements of critical appraisal. Unit , - Clinical Practicum and Community Assessment- Processes and "e.uirements 3his unit reviews the re9uirements of the clinical practicum and community assessment. 3he focus of the clinical practicum and community assessment of this course is =closure.= Students end their student relationship with their preceptors and with members of the community with whom they have developed relationships during your community assessment. Unit / - Advanced Nursing Practice Compre'ensive 01amination During this course students are re9uired to complete a comprehensive examination. 3he examination evaluates /nowledge in both the clinical services and community health development components of advanced nursing practice. Students must pass the comprehensive examination in order to graduate from the Advanced 6ursing ,ractice program. 3his unit provides information about the examination and suggestions to assist students in preparing for the examination. Unit 12 ) Clinical 3eaders'ip

3he unit consists of clinical leadership approaches'theories, decision ma/ing team building reflective practice, managing conflict facilitating change and creating empowered wor/ environments. 3hese topics will be explored in the context of the contemporary healthcare environment and viewed from an ethico-legal stance. 4ncluded will be /nowledge of contemporary issues in health care and trends in the development of effective clinical leadership in professional practice. Unit 11 ) %evelopmental *ealt' 5urrent research-based evidence on developmental and population health. 4nteraction of ecological, biological, psychological and social determinants. Developmental lifespan, including neurobiological, cognitive, social, emotional and moral development. >io-psycho-social and cultural aspects utilising appropriate research findings and conceptual framewor/s to assess, plan, implement and evaluate interventions targeting individuals, families and communities. Unit 12 ) *ealt' Pro4ect Preparation Development of an investigation into an individual area of speciality. Development of a critical review of related literature, study design and methodology for the proposal in consultation with the project supervisor. ,reparation of a project'research proposal. Unit 1 - Pro4ect %evelopment in Advanced Nursing Practice 4n this unit students learn how to develop project proposals. Unit 1! - Preparation for Advanced Nursing Practice 4n this unit students consider possible futures of advanced nursing practice, including both components of extended health services and community health development. "eference Affara F ? Schober <. !@@*. Advanced 6ursing ,ractice. Aondon. >lac/well Association of 1egistered 6urses of 6ewfoundland and Aabrador. %!@@+&. Advanced practice-clinical nurse specialist B,osition statementC. St. Dohn:s. Author. De;rasse, 5., ? 6ic/lin, E. %!@@1&. Advanced nursing practice. Fld hat, new design. 5anadian Dournal of 6ursing Aeadership, 1$%$&, +-1!. Furlong, "., ? Smith, 1. %!@@(&. Advanced nursing practice. ,olicy, education and role development. Dournal of 5linical 6ursing, 1$, 1@(2-1@**. Gamric, A., Spross, D., ? Ganson, 5. %!@@2&. Advanced nursing practice: An integrative approach %$th ed.&. St. Aouis. "lsevier Saunders. >ryant-Au/osius, D., ? Di5enso, A. %!@@$&. A framewor/ for the introduction and evaluation of advanced practice nursing roles. Dournal of Advanced 6ursing, $0%(&, (#@-($@. >ryant-Au/osius, D., Di5enso, A., >rowne, ;., ? ,inelli, D. %!@@$&. Advanced practice nursing roles. Development, implementation and evaluation. Dournal of Advanced 6ursing, $0%(&, (12-(!2. 3extboo/s and readings from other Advanced 6ursing ,ractice courses will be used as appropriate.

Advanced Nursing Practice

A National Framework

2008

www.cna -aiic .ca

3his document has been prepared by 56A in the pursuit of 56A:s mission, vision and goals. 4t has been approved by the 56A >oard of Directors. All rights reserved. ,ermission to photocopy or download for individual use is granted. Further reproduction in any manner, including posting to a website, is prohibited without prior written permission of the publisher. ,ermission may be obtained by contacting 56A at permissionsHcna-aiic.ca. I 5anadian 6urses Association (@ Driveway Fttawa, F6 J!, 1"! 3el.. *1#-!#+-!1## or 1-0@@-#*1-0$@$ Fax. *1#-!#+-#(!@ www.cna-aiic.ca February !@@0 4S>6 2+0-1-((112- !1!-#

Contents

4ntroduction . . . "volution of Advanced 6ursing ,ractice Definition and 5haracteristics . . . Definition . . . 5haracteristics . . . "ducational ,reparation 1oles 1egulation 5ompetencies . . . 5linical 5ompetencies . . . 1esearch 5ompetencies Aeadership 5ompetencies 5onsultation and 5ollaboration 5ompetencies . . . 4mpact of Advanced 6ursing ,ractice Support for Advanced 6ursing ,ractice . . . Aoo/ing to the Future . . . ;lossary Appendix A. ,",,A Framewor/ Appendix >. 3he 5onsultation ,rocess Appendix 5. <embers of the 6ational Eor/ing ;roup . . . 1eferences

1 ( 2 1@ 1@ 1# 1( 12 !1 !! !# !$ !* !2 ## #+ $@ $! $# $$ $(

Advanced Nursing 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. t involves anal!zing and s!nthesizing knowledge" understanding, interpreting and appl!ing nursing theor! and research" and developing and advancing nursing knowledge and the profession as a whole.

ntroduction

Society and its health-care needs are always evolving. As a result, health care in 5anada today faces many challenges, including rising costs, shortages of professionals, an aging population, the introduction of new technology and difficulties with access to care. 3he demand for collaborative, innovative clinical practitioners to act as leaders in health care has never been stronger.

