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To synthesize and analyze the characteristics, responsibilities, and legal underpinnings for advanced practice roles.

Compare and contrast the NP or CNS role to the SNAP model. The paper should include pertinent background information and current perspectives. Compare the role for scope of practice in Canada or within the province that you practice (e.g. standards, competencies, & legislation). Frame the discussion within the SNAP model competencies for advanced practice (i.e. use the SNAP model as a paper outline - direct comprehensive care, evidence informed practice, educative practice, support of systems, and leadership). As appropriate, include insights of what the concepts mean for NP or CNS practice, offer recommendations or alternate approaches.

Direct Comprehensive Care

Despite the fact  that NPs and CNSs in Canada are both highly experienced and educated in clinical practice, each of them have a different role. It is important that in order to identify the main differences existing between them so that an individual aspiring to be an advanced practice nurse can decide the role that suits their skills and/or personality. According to the Canadian Nursing Association, CNSs offer expert nursing care while playing the lead role in developing clinical guidelines and/or protocols (Canadian Health Services Research Foundation, 2011). They also promote evidence-based practice, offer support, consultancy to stakeholders in the healthcare sphere in order to facilitate system change. CNSs are Registered Nurses that have advanced skills in nursing to make complex decisions. A CNS must have a master’s and/or doctoral degree in the field of nursing and expertise in any clinical nursing specialty (Fulton et al, 2014).  They are agents of change bringing value to their clients, organizations and practice settings.

They thus improve safety in healthcare, promote health outcomes that are positive and reduce healthcare costs (Gardenier, 2012). On the other hand, the Canadian Nursing Association indicates that NPs offer direct care to clients and focuses on health promotion, illness treatment and their management. NPs have a more expanded practicing scope where the can diagnose, order and even interpret necessary diagnostic tests. They have the authority to prescribe medication unlike the CNSs. NPs have graduate education and also experience in clinical practice. For one to be an NP, they must be Registered Nurses with working experience. While there are several similarities between their roles, NPs and CNSs usually work in differing environments. Most NPs operate in private practice of in office setting while CNSs find themselves in acute care facilities including hospitals (Hoyt & Proehl, 2011). The roles of CNSs and NPs can be distinguished based on the Saskatchewan Nursing Advanced Practice (SNAP) Model which emphasizes on the 5 major domains of practice which include; direct comprehensive care; evidenced-informed practice, educative practice, support systems, and professional leadership.

Clinical Nurse Specialist

The CNSs has both consistent and broad influence in regard to the provision of direct comprehensive care within the Canadian provinces where they have been posted.  They epitomize their knowledge, abilities, skills and attributes in generating relevant research questions within clinical practice (Lamarche & MacKenzie, 2015). Where necessary, CNSs form part multidisciplinary research teams, contributing as senior members. Their skills and abilities enable them to recruit patients as respondents and obtain informed consent where research on direct comprehensive care is required (Gardenier, 2012). They have great documentation and/or communication skills which enable them to be resourceful to research teams. They take responsibility for any independent nursing decision (Hoyt & Proehl, 2011). More often, CNSs only engage in agreed upon independent direct practice within the supervision of the doctors and/or the senior management team. The CNSs usually influences all nursing practices predominately within the clinic and/or ward setting, being a senior member of the research team.

Unlike the CNSs who cannot directly engage in independent direct comprehensive care without supervision, NPs can conduct comprehensive and/or systematic nursing assessment of patients. They provide comprehensive, effective and safe evidence-based nursing care in order to attain identified individual and/or group health outcomes (Hoyt & Proehl, 2011). It is also there direct role to develop, maintain and conclude therapeutic relationships with their patients in appropriate terms. In regard to collaboration, the NPs work with the rest of the interdisciplinary healthcare team in order to provide clients with comprehensive nursing care directly. The NPs take part in formulating nursing plans for patients in collaboration with RNs, the patients and their caretakers. They also manage the nursing care within their scope as NPs while ensuring that they promote individual and/or group security, integrity and safety while under care (Lamarche & MacKenzie, 2015). Further, the NPs offer support and care to either individuals or groups within their scope of practice in the quest to maintain quality direct comprehensive care

