Singing in Different Keys: Enactment of Advanced Nursing Practice in British Columbia

Abstract

This paper reports on Phase I findings from a three-phase qualitative study on advanced nursing practice in British Columbia. The intent of the study was to guide policy development regarding new and/or advanced nursing roles, and this first phase explored the current understanding of and perceived need for advanced nursing practice roles in British Columbia. Key findings include widespread interest in and confusion about advanced nursing practice; marked variation in the roles, educational background and authority to practise of self-identified advanced practice nurses; and underutilization of registered nurses within the BC healthcare system. In the past decade, interest in advanced nursing practice (ANP) roles, such as that of nurse practitioner, has accelerated in Canada as employers and governments seek efficiencies in delivery of healthcare services (Alcock 1996; Commission on the Future of Health Care in Canada 2002; Howlett and Tamlyn 1999). This growing interest has occurred in spite of confusion about what APN is and how it relates to specialty, extended or expanded nursing roles (Alcock 1996; Manning 1999). In this paper, we report on the qualitative findings from Phase I of a three-phase study designed to inform policy direction regarding advanced nursing practice roles (Schreiber et al. 2003). Background Healthcare in Canada is in flux. Cost pressures, provider shortages, system restructuring and increased patient acuity, chronicity and complexity in institutions and communities have led to increased interest in ANP roles (Commission on the Future of Health Care in Canada 2002; Dunn and Nicklin 1995; Goss Gilroy 2001; National Forum on Health 1997). Nurses working in ANP roles provide appropriate and cost-effective continuity of care (Carter 1997; DiCenso 1998; Horrocks et al. 2002; Safriet 1992) as well as education, support and mentorship for staff nurses and others with whom they work (CNA 2002; Irvine et al. 2000; Schreiber et al. 2003; Sidani et al. 2000). The problem, however, has been considerable confusion regarding definitions, roles, functions, competencies, appropriate practice environments, educational requirements, credentials, regulations and legislation required for ANP (Alcock 1996; Brown 1998; Manning 1999). This confusion reflects international debate regarding the nature and scope of ANP (Castledine 2002; Daly and Carnwall 2003; Redekop 1997; Rose et al. 2003; Scott 1999; Wilson-Barnett et al. 2000). Across Canada there are nurse practitioners, clinical nurse specialists, expandedand extended-role nurses and a variety of nurses with special job titles (e.g., diabetic nurse) (Alcock 1996; Manning 1999). Even within the same job title, there is confusion about the nature of advanced practice, particularly regarding the required educational preparation. For example, 139 of the 295 self-identified clinical nurse specialists (CNSs) in British Columbia at the start of the current study had nursing diplomas as their highest level of education in nursing, even though the Registered Nurses Association of British Columbia (RNABC) and the Canadian Nurses Association (CNA) have stated that a CNS requires a master’s or doctoral degree in nursing (CNA 1993; RNABC 1998a,b). Confusion permeates both nursing and policy circles and stands in contrast to the situation in the United States, where ANP is clearly defined and firmly entrenched (Davies and Hughes 1995; Pinelli 1997; Safriet 2002). This confusion has contributed to the slow acknowledgment, growth and integration of ANP roles into the healthcare system in Canada and in British Columbia. Adding to the confusion is the insufficiency of empirical research to inform the discussion and debate about the nature of ANP roles in the province and in Canada. In the absence of research, much of the debate is based on observation, opinion and anecdotal evidence. To prepare for future growth of ANP roles in the province, representatives from the BC Ministry of Health (now BC Ministry of Health Planning), the University of Victoria School of Nursing, RNABC and the Capital Health Region (now Vancouver Island Health Authority) initiated a collaborative study of ANP. The overall purpose of this three-phase study was to support decision-making and policy direction related to advanced practice by exploring what registered nurses practising in new and/or advanced roles can contribute to health and service delivery needs in British Columbia. Approval for human subject research was obtained from the University of Victoria. In our research project, we used the term “advanced nursing practice” (ANP) because it is the term used in the CNA’s framework on advanced nursing practice (CNA 2002), which provided the conceptual framework for our study. We acknowledge, however, the emerging consensus in the nursing literature about the importance of distinguishing between the term “advanced nursing practice” Singing in Different Keys: Enactment of Advanced Nursing Practice in British Columbia 3