Advanced Nursing Practice : A National Framework

Society and its health-care needs are always evolving. As a result, health care in 5anada today faces many challenges, including rising costs, shortages of professionals, an aging population, the introduction of new technology and difficulties with access to care. 3he demand for collaborative, innovative clinical practitioners to act as leaders in health care has never been stronger. 6urses in advanced nursing practice are well positioned to respond to the evolution of health care. 4n particular, advanced nursing practice plays a /ey role in meeting the health needs of 5anadians, by building nursing /nowledge, advancing the nursing profession and contributing to a sustainable and effective health-care system. 3he >oard of Directors of the 5anadian 6urses Association %56A& approved the /ey elements of a national framewor/ for advanced nursing practice in Dune 1222. 3he first edition of Advanced 6ursing ,ractice. A 6ational Framewor/ was published in <ay !@@@. 3hat 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. 3he framewor/ was deliberately broad, in part to allow for variations among jurisdictions and in part to allow for evolution of advanced nursing practice roles. 4n <arch !@@!, the 56A >oard of Directors revised one of ...advanced nursing practice pla!s a ke! role in meeting the health needs of Canadians , b! building nursing knowledge , advancing the nursing profession and contributing to a sustainable and effective health -care s!stem . 3he overall objective of this national framewor/ is to promote a common understanding of advanced nursing practice in 5anada and the /ey elements of the framewor/ by establishing a graduate degree in nursing as the minimum educational re9uirement for advanced nursing practice.

1 Terms defined in the glossary are resented in italics on first a

earance in the te!t"

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Advanced Nursing Practice : A National

thereby to increase consistency in role definition, curricula and competency development. 3he framewor/ has already been used for a variety n #arch $ % % $ , the CNA &oard of 'irectors revised one of the ke! elements of of purposes, including developing educational courses, outlining concepts for research, shaping government position statements and interpreting advanced nursing practice for employers, the public, the framework b! establishing a graduate degree in nursing as the minimum educational re(uirement for

advanced nursing practice .

other health-care wor/ers and policy-ma/ers. 4n !@@(, 56A organi)ed the Dialogue on Advanced 6ursing ,ractice to bring together nursing sta/eholders - including educators, policy-ma/ers, administrators and representatives of nursing organi)ations - 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 . ,articipants identified the national framewor/ for advanced nursing practice as a useful guide in the continued development of this form of practice in 5anada and recommended that it be updated periodically to respond to the needs of its users and to reflect changes in health-care system environments. 3he 5anadian 6urse ,ractitioner 4nitiative, launched in !@@$, helped in the development of a framewor/ for the integration and sustainability of the nurse practitioner role in 5anada:s health-care system. 1ecommendations for practice, education, legislation and regulation, and health human resources planning were considered in the current revision of the advanced nursing practice framewor/.

Advanced Nursing Practice : A National Framework

3he advanced nursing practice framewor/ contains the following /ey elements. 7 evolution of advanced nursing practice 7 definition and characteristics 7 educational preparation 7 roles 7 regulation 7 competencies 7 impact of advanced nursing practice 7 support for advanced nursing practice

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Advanced Nursing Practice : A National

)volution of Advanced Nursing Practice

Advanced nursing practice has emerged over the past decades as health-care systems and governments around the world have come to recogni)e Kthat optimi)ing the nursing contribution to health care through expanding their role is an effective strategy for improving health servicesL %Schober ? Affara, !@@*, p. !&.

Advanced Nursing Practice : A National Framework

Nurses can choose from a variet! of diverse and e(uall! valuable practice opportunities , of which advanced nursing practice is one . Advanced nursing practice! has emerged over the past decades as health-care systems and governments around the world have come to recogni)e Kthat optimi)ing the nursing contribution to health care through expanding their role is an effective strategy for improving health servicesL %Schober ? Affara, !@@*, p. !&. 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. 4n particular, advanced nursing practice involves the sophisticated use of /nowledge and s/ills %Daly ? 5arnwell, !@@#, p. 1*#&. 3wo advanced nursing practice roles are recogni)ed in 5anada today. the clinical nurse specialist and the nurse practitioner. 3hese two roles evolved from different roots. 5linical nurse specialists first emerged in the 12+@s as client care grew more complex. 3heir role was to provide clinical guidance and leadership to nursing staff managing complex care, to improve the 9uality of care and to promote evidence-based practice. 5utbac/s in the 120@s and 122@s led to the elimination of many of these positions, but as concern over the 9uality of care builds in the early !1st century, there is reason to believe that the clinical nurse specialist role will regain prominence.

4n 5anada, the origin of the nurse practitioner lies in the wor/ of nurses who, decades ago, provided care that was otherwise unavailable in rural and remote areas. 6urse practitioners gained formal recognition in the 12+@s, when this role was recommended by policyma/ers as a way of providing health care to isolated populations. "ducation programs were started,

2 Advanced nursing ractice is used &y 'NA as the um&rella term for the advanced level of clinical ractice descri&ed in this framework( individuals in advanced nursing ractice roles are referred to in this document as advanced ractice nurses" Nurses refers to registered nurses"

) Framework

Advanced Nursing Practice : A National

Canadian advanced practice nurses have but a perceived oversupply of physicians, a lac/ of enabling legislation and problems related the education , clinical expertise , leadership skills and understanding of organizations , health polic! and decision -making to pla! an important role in client and health -care s!stem outcomes now and in the future . to remuneration caused interest to wane. 4nterest was re/indled in the 122@s by health-care reform, an increased demand for access to primary health care and the need for integrated care. 3he 5anadian 6urse ,ractitioner 4nitiative was launched in !@@$ to develop a pan5anadian framewor/ to encourage full integration of nurse practitioners into 5anadian health care.

