Registed Nurses' Association of Ontario

The Evolution of an Advanced Clinical Practice RN

Mindy Nelson
Somerset West Community Health Centre

I have had the pleasure of working at Somerset West Community Health Centre for the last five years. Prior to this, I worked for 20 years as a community visit nurse where I was fortunate enough to be able to develop autonomy in my practice. As one of 50 nurses who attended the RNAO Institute: Primary Solutions for Primary Care, I was inspired to look for ways to enable me to work to full scope of practice as a RN. I wanted to take my years of experience and further develop my skills by participating in the RNAO fellowship.

Key Points from Learning plan

I achieved my overall learning goal which was to expand my knowledge, understanding, and clinical skills to provide advanced clinical practice nursing to clients across the lifespan in a primary health care setting. I have met each of my learning objectives by demonstrating that I can thoroughly perform:

  • Complete physical assessments; male and female adults, babies, infants, children
  • Pap smears, vaginal swabs, and cervical swabs for STI testing
  • Diabetes monitoring and management according to BPGs
  • Lactation advice and support
  • INR management of anticoagulation therapy
  • Prenatal and postpartum assessments
  • Counselling on the signs and symptoms, and short and long term effects of menopause

Challenges Faced

My learning goals and objectives were ambitious given a three month timeframe for the Fellowship. The body of knowledge required to thoroughly assess, examine and advise clients of all ages is large and complex. I also needed to gain knowledge and develop skills in identifying abnormal symptoms and once identified, be able to assess their relevance, prioritize their importance, and determine my next steps as a health care provider.


At the onset of the fellowship I worked alongside my mentors, first observing their assessments; determining their clients’ needs, advising and prescribing care as appropriate. Soon after, my mentors began observing me interviewing and completing physical assessments of clients. As my knowledge and confidence increased, and my mentors’ confidence in me grew, I interviewed and examined clients independently. I discussed each case with my mentor then rejoined the client with my mentor to complete the visit or be observed doing procedures such as pap smears. My mentors would prescribe medications and order diagnostics as needed. Following the visits, we had an opportunity to discuss the clients’ clinical cases. Knowing that I would be preparing a report demonstrating how I utilized this Fellowship time, I maintained journals of client assessments and care that I provided daily. Reviewing these journals also served as an effective method for learning.

Regular presentations to my colleagues were part of my learning plan. My peers generously gave of their time to attend lunch and learn presentations and I was also allotted time at weekly meetings to enable this to occur. In order to deliver effective presentations, I performed literature reviews which supported my learning and ability to share the information. I used various resources such as textbooks, pamphlets, medical internet sites, and professional association guidelines. The process of researching and preparing each presentation ensured that my learning would last. I gave eight presentations to my nursing colleagues, who were receptive to my new-found knowledge and eager to learn with me. Their collective enthusiasm and contributions of their own knowledge and experience made my presentations interactive and enlightening. I received positive feedback, not only on the written evaluations, but also in person afterwards.

This fellowship provided me with an incredible opportunity to observe, question, and problem solve with my mentors. The members of my mentorship team were by far my best resource. I appreciated their willingness to share their knowledge and expertise with me, and I now respect and admire them even more than I did before.

Recommendations/Future Plans/Sustainability

This report signifies the end of my time dedicated to learning the intricacies of health promotion and maintenance and also marks the beginning of new ways of doing things. The subject of how to grow the role of the Registered Nurse within the primary care team has been the focus of many discussions at Somerset West CHC and is considered to be a timely and exciting opportunity.

The centre’s strategic direction has included having all professional staff work to their full scope of practice since 2010. This clinical practice fellowship has enabled us to move further towards our goal. Providers now have a better understanding of the expanded role of the Registered Nurse and have adjusted their attitudes towards sharing the load. The opportunity to demonstrate my abilities to my mentors and their acceptance of my expanded role within the team will help to achieve buy-in from the rest of the physicians and nurse practitioners in the centre.

Somerset West CHC is opening a new branch in June of 2014 and I am a member of the team that will be located there. Our goal (mine, the clinical team and management) is for me to see clients independently for preventative care. Examples of these include the Well Adult (male and female), Well Baby and Well Child visits. Back-up will be provided by the team NP, Chelsea Cameron, who will write prescriptions, order diagnostics tests and expand on assessments as needed. Chelsea and I discovered over the course of this Fellowship that we make a great team and efficiently provide competent, professional care to NP appropriate clients.

By allotting time for me to complete client assessments prior to their NP or Physician visit, our goal is to create more efficiencies in scheduling and increase client access to timely appropriate primary care services. My ability to effectively triage clients in person or on the phone has increased dramatically because of the knowledge acquired through this experience. This results in streamlined, efficient care without the need for duplication. My ability to competently assess clients takes this task off the NP or physician who can quickly make a determination of client needs and order the appropriate care.
The efficiencies mentioned here are dependent on our finding ways to remove some of the duties that are presently being done by the RN. In today’s climate of fiscal restraint and having to accomplish more with less, we must be creative in our approach. Planned strategies for future practice and sustainability include the following:

  • Recruiting volunteers to measure clients’ height, weight, blood pressure and place them in exam rooms
  • Requesting that clients go to a lab, whenever possible, to minimize the amount of blood work being done by nurses
  • Piloting the use of a new lightweight tablet computer will allow the RN’s to access and document client information at the point of care, anywhere in the clinic
  • Bi-monthly meetings to discuss relevant medical and nursing literature, such as evidence-based journal articles, in order to further nursing education
  • Training our Medical Office Assistants (clerical staff) to better triage telephone calls in order to appropriately determine the level of urgency, thereby alleviating some of the time nurses are on the phone

Overall, this fellowship has enabled me to develop new confidence and skills. This dedicated time for learning provided me with an opportunity to work in a new and exciting capacity. Furthermore, it provided me with the ability to play a critical role in primary care from a different point of view. The last three months have been inspiring, educational and satisfying in many ways that were more than expected. Going forward, I am excited and eager to put my new knowledge, skills and experience into practice and support my team in ways that I am now well prepared to do.

Learn more about Advanced Clinical/Practice Fellowships now.