Interviews with 3 nurses who have taken on enhanced responsibilities
Feb 28, 2022, By: Emily Soares, Christina Hurlock-Chorostecki
Registered nurses (RNs) in Canada are increasingly pursuing advanced education intending to become the experts, leaders and change agents needed in the Canadian health-care system. Referred to as advanced practice nurses (APNs), these master- and doctorate-prepared professionals are taking on additional care responsibilities, with some veering away from traditional bedside practice and focusing more on indirect care. Common APN roles include the delivery of autonomous care as well as consultation, leadership, staff education and the management of patient populations.
What is an advanced practice nurse?
APNs are defined internationally as RNs who have acquired an expert-level knowledge in a specialty as well as a graduate degree in nursing. In Canada, two APN roles are recognized (Canadian Nurses Association [CNA], 2019):
- The clinical nurse specialist (CNS): The scope of CNS practice is different than an RN; CNSs use their nursing and systems expertise to manage complex situations, advance nursing knowledge and optimize health systems. The CNS is an agent of change that aligns the values of the clients, staff, and the organization to promote positive health outcomes and reduce financial strain (CNA, 2019). As change agents, they aid in the transformation of an organization by focusing on quality improvements and development.
- The nurse practitioner (NP): In Canada, NPs are defined as APNs who complete additional education and pass an extended nursing class registration exam authorizing them to practise with an expanded scope. In addition to the APN sub-role expectancies, the NP scope includes diagnosing, prescribing medications and treatments, performing medical procedures, and ordering and interpreting diagnostic tests (CNA, 2019).
You will find APNs practising in direct care but also in positions of management, health policy and research, and as nurse educators. Furthermore, APNs promote nursing research, generate new knowledge, and harmonize their education and skills to further clinical practice.
‘You begin just as scared in this role as you were when you began nursing.’
Interviews with three APNs
By acquiring a graduate-level education in nursing, RNs can advance their scope and practise as an APN. The main purpose of this article is to understand the transition from nurse to APN and to gain insight into this advanced nursing role. To achieve this goal, we conducted interviews with three practising APNs who work at a hospital in southern Ontario.
What is your current role?
CNS: I am a clinical nurse specialist and have been for the past 11.5 years.
Educator: I am currently a staff educator and have previously worked as an NP/CNS.
NP: My current role is an NP/CNS [the title is organization specific]. I began in 2004 as a CNS and have been an NP/CNS since 2009.
How was your experience transitioning from an RN to an APN?
CNS: As an RN, I felt I was an expert and anticipated that the next step was also expert. Then all of a sudden you realize that you are a novice again; however, no one looks at you like a novice. You begin just as scared in this role as you were when you began nursing.
Educator: School certainly was not over after I finished my program. I was constantly still studying and reading. I had to be very self-directed and motivated. Wherever I [advanced my practice], I would need to learn more. There is no formal orientation for someone in advanced practice; you start, and you do the role to the best of your ability and you ask questions. You seek out and arrange your learning opportunities. It primarily comes from you knowing that you have the knowledge, skills and judgment for what you are doing.
NP: There are a lot of gaps. No one tells you how to move from the RN role to be an APN. It took me 18 months to transition to the role of master of science in nursing-prepared CNS. It was a really hard transition. Not only did I need to understand what my role would be, but I had to help other people understand what that role was as well. I was the first APN on the unit, so I pioneered the CNS role.
What obstacles/challenges did you face when transitioning into this role?
CNS: I found my first few months very daunting because there is no real role description for a CNS. You have to gain people’s trust and credibility. I had credibility [where I worked in the past], and now I have to create a new position. I am still not 100 per cent confident that others understand the CNS role. I think there are a lot of ambiguities, where I am given tasks because no one else is doing them.
Educator: The biggest challenge is coming into a clinical environment you’ve never been in before. I had to get my head around the resources here, and this unit is very new to my practice. I am still trying to understand the intricacies of that so I can teach it.
NP: The biggest obstacle was the pressure I put on myself. I felt that I should know what I was doing in the first month or less. I always had this sense that I would get in trouble if I did not produce anything. Another obstacle was trust. I was young and starting in the APN role. There were a lot of seasoned nurses who felt, “Well, how could this new person be coming into this role just because they have this education? Who do they think they are?” Building trust was a big obstacle. I also had to learn the culture of the area I was working in — to be a part of that culture, but also influence it.
How has this role evolved since you began your practice?
CNS: If entry to practice is BScN, then someone who is responsible for staff development has to be at a higher educational level than that. The knowledge you acquire through an MScN is what brings you to the next level.
Educator: I became strong, more knowledgeable, more independent and more of a resource to staff. Given my previous background, I bring some of those thought processes with me. So I do find that the role I am in is as an educator/CNS, because I am doing things like introducing a new protocol, or changing practice around a procedure. Those things would not traditionally be educator roles, but because I have previous experience as a CNS, I find that the role has evolved that way to involve some of those components.
NP: It is not what you see me doing, it is how I am doing it — how I am teaching and treating my patients and their families and using guidelines to guide my practice.
What advice would you give new APNs?
CNS: Listen. Ask a lot of questions. Find the strengths of your nursing staff and identify gaps. Determine those who support you and those who are naysayers — and then be okay to ignore the negativity. I think that nurses always want to have an impact on their patients, but do not always realize the impact that they have as nurses. So my role is to support everyone by listening to the staff, the patient and the families.
Educator: Be mindful that you are in a role that advances nursing practice. Make sure that you are supporting and championing other nurses through their interests and education. Always keep the patient at the centre of your practice. You’ll always be doing the right thing if you keep them at the centre of your practice. Don’t forget where you came from.
NP: What is important is the team you work with and having a really strong, supportive environment to work in. I had a mentor when I first started, and they were so supportive in helping me learn the role. My leader was also very supportive, which gave me the chance to understand what the unit needed, what my interests were and how I could marry those together in a satisfying way. It is hard to know if you will have this support in a new job, so ask a lot of questions in your interview and go into the position with an open mind.”
The interviews with each APN brought forth a different perspective on the experience of role transition. Despite differing roles and organizations, common themes emerged:
- The APNs emphasized that nurses considering advanced practice must understand that with further education comes greater expectations and responsibilities.
- Patience in self-development is necessary for success. Through ongoing learning and the seeking of peer support, the transition can be much more manageable.
- Credibility, respect and trust are essential for success in the APN role; however, it takes time to earn these perceptions.
- By advancing their overall nursing practice while consistently showing support to fellow staff, APNs should assume leadership roles and assist in accomplishing the goals of the organization.
- APNs are leaders in advancing nursing practice, including efforts to ensure that their role’s full scope is recognized.
Canadian Nurses Association. (2019). Advanced practice nursing: A pan-Canadian framework. Retrieved from https://hl-prod-ca-oc-download.s3-ca-central-1.amazonaws.com/CNA/2f975e7e-4a40-45ca-863c-5ebf0a138d5e/UploadedImages/documents/Advanced_Practice_Nursing_framework_EN.pdf
Emily Soares, MScN, RN, is a public health nurse in the Algoma District of Ont., and policy and political action executive network officer with the Registered Nurses’ Association of Ontario. Emily strives to promote excellence in nursing and influence decisions that affect nurses and the public they serve.
Christina Hurlock-Chorostecki, PhD, NP, has worked in a variety of hospital NP roles in London, Ont. She is a limited duties professor at Western University, London.