As demand, technology and /nowledge change the ways in which health care is delivered, interest in advanced nursing practice is on the rise. 3rends in the delivery of health care are providing opportunities for nurses to expand current roles and create new ones. 6urses can choose from a variety of diverse and e9ually valuable practice opportunities, of which advanced nursing practice is one. As nurses move along the continuum of experience and education, they ac9uire additional competencies that become incorporated into their practice. 3his evolution enables nurses to contribute to the health-care system in new ways.

Although all nurses contribute to the health-care system through their wor/ in clinical practice, education, administration, research and policy, advanced nursing practice focuses on the clinical domain in a wide array of practice settings. 5linical practice not only incorporates direct client care but also involves a supportive and consultative role. 5anadian advanced practice nurses have the education, clinical expertise, leadership s/ills and understanding of organi)ations, health policy and decisionma/ing to play an important role in client and health-care system outcomes now in the future. and

Advanced Nursing Practice : A National Framework

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Advanced Nursing Practice : A National

'efinition and Characteristics

'efinition

Advanced nursing practice is an umbrella term describing an advanced level of clinical nursing practice that maximi)es the use of graduate educational preparation, in-depth nursing /nowledge and expertise in meeting the health needs of individuals, families, groups, communities and populations.

Advanced Nursing Practice : A National Framework

'efinition

Advanced nursing practice is an umbrella term describing an advanced level of clinical nursing practice that maximi)es the use of graduate educational preparation, in-depth nursing /nowledge and expertise in meeting the health needs of individuals, families, groups, communities and populations. 4t involves. 7 analy)ing and synthesi)ing /nowledge 7 understanding, interpreting and applying nursing theory and research and 7 developing and advancing nursing /nowledge and the profession as a whole.

Characteristics

4n advanced nursing practice, nurses build on their expertise in a specialty area, integrating and consistently displaying the following features and

characteristics. 7 provision of effective and efficient care, delivered with a high degree of autonomy, to an identified population 7 demonstration of leadership and initiation of change to improve client, organi)ation and system outcomes 7 deliberate, purposeful and integrated use of in-depth nursing /nowledge, research and clinical expertise, as well as integration of /nowledge from other disciplines 7 depth and breadth of /nowledge that draws on a wide range of strategies to meet the needs of clients and to improve access to and 9uality of care 7 ability to explain and apply the theoretical, empirical, ethical and experiential foundations of nursing practice

10

Advanced Nursing Practice : A National

Framework

7 understanding, development and dissemination of evidence-based nursing /nowledge 7 ability to initiate or participate in planning, coordinating, implementing and evaluating programs to meet client needs and support nursing practice 7 use of /nowledge-transfer techni9ues to put research-based /nowledge into practice 7 demonstration of advanced judgment and decision-ma/ing s/ills and 7 critical analysis of and influence on health policy.

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Advanced Nursing Practice : A National

)ducational Preparation

3he 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 /nowledge and use academic preparation, synthesis and /nowledge-transfer s/ills to interpret and incorporate new /nowledge into clinical practice.

Advanced Nursing Practice : A National Framework

1#

3he 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 /nowledge and use academic preparation, synthesis and /nowledgetransfer s/ills to interpret and incorporate new /nowledge 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. 4t is the combination of graduate education and clinical experience that allows nurses to develop the competencies re9uired in advanced nursing practice. Ai/e all nurses, advanced practice nurses are committed to lifelong learning. 4n 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 Nursing Practice : A National

*oles

Advanced nursing practice focuses on clinical practice, whether through a direct relationship with clients or through a supportive and consultative role. 6urse 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 Nursing Practice : A National Framework

1%

Advanced nursing practice focuses on clinical practice, whether through a direct relationship with clients or through a supportive and consultative role. 6urse 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. Fnly two advanced nursing practice roles are recogni)ed in 5anada today. the clinical nurse specialist and the nurse practitioner. 3hese two roles are fundamentally different. 5linical nurse specialists provide expert nursing care for speciali)ed client populations. 3hey 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 1egistered 6urses of 6ewfoundland and Aabrador, !@@+&. 4n contrast, nurse practitioners provide direct care focusing on health promotion and the treatment and management of health conditions. 3hey are Kregistered 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 practiceL %56A, !@@*a&.

+ith a focus on health promotion and disease prevention , both the clinical nurse specialist and the nurse practitioner ,enhance the provision of timel! , accessible , cost -effective and (ualit! health care for all Canadians .CNA , $ % % / b , p . 0 1 .

