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Extended Class: Present and Future    

Last modified: August 22, 2006

Foundational Document

Registered Nurses in the Extended Class: Description of Three Streams of Nurse Practitioner Practice

Introduction

In 2005, the College described the differences between primary health care, adult acute care and child acute care nurse practitioners in a working document. To gauge the relevance, clarity and completeness of the document, a questionnaire was sent to 80 randomly selected primary health care and acute care nurse practitioners, as well as 34 professional, regulatory, educational and governmental bodies.

The College assessed the responses, and used the suggestions and comments to change and clarify its document Registered Nurses in the Extended Class: Description of Three Streams of Nurse Practitioner Practice (CNO, 2006).

An RN(EC) brings advanced nursing knowledge and experience to the provision of health care services to prevent disease, and to optimize, promote and maintain health. The competencies of an RN(EC) in Ontario are those of the Canadian Nurse Practitioner Core Competencies (CNPCC)¹ in health assessment and diagnosis, health care management and intervention, health promotion and prevention of illness, injury and complications, and professional roles and responsibilities.

An RN(EC) is a role model for the College’s standards and guidelines and for professional practice. The three major contexts of present and future RN(EC) practice are primary health care (family/all ages), acute care adult and acute care child. To regulate each stream, descriptions of the differences in the context of practice and client characteristics are needed.

The CNPCCs are the same in every stream, such as the competencies that characterize professional role and responsibility. However, there are clear differences between the three streams in the context of practice and client characteristics. To protect the public, these differences must be addressed in regulatory testing criteria. The College will regulate the three streams of nurse practitioner practice. In the future, a focus in an area of practice through quality assurance may be considered.

The differences in population and client characteristics, legislated scope of practice and application of core competencies among nurse practitioners [RN(EC)s] in primary health care (family/all ages), adult acute care and child acute care are:

