Moving Towards Harmony: Exemplars of Advanced Nursing Practice for British Columbia

This paper reports the Phase II findings from a three-phase qualitative study on advanced nursing practice (ANP) in British Columbia, Canada. The study intent was to guide policy development regarding new and advanced nursing roles. Comparisons across five sites are presented in relation to (a) the evolution of the role, (b) educational preparation of nurses, (c) role responsibilities, (d) role impact and benefits, (e) supports and challenges to implementation, (g) understanding of the meaning of ANP and (h) congruence with the Canadian Nurses Association framework on advanced practice. The implications of these findings are discussed. Interest in the development of advanced nursing practice (ANP) roles has grown over the past decade in Canada. In British Columbia, there has been considerable interest by government, the nursing profession, healthcare organizations and communities in expanding the scope of nursing practice, developing new nursing roles to meet gaps in health services and providing cost-effective, accessible care to the citizens of the province, particularly to those whose access to healthcare is limited. As a result, we initiated a collaborative, three-phase research project, involving government decision-makers, researchers, healthcare employers and the nursing regulatory body to study the opportunities and challenges related to implementing new and advanced nursing roles in British Columbia (Schreiber et al. 2003). This is the second of three papers that report the findings of this study. The first paper (Schreiber et al. 2005a) was based on the findings from Phase I. In this paper, we report the Phase II findings of five qualitative case studies conducted in other jurisdictions to explore models of ANP that might be appropriate for implementation in British Columbia. The third paper (Schreiber et al. 2005b) describes the results of a think tank in which we brought together stakeholders to report and discuss the findings from Phases I and II and to obtain their guidance in formulating policy recommendations for new and/or advanced nursing roles in the province. Jane Crickmore, RN, MPA Public Health Nursing Consultant Disease and Injury Prevention Branch BC Ministry of Health Planning Victoria, BC Carolyn Hammond, RN, MN Practicum Coordinator, School of Nursing University of Victoria, BC In the first paper in this series, we commented on discrepancies in the literature regarding use of the terms “advanced nursing practice” (ANP) versus “advanced practice nursing” (APN), and we defined these terms. We also explained that we are using the term ANP because it was the prevalent and agreed-upon term by the CNA and nursing regulatory bodies in Canada at the time we began our study, and it is the term most consistent with our research process and data. At the same time, we agree that there is a need to move towards consistency in language. We refer the reader to our first paper (Schreiber et al. 2005a) for the full explanation. Background A number of ANP roles are well established in the United States, including clinical nurse specialist (CNS), advanced rural nurse practitioner (ARNP), nurse practitioner (CRNP), certified nurse midwife (CNM) and certified registered nurse anaesthetist (CRNA) (Hamric et al. 2000). More recently, a combined clinical nurse specialist–nurse practitioner (CNS-NP) role has emerged (Skalla and Hamric 2000), and the development of the case manager as an ANP role is evolving (Mahn and Zazworsky 2000), although the expansion of these roles has not proceeded without concern. For example, the merging of the CNS and NP roles has been challenged (Deane 1997; Donagrandi and Eddy 2000). The development of ANP roles has moved more cautiously in Canada, with considerably more involvement from professional nursing bodies than in the United States. In part, this occurred because of concern in the Canadian profession about maintaining the nursing focus of advanced practice. Thus, nursing associations tended not to pursue the development of NP roles in which the scope of practice overlapped with that of medicine. In contrast, although professional nursing bodies in the United States now embrace all ANP roles, however, the initiation of various roles applies only to the CNS role (developed in response to the more medically oriented NP role) and to the CRNA role (which predated that of the NP) (Schreiber et al. 2003). The CNS role is the best-established advanced practice role in Canada and, until recently, was the only officially recognized advanced role in British Columbia (Davies and Eng 1995; Schreiber et al. 2003). As suggested above, the NP role has had a variable and uncertain history in this country (Nurse Practitioner Association of Ontario 2003). It appears, however, that the NP role is now becoming established in several provinces in both primary and acute care settings (CNA 2003). For the most part, at least until recently, only acute care nurse practitioners (ACNPs) have been prepared at the graduate level. Midwifery in this country has emerged as a discipline regulated separately from nursing. The nurse anaesthetist role does not currently exist in Canada; however, we have recently proposed that it be explored for implementation in this country (Schreiber and MacDonald 2003). Moving Towards Harmony: Exemplars of Advanced Nursing Practice for British Columbia 3

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