Clinical Nurse Specialists and Nurse Practitioners In Canada: A decision support synthesis

by Alba DiCenso, RN, PhD, Denise Bryant-Lukosius, RN, CNS, PhD | Jun 01, 2010
Full Report (PDF, 1 MB)
Appendices (PDF, 834 KB)


Increasingly, there is a growing demand for advanced practice nursing (APN) in Canada and around the world. As clinical experts, leaders and change agents, APNs are recognized as an important human resource strategy for improving access to high-quality, cost-effective and sustainable models of healthcare.

This special report was commissioned by CHSRF to develop a better understanding of the roles of APNs, the contexts in which they are currently being used, and the health system factors that influence the effective integration of advanced practice nursing in the Canadian healthcare system. Three types of APNs were the focus of this report: clinical nurse specialists (CNSs), primary healthcare nurse practitioners (PHCNPs), and acute care nurse practitioners (ACNPs).

Based on over 60 stakeholder interviews and a review of over 500 papers, the findings in this report show that there is a growing consensus related to the purpose of APN roles. However, the evidence also reveals inconsistencies in perceptions and practice related to the roles of APNs. For example, there are striking differences between CNSs and nurse practitioners (NPs) in understanding their roles, patterns of deployment, and integration.

  • NP roles in Canada have demonstrated significant growth and improved integration through, among other initiatives, the development of legislation to support autonomous practice, an increase in the number of graduates, and the funding of new education programs.
  • Conversely, there is limited provincial/territorial or national investment in supporting the development of CNS roles. This is characterized by a lack of formal CNS education programs and credentialing mechanisms, lack of title protection, and overall decline in the current numbers of CNS roles between 2003 and 2006, especially in British Columbia and Ontario.

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

-Advanced Nursing Practice: A National Framework, 2008. Canadian Nurses Association

Overall, a number of key factors are essential to the successful integration of APNs. These include the need to establish mechanisms to support a full scope of practice, to raise awareness of the function of APNs, to clearly define roles, and to sustain strong administrative leadership to support the implementation of those roles.


The findings in this report support the recommendations proposed at a roundtable convened by CHSRF and the Office of Nursing Policy, Health Canada, in April 2009.

  • Create a vision statement that clearly articulates the value-added role of advanced practice nursing, across settings.
  • Establish a pan-Canadian multidisciplinary task force involving key stakeholder groups to facilitate the implementation of advanced practice nursing roles.
  • Consider advanced practice nursing as part of health human resources planning, based strategically on population healthcare needs.
  • Standardize advanced practice nursing regulatory and educational standards, requirements and processes across the country.
  • Include, in all undergraduate and post-graduate health professional training programs, components that address interprofessionalism.
  • Develop a communications strategy to disseminate to a wide readership the positive contributions of advanced practice nursing.
  • Protect funding support for advanced practice nursing positions and education, to ensure stability and sustainability.
  • Conduct further research on
    • the "value-added" of advanced practice nursing roles
    • their impact on healthcare costs
    • the CNS role


While great strides have been made over the past 40 years in the development and deployment of advanced practice nursing, the full contribution of APNs has yet to be realized. Considerable opportunity exists to more clearly define roles, to improve integration, and to maximize APNs' contribution to the Canadian healthcare system, thereby improving the quality and delivery of healthcare.