1) Framework

Advanced Nursing Practice : A National

,2he clinical nurse specialist pla!s 5linical nurse specialists and nurse practitioners spend different amounts of time providing direct clinical care, but both roles incorporate education, research, consultation and leadership components. 5lient, organi)ation and system needs will help to shape and determine the role of individual clinical nurse specialists and nurse practitioners. Eith a focus on health promotion and disease prevention, both the clinical nurse specialist and the nurse practitioner Kenhance the provision of timely, accessible, cost-effective and 9uality health care for all 5anadiansL %56A, !@@*b, p. #&. 4t is anticipated that new advanced nursing practice roles will develop to meet the existing and emerging health-care needs of 5anadians. For example, several jurisdictions are exploring an advanced nursing practice role within anesthesia care. ,A nurse than practitioner replaces complements other health a pivotal role in the provision of safe , effective , evidence -based care , supporting nurses to ensure that the! maximize their skills and abilities . , -ernadine .allis/ clinical nurse s ecialist .inni eg/ 0anito&a

rather

care providers , bridges the gap in service deliver! for patients , expands care options , and supports a shift to wellness -based care . , 0ary Nugent/ nurse ractitioner Ta&er/ Al&erta

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Advanced Nursing Practice : A National

*egulation

A framewor/ 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-9uality nursing services across the country. 4t will also facilitate labour mobility for advanced practice nurses who are subject to

specific provincial or territorial legislation.

Advanced Nursing Practice : A National Framework

1+

A framewor/ 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-9uality nursing services across the country. 4t 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 re9uired because they practise within the scope of registered nursing in their respective jurisdictions. 4n some cases, the scope of practice includes additional responsibilities,

such as prescriptive authority, that may re9uire additional regulatory authority, but these

additional authorities are all within the scope of practice of nursing. 3he regulation of nursing practice is intended to safeguard the public by ensuring that nurses meet standard levels of /nowledge and education. 4n 5anada, regulatory titles, including Kregistered nurseL and K16,L are protected, but other titles, such as Knurse,L Knurse practitionerL and K6,,L may or may not be protected according to the legislation of specific jurisdictions. 5urrently, the only advanced nursing practice 20

A framework describing advanced nursing practice allows for a coordinated national approach , permits flexibilit! among provinces and territories , and allows new roles to develop .

role with additional regulation and title protection in 5anada is the nurse practitioner, although the specific title used varies among the provinces and territories. As new roles in advanced nursing practice emerge, they may or may not re9uire additional legislation and regulation.

Advanced Nursing Practice : A National Framework

Competencies

5ompetencies are the specific /nowledge, s/ills, judgment and personal attributes re9uired for a registered nurse to practise safely and ethically in a designated role and setting %56A, !@@(&. 5ore competencies for advanced nursing practice are based on an appropriate depth, breadth and range of nursing /nowledge, theory and research, enhanced by clinical experience.

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21

5ompetencies are the specific /nowledge, s/ills, judgment and personal attributes re9uired for a registered nurse to practise safely and ethically in a designated role and setting %56A, !@@(&. 5ore competencies for advanced nursing practice are based on an appropriate depth, breadth and range of nursing /nowledge, theory and research, enhanced by clinical experience.# 3hey cut across specialty lines and are exhibited by all advanced practice nurses. 3his framewor/ separates competencies into four categories. clinical, research, leadership, and consultation and collaboration. Gowever, it is the effective and simultaneous interaction, blending and execution of /nowledge, s/ills, judgment and personal attributes in a wide variety of practice environments that characteri)es advanced nursing practice.

Clinical Competencies

3he cornerstone of advanced nursing practice is expertise in a speciali)ed area of nursing. 3hrough a holistic and integrated approach, the nurse wor/s 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 /nowledge to. 7 develop multiple advanced assessment and intervention strategies within a client-centred framewor/ for individual clients, communities and populations 7 use 9ualitative and 9uantitative data from multiple sources, often in ambiguous and complex situations, when ma/ing clinical decisions and initiating and managing change 7 analy)e the complex interaction of sociological, psychological and physiological processes, determinants of health and clients: lived experience

# 'om etencies s ecific to the nurse ractitioner role and res onsi&ilities are identified in 'anadian Nurse Practitioner: 'ore 'om etency Framework 1'NA/ 200%2"

22 Framework

Advanced Nursing Practice : A National

7 anticipate and explain the wide range of client responses to actual or potential health problems and recommend action 7 guide decision-ma/ing in complex clinical situations 7 engage clients and other team members in resolving issues at the individual, organi)ational and health-care system levels 7 identify and assess trends or patterns that have health implications for individuals, families, groups or communities 7 generate and incorporate new nursing /nowledge and develop new standards of care, programs and policies 7 plan, initiate, coordinate and conduct educational programs based on needs, priorities and organi)ational resources and 7 manage a wide range of patient responses to actual and potential health problems.

*esearch Competencies

;enerating, synthesi)ing and using research evidence is central to advanced nursing practice. An advanced practice nurse is able to. 7 identify and implement research-based innovations for improving client care, organi)ations or systems 7 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 Nursing Practice : A National Framework

2#

Advanced practice nurses are leaders in the organizations where and the! 7 collect data on, and evaluate the outcomes of, advanced nursing practice for clients, the nursing profession and the health-care system 7 criti9ue, interpret, apply and disseminate evidence-based findings and 7 contribute to nursing and the health-care system by disseminating new /nowledge through formal and informal channels, including presentation and publication at the local, regional, national and international levels. 7 evaluate current practice at individual and system levels in light of research findings

communities work .

