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Advanced Practice Psychiatric Nursing In Canada

Ruth Gallop, RN, Ph.D.
Professor and Associate Dean - Research
University of Toronto

As a nurse who has worked in Canada and the USA, I am struck by both the similarities and differences in our systems.  Although our educational programs and clinical challenges are similar, the recognition of advanced practice psychiatric nursing in the USA and Canada is quite different.  Much of this difference can be explained in terms of history.  During the 70’s and 80’s, graduate programs in the USA developed a cadre of highly skilled nurse psychotherapists who were recognized by other professionals as competent practitioners.  Canada has no tradition of nurse psychotherapists and certainly no formal recognition of advanced practice as it exists in the USA.  Graduate programs preparing MSNs have attempted to prepare a combined clinical specialist and beginning nurse scientist.  MN programs appeared in the 90’s but without formal designation of Mental Health Nurse Practitioners.  Graduates from these programs work at the CNS level often within traditional institutional settings or in administrative roles.  Some positions exist in community agencies.  Nurses who want advanced psychotherapy skills take courses independently at Institutes for Group Psychotherapy, Cognitive Therapy, Psychodynamic Therapy, Family Therapy and then, often with difficulty, find positions where they can demonstrate their skills.  But these positions are not based on their preparation as advanced practice nurses, but rather on their other skills.  In many clinical sites, nurses perform much of the therapy because other disciplines are unavailable.  This is rarely acknowledged in any formal sense and, if a professional deemed “more qualified” appears, the nurse is replaced. 

The only certification existing for registered nurses in mental health nursing is at a basic competence level, requiring a minimum of two years experience after basic education.  We have no advanced certifying organization.  The net result is a lack of tradition supporting advanced practice and a lack of consideration by other professionals that there is a role for registered nurses at the advanced practice level.  If we are to achieve a true advanced practice role for nurses, we need to put in place graduate programs that offer true advanced practice skills and have requirements of clinical supervision that prepare advanced practitioners.

Canadian psychiatric / mental health nursing must overcome significant hurdles.  As elsewhere, health care in Canada is an economic issue.  Physicians are funded on a fee-for-service basis by the government.  In Ontario, where I live, physicians can receive payment from government funded health insurance for unlimited psychotherapy.  Private insurance can cover time-limited therapy by a psychologist.  A nurse cannot receive compensation from our health insurance plan for psychotherapy nor for prescribing medication.  Variations of this exist in other provinces resulting in a profound effect on the advancement of psychiatric nursing and the perpetuation of the hierarchical and patriarchal models of psychiatry.  In Ontario, with 38% of Canadian population, efforts to establish an APNP program have met with indifference at clinical and governmental levels.  We have not been supported, and even opposed, by medicine.  One might ask, why would medicine support us when the one of chief billing categories of general practice physicians is counseling?

So few nurses in Canada have advanced degrees (MSN, MN, PhD) that the capacity to lobby for change is difficult and often seen as elitist by nursing peers.  We need to demonstrate that forging autonomous roles for truly advanced practitioners is in the interest of both clients and nurses.  We need to lobby for support for nurses with advanced skills--to create appropriate recognition, regulation, opportunities and compensation.