Support of Systems

Clinical Nurse Specialist

CNSs make crucial contributions to both local and national clinical guidelines within their specific areas of specialty area. They can contribute to peer review publications which they submit to national and/or international journals in their areas of specialty. Where local clinical guidelines require reviews, the Clinical Nurse Specialists take part in the review process. Their knowledge, skills and attributes enable them to take part in such processes with efficiency and effectiveness (Carter et al, 2010).  They contribute to different processes aimed at supporting clinical research. For instance, they form part of the ethics committees by representing nursing. They also represent their areas of specialty when there are reviews of organizational processes within the settings they could be working in.  Clinical Nurse Specialists also recognize the contributions of any research endeavors in the clinical environment while actively advocating increased awareness among nurses of what conducting a good research constitutes.  Further in supporting systems, CNSs model expert skills and/or behaviors that guide interactions with different patients and their families.

In supporting systems, Nurse Practitioners operate as a consultant to different entities in the healthcare system and also refer or accept referrals of patients from different health-care providers, allied community agencies and professionals. They offer client advocacy in regard to therapeutic interventions, access to healthcare and decision making on health. They also support the system through collaborating with healthcare team members in the provision and promotion of inter-professional care that is client-centered both at system and individual levels. Nurse Practitioners also collaborate with healthcare team members in promoting and guiding initiatives related to quality improvement at system, organizational and individual levels. They apply advanced knowledge and abilities in terms of communication, analysis, coalition building, negotiation, management of change and even conflict-resolution. This is important in facilitating systemic functions in health sector. It is however important to note that NPs do not participate directly in policy and/or protocol development reviews as is the case for Clinical Nurse Specialists.

Clinical Nurse Specialists take part in different local and national health education programs. They also work with their junior nursing colleagues in developing their capabilities in their specialty areas and this improves their competencies while setting their role limits. More particularly, CNSs provide specialized education including nursing knowledge and skills in their own clinical specialty areas to the members of different multidisciplinary teams, patients and their families formats (Fulton et al, 2014). They advise on methodologies, procedures, research programs, special protocols and guidelines in line with their specialty areas. CNSs have skills in communication, documentation and research which they use to carry out health promotion through planning and executing health education activities within their areas of jurisdiction in the Canadian provinces. They are mentors to the nurses within the organizations they work in as they also help each other in professional development and growth.

Nurse Practitioners are mainly preceptors to nurses that are less experienced and these can include graduate and/or undergraduate nurses.  In this regard, NPs play an important role in facilitating ongoing individual and group professional development of themselves and others. As an educationist in their specialty area, NPs accept accountability and responsibility for their own individual actions within the nursing practice. In their educative practice, they lead or collaborate with healthcare teams in staging community initiatives on health promotion. This is aimed at reducing risks to complications, injuries and illnesses for individuals, groups and the whole population(Carter et al, 2010). A Nurse Practitioner has the skills to carry out the assessment, identification and critical analysis of information from various sources in order to determine patient or population trends and patterns. They then initiate and take part in developing strategies which can be used to address some of the identified implications.

Educative Practice: Clinical Nurse Specialist

CNSs actively take part in generating new evidence and knowledge since they take part in different research initiatives that aim at improving both patient care and their profession. They can also be associate investigators in different projects concerning the improvement of health outcomes within the population and in the nursing practice (Canadian Institute for Health Information, 2015). The CNS has skills necessary to develop, implement, analyses and disseminate new audit and research projects which are aimed at optimizing healthcare in their specialty areas.  They also take part in protocol development during research projects and their high level skills in documentation and ability to maintain Case Record Files facilitates them to offer evidence-based practice (Lamarche & MacKenzie, 2015). They use their knowledge and skills in obtaining information on latest appropriate nursing practice and they implement them on their patients or impart the knowledge to the members of healthcare teams.  CNS understands that it is their responsibility to offer patients and groups evidence-based healthcare services. They therefore strive to use their skills in using and/or contributing knowledge to evidence-based nursing practice platforms for them and others to rely on while offering comprehensive care. The information they retrieve of add to such platforms include latest guidelines, new knowledge, procedures and protocols on nursing practice in different care settings.