	Primary Health Care (Family/All Ages)	Acute Care Adult RN(EC)	Acute Care Child RN(EC)
	Usually in, but not limited to, community clinics or services where primary health care is delivered in urban, rural or isolated areas and outpatient clinics in hospitals, long-term care	Usually in, but not limited to, hospital acute care in-patient or outpatient settings	Usually in, but not limited to, hospital acute care in-patient or outpatient settings
	• Communities or community groups • Families • All ages • Those clients or client groups who are well with or without health and social risk factors • Those striving for physical and psychosocial well-being with a diagnosed chronic or complex stable health condition • Those choosing health services from an RN(EC) • Those experiencing a minor acute episodic illness that is expected to completely resolve with appropriate treatment within a predictable time frame	• Adults of all ages, older adolescents and families • In-patients with an acute illness, an acute episode within a chronic illness, an illness with a life-changing outcome or outpatients with a chronic illness requiring frequent assessment and ongoing management • Those at high risk for complications due to age and/or co-morbidities • Those experiencing a predictable or unpredictable response to an acute illness • Those experiencing multiple complex health-related problems at the same time • Those at risk due to personal or social factors	• Children from birth to 18 years and their legally defined family • In-patients with an acute illness, an acute episode within a chronic illness, an illness with a life- changing outcome or outpatients with a chronic illness requiring frequent assessment and on-going management • Those at high risk for complications due to developmental stage and/or co-morbidities • Those experiencing a predictable or unpredictable response to an acute illness • Those experiencing multiple complex health-related problems at the same time • Those at risk due to personal or social risk factors
	Practise independently and in consultation and collaboration with other health professionals in providing care to promote health, prevent disease, and assess, diagnose and manage clients’ health needs.	Practise independently to provide advanced practice nursing care to adults. Practice is always in consultation and collaboration with other health professionals using joint communication and decision-making processes in which mutual goal setting, authority and responsibility for action and outcomes belong to individual parties, and there is a belief that the collaboration will enhance client care.2	Practise independently to provide advanced practice nursing care to children. Practice is always in consultation and collaboration with other health professionals using joint communication and decision-making processes in which mutual goal setting, authority and responsibility for action and outcomes belong to individual parties, and there is a belief that the collaboration will enhance client care.3
	• May span years and be a periodic ongoing process with an individual, family and/or community • Grounded in knowledge of epidemiology and conditions of clients across the lifespan, groups and communities • Adapts to clients’ conditions over time and includes periodic monitoring for signs, symptoms and subtle changes • Orders, performs and interprets diagnostic tests and screening procedures based on assessment, differential diagnoses and knowledge about age and health status of clients across the lifespan • Documents assessments and reviews with the collaborating physician if necessary	• Frequent and focused, informed by depth of knowledge of adult responses to acute illness and variability within a specific condition • Identifies predictable and unpredictable acute illness responses • Identifies signs and symptoms of multiple problems including relationship of vague or fluctuating symptoms • Orders, performs and interprets diagnostic tests and screening procedures based on assessment results, differential diagnoses and advanced knowledge about age, gender and health status of adult clients • Documents assessments and reviews with the collaborating physician, if necessary • Collaborates with the physician and other health care providers to plan care, insuring client preferences inform the plan	• Frequent and focused, informed by knowledge of growth and development of children and their response to an acute illness, and variability within a specific condition • Identifies predictable and unpredictable acute illness responses • Identifies signs and symptoms of multiple problems including relationship of vague or fluctuating symptoms • Orders, performs and interprets diagnostic tests and screening procedures based on assessments results, differential diagnosis and advanced knowledge about age, gender and health status of children • Documents assessments and reviews with the collaborating physician if necessary • Collaborates with the physician and other health care providers to plan care, insuring client preferences into the plan
	• Builds and maintains a therapeutic partnership with the client, family and community, and periodically clarifies their goals • Prescribes appropriate drugs based on knowledge of altered pharmacodynamics and pharmacokinetics in groups such as infants and children, pregnant women and older adults • Manages stable complex needs of older adults arising from age-related changes and multiple system disease • Performs therapeutic interventions as supported by the collaborating physician(s) • Considers the impact of individual and family transitions, such as parenthood, retirement and end-of-life issues on the health of family members • Advocates to minimize gaps in health services and improve continuity of health care • Improves transitions to community from other health care settings • Knows about community or population transitions (e.g., loss of a key employment industry, community crises or disasters) and adapts care to circumstances and advocate for client and community health strategies	• Starts and maintains a therapeutic partnership with the client and his/her defined family, continually clarifying their goals • Frequently monitors the impact of illness, previous or concurrent illnesses, emotional and functional capacity • Manages acute illnesses including multi-system problems, preventing complications when possible • Performs therapeutic interventions as supported by the collaborating physician(s) • Prescribes appropriate drugs based on knowledge of altered pharmacodynamics and pharmacokinetics for adults who are ill • Provides leadership in care planning in collaboration with the client and health team in order to focus care • Advocates for clients and organizes their activities in the health care system • Ensures continuity of care in acute episodes and across an illness by planning with the client, providing anticipatory guidance of future health care needs and co-ordinating transitions and referrals between health care settings or the client’s home	• Initiates and maintains a therapeutic partnership with the client and family, continually clarifying their goals • Uses advanced knowledge about child health conditions, chronic diseases and multi-system physical and mental conditions to determine and/or monitor the impact of present, previous or concurrent illnesses, emotional and functional capacity • Intervenes in a manner that supports normal developmental processes in the client and family • Manages acute illnesses including multi-system problems preventing complications when possible • Performs therapeutic interventions as supported by the collaborating physician(s) • Prescribes appropriate drugs based on knowledge of altered pharmacodynamics and pharmacokinetics for children who are ill • Provides leadership in care planning in collaboration with the client, family and other health care providers in order to focus care • Advocates for clients and coordinates their activities in the health care system • Ensures continuity of care in acute episodes and across an illness by planning with the client, providing anticipatory guidance of future health care needs and co-ordinating transitions and referrals between health care settings or the client’s home
	• Identifies determinants of health, specific community risk factors and wellness screening actions; effectively modifies health promotion strategies for clients, communities and community groups with a shared culture, health condition or demographic such as age • Knows and follows best practice guidelines with the overall goal of improving clients’ quality of life • Understands vulnerabilities of different developmental stages (epidemiology of health and disease) and provides anticipatory guidance in order to improve clients’ health status and/or quality of life • Manages care to decrease community, family and individual risk	• Identifies risk potential due to co-morbidities and specific illness • Manages client care to decrease individual risk • Manages risk of groups of in-patients by developing evidence-based guidelines aimed at decreasing adverse events • Prevents likely complications and losses by initiation of complication prevention strategies • Interprets what is possible for a client to do in the context of a specific illness • Considers the client and family within health education programs • Acts as an expert to community programs aimed at promotion of health through risk factor modification in a specific illness • Provides anticipatory guidance through advanced understanding of client and family vulnerabilities in order to improve health status and/or quality of life	• Identifies risk potential due to co-morbidities and specific illness • Manages client care to decrease individual risk • Manages risk of groups of in-patients by developing evidence-based guidelines aimed at decreasing adverse events • Prevents likely complications and losses by initiating complication prevention strategies • Interprets what is possible for the client to do in the context of a specific illness • Considers client and family in health education programs • Acts in regional programs as an expert on health promotion through risk factor modification of specific illnesses • Provides anticipatory guidance based on advanced knowledge of child and family vulnerabilities at different developmental stages, self-management and parenting strategies in order to improve the health status and/or quality of life
	Applies knowledge of legislation and ethics to: • Clients across the lifespan, families and communities • Encourages and empowers clients and communities to live well • Analyses costs and uses resources in an effective manner • Generates and communicates ideas to improve health services and accessibility to services and wellness care • Uses research knowledge to improve environment and advocate for appropriate support for clients and communities	Applies knowledge of legislation and ethics to: • Adult clients in context of practice • Provides leadership to integrate client’s perspectives into care • Promotes client advocacy • Improves quality of client’s education in acute care and program delivery • Understands, promotes and conducts research • Plans, implements and evaluates acute care and follow-up programs	Applies knowledge of legislation and ethics to: • Child clients in context of practice • Provides leadership to integrate client’s perspectives into care • Promotes client advocacy • Improves the quality of client education and program delivery • Understands, promotes and conducts research • Plans, implements and evaluates acute care and follow-up programs

Endnotes

1. Canadian Nurse Practitioner Core Competency Framework (CNPCC), Canadian Nurses Association, 2005.
2. Canadian Medical Protective Association/Canadian Nurses Protective Society Joint Statement on Liability Protection for Nurse Practitioners and Physicians in Collaborative Practice, 2005.
3. Canadian Medical Protective Association/Canadian Nurses Protective Society Joint Statement on Liability Protection for Nurse Practitioners and Physicians in Collaborative Practice, 2005.

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