3eadership Competencies

Advanced practice nurses are leaders in the organi)ations and communities where they wor/. 3hey are agents of change, consistently see/ing effective new ways to practise, to improve the delivery of care, to shape their organi)ations, to benefit the public and to influence health policy. An advanced practice nurse demonstrates leadership by. 7 advocating for individuals, families, groups and communities in relation to treatment, the health-care system and policy decisions that affect health and 9uality of life 7 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 7 mentoring and coaching nursing colleagues, other members of the healthcare team, and students 7 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-ma/ers

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Advanced Nursing Practice : A National

7 contributing to and advocating for an organi)ational culture that supports professional growth, continuous learning and collaborative practice 7 evaluating programs in the organi)ation and the community and developing innovative approaches to complex issues 7 understanding and integrating the principles of resource allocation and cost-effectiveness in organi)ational and system-level decision-ma/ing 7 identifying gaps in the health-care system and developing partnerships to facilitate and manage change 7 developing and clearly articulating a vision for nursing practice, influencing and contributing to the organi)ation:s and the health-care system:s vision and implementing approaches to reali)e that vision 7 advising clients, colleagues, the community, health-care institutions and policy-ma/ers on issues related to nursing, health and health care 7 identifying problems and initiating change to address challenges at the individual, organi)ational or system level and 7 understanding legislative and socio-political issues that influence health policy, and building strategies to improve health, health-care access and healthy public policy.

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Consultation and Collaboration Competencies "ffective collaboration and communication with clients and others on the health-care team represent important aspects of any nursing practice. 3he ability to consult and collaborate with colleagues across sectors and at the organi)ational, provincial, national and international level is a characteristic of nurses in advanced practice. A nurse in advanced practice is able to. 7 initiate timely and appropriate consultation, referrals and collaboration with other health-care providers 7 consult and collaborate with members of the health-care team to develop 9uality-improvement and ris/-management strategies 7 wor/ with others to gather and synthesi)e 9ualitative and 9uantitative information on determinants of health from a variety of sources 7 practise collaboratively and build effective coalitions 7 apply theories related to group dynamics, roles and organi)ations

,Collaboration is a complex process re(uiring knowledge sharing and 4oint responsibilit! for patient care , management and outcomes . , 3andra 4uke/ nurse ractitioner 5alifa!/ Nova 3cotia

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Advanced Nursing Practice : A National

7 demonstrate /nowledge and s/ill in communication, negotiation and conflict resolution, including the ability to analy)e, manage and negotiate conflict 7 clearly articulate the contribution of advanced nursing practice within the interprofessional health-care team 7 participate in collaborative projects with academic institutions and maintain cross-appointments and 7 advocate for changes in health policy by participating on regional, provincial' territorial, and federal committees that influence decision-ma/ing at those levels.

Advanced Nursing Practice : A National Framework

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28 Framework

Advanced Nursing Practice : A National

mpact of Advanced Nursing Practice

Advanced nursing practice has evolved to meet the demands of modern health care through increasingly advanced /nowledge and s/ills. 4t 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.

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Advanced practice nurses have used their experience and education to take nurs ing practice to new levels , as the! have moved from a supportive to a leading role in client care . Advanced nursing practice has evolved to meet the demands of modern health care through increasingly advanced /nowledge and s/ills. 4t 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 practice nurses have used their experience and education to ta/e nursing practice to new levels, as they have moved from a supportive to a leading role in client care. "vidence about the benefits of advanced nursing practice is now building. 5unningham %!@@$, p. !12& has stated that nurses in advanced nursing practice KenrichL health care by

adding value to the delivery of health-care services. >ryant-Au/osius, Di5enso, >rowne and ,inelli %!@@$, p. (!*& found that advanced practice nurses may improve client and health-care system outcomes related to health status, functional status, 9uality of life, satisfaction with care and cost efficiency. De;rasse and 6ic/lin %!@@1, p. 0& 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 research practice and through the education, of department visits, shortened lengths of stay and resulted in cost savings for the institutions where they were employed. Fther outcomes that improved with advanced nursing practice included fewer readmissions for heart failure, shorter lengths of stay when patients were readmitted and lower rates of urinary tract infections, s/in brea/down and pneumonia %Jleinpell, !@@+, p. !@&. Jleinpell also , 6rlene 3ea&orne/ clinical nurse s ecialist 5amilton/ 7ntario reported that advanced nursing practice helped promote evidence-based care, improved patients:

development

s!stems that meet patient and famil! needs . -

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,Clinical nurse specialists support and teach other health -care providers and adherence to health promotion and built the evidence base of nursing. Advanced nursing practice is an innovative and exciting development that provides nurses with an opportunity to wor/ at an advanced level of clinical practice %Furlong ? Smith, !@@(, p. 1@*!&. 3he role of the nurse practitioner has been studied for many years. 4n a literature review commissioned by the 5ollege of 1egistered 6urses of 6ova Scotia and released in Dune !@@+, Sangster-;ormley reported that client satisfaction and education are the most commonly researched outcomes of nurse practitioner care. Gowever, the author went on to describe solid evidence for many other benefits to care. nurse practitioners are more li/ely to follow practice guidelines, and their patients have shorter stays, fewer readmissions and other successful outcomes. 3he body of research on advanced nursing practice is smaller than is the case for many can influence and improve health care at the individual and the s!stem level . , 8inda 9ead Paul/ clinical nurse s ecialist 'algary/ Al&erta

other topics in nursing. 4n another review of recent research, Ferman and Floyd %!@@!, p. 1$@& identified and described this lac/ of evidence. 3hey found that research

on outcomes has focused too much on cost savings, ignoring important aspects of the wor/ of advanced practice nurses such as resolution of symptoms, enhancement of clients: 9uality of life and improvements in /nowledge among patients and families. 3hey called for advanced practice nurses to lead more research on the results of specific nursing interventions. For their annotated bibliography, published in !@@$, Fulton and >aldwin reviewed +@ research papers that had been written by nurses or had examined the impact of clinical nurse specialists. Fulton and >aldwin 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