Nurse Practitioners just like the rest of Registered Nurses in Canada are required to practice within the evidence-based framework. In this regard, they seek for new knowledge on different platforms in order to inform their decision making in the direct diagnosis of patient illnesses, their treatment and how nursing plans should be drawn for different disease conditions (Lamarche & MacKenzie, 2015).  Nursing Practitioners also need to establish therapeutic relationships with their patients and this needs evidence-based practice especially in managing special conditions among patients with mental problems.  The Nurse Practitioners thus assess and review the latest evidence based practice materials, guidelines and protocols some of which are developed by CNSs, to inform their nursing decisions.  The NPs identify and implement research-based innovations to improve the care of patients individually, organizationally and systemically (Canadian Institute for Health Information, 2015). They especially, identify, collect and evaluate data on nursing practice outcomes for their clients and for the benefit of improving the healthcare system. They also act as agents of change through translating and disseminating new knowledge in platforms such as formal presentations, discussions, and publications. 

A CNS provides professional leadership, advice and consultancy in nursing and in their specialty areas.  This is done at individual/group level of clients, healthcare providers and organizational management. As professional leaders, Clinical Nurse Specialists increase the efficiency of patient care processes and the effectiveness delivering such services through leading and establishing various quality improvement projects (Carter et al, 2010). This is also possible where CNSs are able to facilitate the creation and maintenance of special frameworks for both policy and education in their area of jurisdiction (Canadian Nurses Association, 2008).  The CNSs in Canada play an important role in contributing to the development of provincial and territorial healthcare policies.  They also play an important leadership role in advanced nursing practice as members of different research teams as well as in multidisciplinary nursing teams. CNSs while taking part in research projects advocate for the rights of patients and families involved in order to ensure ethical considerations are taken care of by the research teams (Fulton et al, 2014).  They are positive role models to their junior colleagues as they work towards developing themselves and others in the nursing environment. As leaders, CNSs carry out their activities in line with relevant legislation, procedures and policies which affect nursing practice. Further, their professional leadership is seen when they conduct nursing practice in ethically justified ways. 

A Nurse Practitioner also practices professional leadership as is the case for Clinical Nurse Specialists. NPs offer special leadership in managing of clinical care as they are not only resource persons but also educators and role models. They are preceptors, mentors and coaches to their colleague nurses, health-care team members and student nurses within their areas of practice. As leaders, Nursing Practitioners articulate and promote their role to patients, healthcare providers, the public, policy makers and to the social and/or public service sectors (Canadian Nurses Association, 2008). They also advocate for and participate in the creation of organizational environments which support safe client-care, professional growth and collaborative practice. Further, Nurse Practitioners guide, initiate and provide professional leadership in establishing and implementing standards, guidelines for practice, quality assurance, education and relevant important research initiatives.

Conclusion

In conclusion, the discussion above provides a clear definition of the roles of the CNSs and the NPs in Canada according to the Canadian Nursing Association. While the roles differ in regard to autonomy in offering comprehensive care and specifics in the provision of direct care; they all play major roles as professional leaders, educators and promoters of evidence-based nursing practice. Their common ground is that they must first be Registered Nurses bound to a common code of ethics, who are leaders, consultants, educators and advancers of evidence based practice. The discussion thus outlines their specific differences and similarities in line with the SNAP conceptual framework.