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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. ,erhaps the most important aspect of the article was the scope of information it covered. in addition to the research pieces, the authors reviewed #1 publications about program development and evaluation and !( anecdotal accounts. 3hese numbers are a sign that the /nowledge base for advanced nursing practice is building, but Fulton and >aldwin %!@@$, p. !!& warned that Kalthough the number of articles had drastically increased, the scope of everyday Bclinical nurse specialistC accomplishments is not completely captured in published wor/. B5linical nurse specialistsC improve care practice on a daily basis.L

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5upport for Advanced Nursing Practice

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, organi)ations and the community as a whole.

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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, organi)ations and the community as a whole. 3he 8niversity Gealth 6etwor/ Framewor/ for Advanced 6ursing ,ractice states that Ksignificant challenges have emerged in role implementation and development, as a result of inconsistent professional and organi)ational support for Badvanced nursing practiceC. 1ole clarity, demonstrated value and consistent support have been identified in the literature as /eys to successful role implementationL %<icevs/i et al., !@@$, p. (#&. 3o flourish, advanced nursing practice needs. 7 leadership by 56A, other nursing organi)ations and governments to encourage creation of positions for nurses in this type of practice 7 leadership by 56A and other nursing organi)ations to identify opportunities for the introduction of future advanced nursing practice roles that align with current and emerging population health and system needs 7 health human resources planning that ta/es a pan-5anadian, interprofessional approach and that is based on a conceptual framewor/ 7 organi)ational and administrative support and resources to implement, develop and sustain various aspects of advanced nursing practice 7 communication and education tools to inform the public, policy-ma/ers, administrators and other professions about the contributions of advanced nursing practice 7 human resources policies that allow nurses to pursue graduate education 7 specially designed graduate curricula based on the characteristics and competencies of advanced nursing practice 7 flexible pathways to graduate nursing education

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7 support for professional development and lifelong learning 7 funding for research about and by nurses in advanced nursing practice 7 interprofessional education and organi)ations that foster team wor/ 7 resources to put in place the positions, technology, administrative infrastructure and culture for advanced practice nurses to wor/ most effectively and 7 policy processes that promote advanced nursing practice and are shaped by the expertise of advanced practice nurses.

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#) Framework

Advanced Nursing Practice : A National

3ooking to the 6uture

5anada:s 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. 3o have a farreaching impact, however, advanced nursing practice must be promoted and sustained.

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5anada:s 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. 3o have a far-reaching impact, however, advanced nursing practice must be promoted and sustained. 6ew advanced nursing practice roles should be introduced only in response to the healthcare needs of 5anadians and must be based on solid evidence of those needs. 56A:s position statement 6ational ,lanning for Guman 1esources in the Gealth Sector states that needs-based planning anticipates health needs on the basis of Kdemographic,

epidemiological, and cultural factorsL and includes benchmar/ing for regional variation and review of specialty mix within and between disciplines %56A, !@@*c&. New approaches to health care , based on strategies that will enhance access to service deliver! while improving the health of the population , must be developed collaborativel! . ,rogress has been made in providing guidelines for the introduction and evaluation of advanced nursing practice roles %>ryant-Au/osius ? Di5enso, !@@$, p. (#1 Einnipeg 1egional Gealth Authority, !@@(, !@@*&. 4n particular, >ryantAu/osius and Di5enso %!@@$, p. (#!& presented the ,",,A framewor/, a Kparticipatory, evidence-based, patient-centred process for Badvanced nursing practiceC role development, implementation and evaluation,L which set out nine steps for determining whether a new advanced nursing practice role is needed and whether it will be effective. 3hese 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. 3he 5anadian 6urse ,ractitioner 4nitiative includes an implementation and evaluation tool/it, which serves as a practical guide to assessing the need and readiness for the nurse practitioner role. 4n addition, the tool/it identifies /ey steps and factors to support the implementation of this role and ongoing monitoring of its effectiveness through a

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structured, forward-loo/ing evaluative approach. 4n particular, the tool/it offers guidance on tailoring the planning, implementation and evaluation of the nurse practitioner role to the uni9ue re9uirements of specific practice settings. 3he design of the tool/it was based on the ,",,A framewor/, extensive literature review and experimental research, /ey sta/eholder consultation and a review of best practices %56A, !@@*d&. 4n addition, a needs-based simulation model for health human resources planning was developed in conjunction with the 5anadian 6urse ,ractitioner 4nitiative this model is applicable to primary health care nurse practitioners across all jurisdictions in 5anada. 4t 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 re9uired to meet those needs %56A, !@@*e&. 5oordination of the preparation and roles for advanced nursing practice is another necessary step. 3he 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. 3he goal must be to ensure that all 5anadians have access to similar types of expertise. 3o effectively develop and sustain the health-care system, the roles of health-care providers, including advanced practice nurses, must be optimi)ed. 5anadians can anticipate many new challenges to their health-care system, including increases in chronic diseases such as diabetes mellitus and arthritis. 6onetheless, 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 %Milleneuve ? <acDonald, !@@*&. Advanced practice nurses must be part of the solution to these health-care challenges and the changes that lie ahead. 6ew 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. Eith commitment and an understanding of its importance at all levels of health care, advanced nursing practice can play a /ey role in meeting the health needs of 5anadians, building nursing /nowledge and contributing to a sustainable and effective health-care system.