References

Carter, N., Martin-Misener, R., Kilpatrick, K., Kaasalainen, S., Donald, F., & Bryant-Lukosius, D. et al. (2010). The Role of Nursing Leadership in Integrating Clinical Nurse Specialists and Nurse Practitioners in Healthcare Delivery in Canada. Nursing Leadership, 23(sp), 167-185. https://dx.doi.org/10.12927/cjnl.2010.22274

Gardenier, D. (2012). Does Nursing Need the Clinical Nurse Leader?. The Journal For Nurse Practitioners, 8(1), 30-31. https://dx.doi.org/10.1016/j.nurpra.2011.11.007

Hoyt, K., & Proehl, J. (2011). Advanced Practice Registered Nursing Consensus Model. Advanced Emergency Nursing Journal, 33(2), 107-108. https://dx.doi.org/10.1097/tme.0b013e318217e5e2

Lamarche, K., & MacKenzie, S. (2015). Target Locked: Nurse Practitioners and the Influence of Pharmaceutical Marketing Practices in Canada. The Journal For Nurse Practitioners, 11(7), 695-701. https://dx.doi.org/10.1016/j.nurpra.2015.04.025

DiCenso, A., & Bryant-Lukosius, D. (2010). The long and winding road: Integration of nurse practitioners and clinical nurse specialists into the Canadian health-care system [Guest editorial]. Canadian Journal of Nursing Research, 42(2), 3-8.

Doerksen, K. (2010). What are the professional development and mentorship needs of advanced practice nurses? Journal of Professional Nursing, 26, 141-151. https://dx.doi.org/10.1016/j.profnurs.2009.04.005

Donald, F., Bryant-Lukosius, D., Martin-Misener, R., Kaasalainen, S., Kilpatrick, K., Carter, N.,  DiCenso, A. (2010). Clinical nurse specialists and nurse practitioners: Title confusion and lack of role clarity. Nursing Leadership, 23(Special Issue), 189-210. doi:10.12927/cjnl.2010.22276

Fulton, J. S., Lyon, B. L., & Goudreau, K. A. (Eds.). (2014). Foundations of clinical nurse specialist practice (2nd ed.). New York: Springer Publishing.

Hamric, A. B., Hanson, C. M., Tracy, M. F., & O’Grady, E. T. (2014). Advanced practice nursing: An integrative approach (5th ed.). Philadelphia: W. B. Saunders.

Kilpatrick, K., DiCenso, A., Bryant-Lukosius, D., Ritchie, J. A., Martin-Misener, R., & Carter, N. (2013). Practice patterns and perceived impact of clinical nurse specialist roles in Canada: Results of a national survey. International Journal of Nursing Studies, 50, 1524-1536. doi:10.1016/j.ijnurstu.2013.03.005

Association of Registered Nurses of Newfoundland and Labrador. (2013). Advanced practice — Clinical nurse specialist [Position statement]. Retrieved from https://www.arnnl.ca/sites/default/files/documents/PS_Advanced_Practice_Clinical_Nurse_Specialist.pdf

Bryant-Lukosius, D., & Martin-Misener, R. (2015). Advanced practice nursing: An essential component of country level human resources for health [Policy brief]. Retrieved from the International Council of Nurses website: https://fhs.mcmaster.ca/ccapnr/documents/ICNPolicyBrief6AdvancedPracticeNursing.pdf

 Canadian Council of Registered Nurses Regulators. (2015). Practice analysis study of nurse practitioners. Retrieved from https://www.ccrnr.ca/assets/ccrnr-practice-analysis-study-of-nursepractitioners-report---final.pdf

 Canadian Health Services Research Foundation. (2011). Myth: Seeing a nurse practitioner instead of a doctor is second-class care. Journal of Health Services Research and Policy, 16, 124-125. doi:10.1258/jhsrp.2010.211110

Canadian Institute for Health Information. (2015). Regulated nurses, 2014. Retrieved from https://secure.cihi.ca/free_products/RegulatedNurses2014_Report_EN.pdf

 Canadian Nurses Association. (2008). Advanced nursing practice: A national framework. Retrieved from https://www.cna-aiic.ca/~/media/cna/page-content/pdfen/anp_national_framework_e.pdf

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