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7lossar!

Advanced nursing practice 8mbrella term for an advanced level of clinical nursing practice that maximi)es the use of graduate educational preparation, in-depth nursing /nowledge and expertise in meeting the health needs of individuals, families, groups, communities and populations. 4t involves. 7 analy)ing and synthesi)ing /nowledge 7 understanding, interpreting and applying nursing theory and research and 7 developing and advancing nursing /nowledge and the profession as a whole. 5lient 3he beneficiary of care may be an individual, family, group, population or entire community

5lient-centred care K6urses achieve client-centred care by actively including the client and significant others as partners in the care, Band byC identifying the client:s goals, wishes and preferences and ma/ing these the basis of the plan of care...L %5ollege of 6urses of Fntario, !@@*& 5linical nurse specialist A registered nurse who holds a master:s or doctoral degree in nursing with expertise in a clinical nursing specialty uses in-depth /nowledge and s/ills, advanced judgment and clinical experience in a nursing specialty to assist in providing solutions for complex health-care issues 5ompetencies

5redentials

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4ntegrated /nowledge, s/ills, judgment and personal attributes re9uired of a registered nurse to practise safely and ethically in a designated role and setting %56A, !@@(& <ar/s or KstampsL of 9uality and achievement communicating to employers, payers and consumers what to expect from a KcredentialedL nurse, specialist course or program of study, institution of higher education, hospital or health service, or health-care product, technology or device

Adva nced Nursi ng Pract ice : A Natio nal Fram ewor k

;raduate education "ducation beyond the baccalaureate level, including master:s, doctoral and postdoctoral levels %Field, Stinson ? 3hibaudeau, 122!& <entoring A voluntary, mutually beneficial, long-term relationship in which an experienced and /nowledgeable leader %the mentor& supports the maturation of a less experienced nurse with leadership potential %the KmenteeL&

6urse 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 %56A, !@@*a& 1egulation 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, 122+&

Scope of nursing practice 3he activities that nurses are educated and authori)ed to perform, as established through legislated definitions of nursing practice, complemented by standards, guidelines and policy positions issued by professional nursing bodies %56A, !@@(& Speciali)ed practice ,ractice that concentrates on a particular aspect of nursing, related to the client:s age %e.g., pediatrics, gerontology&, the client:s 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&

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Appendix A

P)PPA 6ramework

Participator!, evidence-based, patient-centred process for advanced practice nurse 8APN9 role development, implementation and evaluation

From: -ryant,8ukosius/ 4"/ : 4i'enso/ A" 1200$2" A framework for the introduction of an evaluation of advanced ractice nursing roles" ;ournal of Advanced Nursing/ $8 1%2/ %#0,%$0" 9e rinted with the ermission of -lackwell Pu&lishing"

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Appendix &

2he Consultation Process

3he >oard of Directors of the 5anadian 6urses Association %56A& approved the /ey elements of a national framewor/ for advanced nursing practice in Dune 1222. 3he framewor/ was first published in <ay !@@@ in Advanced 6ursing ,ractice. A 6ational Framewor/. 4n <arch !@@!, the 56A >oard of Directors revised one of the /ey elements of the framewor/ by establishing a graduate degree in nursing as the minimum educational re9uirement for advanced nursing practice 5hanges in practice that emerged during 56A:s !@@( Dialogue on Advanced 6ursing ,ractice and the 5anadian 6urse ,ractitioner 4nitiative %!@@$-@*& signalled the need to update 56A:s framewor/ on advanced nursing practice. 4n !@@*, the 56A >oard of Directors created a national wor/ing group to guide revision of the framewor/. 4ts 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 organi)ations. 4n addition, a discussion of the draft framewor/ by the 56A >oard of Directors helped to guide the final version. Feedbac/ from the consultation process was extensive. Gundreds of responses were received from associations, organi)ations and individual nurses. Although views on specific

aspects of the framewor/ differed, there was strong consensus on the /ey concepts for advanced nursing practice. 3a/ing into consideration the feedbac/ received and the consensus recommendations from the national wor/ing group, the 56A >oard of Directors approved the updated framewor/ for advanced nursing practice in 6ovember !@@+.

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Appendix C

#embers of the National +orking 7roup

Co-Chairs 5hristine 1iec/ >uc/ley Debbie ,hilipchu/ #embers Jaren Antoni ;ail >eatty <ichNle >rennan Su)anne Durand Stephen Aec/ Francis Aoos >etty Aundrigan ,atricia <c;arr >la/e ,ar/in 5heri Migar >arb Eaters Do Eearing Doug Eheeler Doanne Einsor 5anadian Association of Advanced ,ractice 6urses 1egistered 6urses: Association of Fntario 5ollege of 1egistered 6urses of 6ova Scotia Frdre des infirmiNres et infirmiers du OuPbec 1egistered 6urses Association of 6orthwest 3erritories and 6unavut Sas/atchewan 1egistered 6urses: Association Association of 1egistered 6urses of 6ewfoundland and Aabrador Qu/on 1egistered 6urses Association Association of 1egistered 6urses of ,rince "dward 4sland 5ollege of 6urses of Fntario 6urse ,ractitioner 5ouncil of 5anada 5ollege of 1egistered 6urses of >ritish 5olumbia 6urses Association of 6ew >runswic/ 5ollege of 1egistered 6urses of <anitoba 5anadian 6urses Association 5ollege ? Association of 1egistered 6urses of Alberta

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*eferences

Association of 1egistered 6urses of 6ewfoundland and Aabrador. %!@@+&. Advanced practice-clinical nurse specialist B,osition statementC. St. Dohn:s. Author. >ryant-Au/osius, D., ? Di5enso, A. %!@@$&. A framewor/ for the introduction and evaluation of advanced practice nursing roles. Dournal of Advanced 6ursing, $0%(&, (#@-($@. >ryant-Au/osius, D., Di5enso, A., >rowne, ;., ? ,inelli, D. %!@@$&. Advanced practice nursing roles. Development, implementation and evaluation. Dournal of Advanced 6ursing, $0%(&, (12-(!2. 5anadian 6urses Association. %!@@(&. 5anadian nurse practitioner. 5ore competency framewor/. Fttawa. Author. 5anadian 6urses Association. %!@@*a&. ,ractice framewor/ for nurse practitioners in 5anada. Fttawa. Author.

5anadian 6urses Association. %!@@*b&. 1eport of !@@( dialogue on advanced nursing practice. Fttawa. Author. 5anadian 6urses Association. %!@@*c&. 6ational planning for human resources in the health sector B,osition statementC. Fttawa. Author. 5anadian 6urses Association. %!@@*d&. 5anadian nurse practitioner initiative. 4mplementation and evaluation tool/it for nurse practitioners in 5anada. Fttawa. Author. 5anadian 6urses Association. %!@@*e&. Gealth human resources chapter. 4n. 5anadian nurse practitioner technical report. Fttawa. Author. 5ollege of 6urses of Fntario. %!@@*&. Aearning module. 3herapeutic communication and client-centred care. 3herapeutic 6urse-5lient 1elationship, 1evised !@@*, practice standard. 3herapeutic 5ommunication and 5lient-5entred 5are, slide 0. 1etrieved February +, !@@0, from http.''www.cno.org'prac'learn' modules'tncr'pdf'3651-5hapter#.pdf 5unningham, 1. S. %!@@$&. Advanced practice nursing outcomes. A review of selected empirical literature. Fncology 6ursing Forum, #1%!&, !12-!#@. Daly, E., ? 5arnwell, 1. %!@@#&. 6ursing roles and levels of practice. A framewor/ for differentiating between elementary, specialist and advancing nursing practice. Dournal of 5linical 6ursing, 1!, 1(0-1*+.

De;rasse, 5., ? 6ic/lin, E. %!@@1&. Advanced nursing practice. Fld hat, new design. 5anadian Dournal of 6ursing Aeadership, 1$%$&, +-1!.

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Field, ,. A., Stinson, S., ? 3hibaudeau, <-F. %122!&. ;raduate education in nursing in 5anada. 4n A. D. >aumgart ? D. Aarsen %"ds.&, 5anadian nursing faces the future. 3oronto. 5M <osby, 1220. Fulton, D., ? >aldwin, J. %!@@$&. An annotated bibliography reflecting 56S practice and outcomes. 5linical 6urse Specialist, 10%1&, !1-#2. Furlong, "., ? Smith, 1. %!@@(&. Advanced nursing practice. ,olicy, education and role development. Dournal of 5linical 6ursing, 1$, 1@(2-1@**. Jleinpell, 1. <. %!@@+&. A,6s. 4nvisible championsR 6ursing <anagement, #0%(&, 10-!!. <icevs/i, M., Jor/ola, A., Sar/issian, S., <ulcahy, M., Shobbroo/, 5., >elford, A., et al. %!@@$&. 3he 8niversity Gealth 6etwor/ framewor/ for advanced nursing practice. 6ursing Aeadership, 1+%#&, (!-*$. Ferman, <. G., ? Floyd, D. %!@@!&. Futcomes research. An essential component of the advanced practice nurse role. 5linical 6urse Specialist, 1*%#&, 1$@-1$$. Sangster-;ormley, ". %!@@+&. 6urse practitioner-sensitive outcomes. Galifax. 5ollege of 1egistered 6urses of 6ova Scotia. Schober, <., ? Affara, F. %!@@*&. Advanced nursing practice. ;eneva. 4nternational 5ouncil of 6urses. Styles, <. <., ? Affara, F. A. %122+&. 456 on regulation. 3owards a !1st century model. ;eneva. 4nternational 5ouncil of 6urses. Milleneuve, <., ? <acDonald, D. %!@@*&. 3oward !@!@. Misions for nursing. Fttawa. 5anadian 6urses Association. Einnipeg 1egional Gealth Authority. %!@@(&. A guide to the implementation of the nurse practitioner role in your health setting. Einnipeg. Author. Einnipeg 1egional Gealth Authority. %!@@*&. 4mprove patient care outcomes. Adding a clinical nurse specialist to your team. Einnipeg. Author.

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