Advanced practice: which path should nurses take?
How the advanced clinical practitioner role could affect the future of nursing
How the advanced clinical practitioner role could affect the future of nursing
The debate about how to meet the rising demand for emergency care goes back a long way.
In 1996, the now-defunct Audit Commission published By Accident or Design?, a report arguing that a shortage of emergency doctors, combined with increasing patient numbers and long waiting times, required a reconfiguration of services and a wider role for nurses.
In the 22 years since this report was published, the debate has rumbled on and nursing practice has expanded to meet the growing need, but not in a consistent or regulated way.
Some say that professional boundaries have become blurred and that, to help services cope, highly skilled practitioners – including nurses and paramedics – are being diverted along career paths away from their first-choice profession.
Others maintain that nurses should seize every opportunity to advance and develop, even if this means taking on roles that were once the preserve of doctors.
The debate on higher-level practice was fuelled by the publication last year of a Royal College of Emergency Medicine (RCEM) curriculum for advanced clinical practice in emergency medicine.
The advanced clinical practitioner (ACP) role is governed by a standardised competency framework.
Appropriately skilled and educated applicants are taught to look after patients with a wide range of pathologies, from the life-threatening to the self-limiting. Its curriculum was endorsed by the RCN.
‘Emergency nurse practitioners may not realise that this is not a nurse or doctor role’
Writing in Emergency Nurse earlier this year, independent nurse consultant and nurse practitioner Mandy Rumley-Buss gave her support for the ACP role, but warned: ‘We need to consider the consequences if all we do is move our senior experienced nurse clinicians into this new role.’
Speaking to Emergency Nurse now, Ms Rumley-Buss said all the ACPs she knows personally are ‘absolutely brilliant’.
But she is concerned that, as funding for new ACP positions leads trusts to consider who from among their emergency care staff is equipped to train for the role, nurses may feel they are under pressure to follow the ACP path rather than developing as emergency nurse practitioners (ENPs).
‘I believe ENPs may not realise that this is a completely different role,’ Ms Rumley-Buss says. ‘It is not a nurse or doctor role, it is a hybrid. Do ENPs want that?
‘Some will, and that’s fine, but some won’t. And some might enter into it not realising the intensity and the work they’ll have to do to achieve it.’
She adds: ‘What worries me about the ACP role is that, instead of seeing it as a way to support medicine and the middle-grade shortage, we will rob Peter to pay Paul.
‘We have a skilled nursing workforce in our emergency departments, but if we train them to become ACPs, what happens to our minors that have been supported by advanced nurse practitioners (ANPs)?’
Regulation is a thorny issue in conversations about advance nursing practice. The topic has been ‘well debated and discussed’, according to an advanced practice toolkit produced by NHS Education for Scotland, with ‘strong proponents’ on both sides.
Some argue in favour of a separately registered title for ANPs, others say there is no need.
A command paper presented to parliament in 2011 by the then health secretary Andrew Lansley states that, at that time, there were 30 different health professions overseen by nine regulatory bodies. This, it argues, was excessive.
‘If an advanced clinical practitioner’s base registration is a nurse, they’re still a nurse but they have an additional skill set’
The paper highlights the cost of the regulatory system and states that ‘it does not follow inevitably that statutory regulation is the most effective or efficient way of ensuring high quality care’.
A recordable qualification on the Nursing and Midwifery Council (NMC) register should not affect the quality of care given by ANPs, but it could better define the role and offer a clearer career trajectory for experienced nurses.
Legitimacy to practice
Ollie Phipps, acute care nurse consultant and advanced practice lead at East Kent Hospitals University NHS Foundation Trust, chairs the RCN’s advanced nurse practitioner forum.
He says that whenever the NMC is asked to consider regulation of ANPs, it says it will look into it, ‘but nothing ever happens’.
‘Advanced practice leaders, with national hats on, have asked the question many times but have just been stalled,’ he says.
In the absence of an ANP register, credentialing is the next best thing, Mr Phipps says.
Credentialing – as offered by the RCN, for example – allows nurses formal recognition of their skills and expertise by assessing their legitimacy to practice at an advanced level.
‘What credentialing does, and what an advanced nurse practitioner register would do, is allow for a set standard of practice that ensures patient safety,’ Mr Phipps says.
‘This would also ensure the patient sees the right person with the right skills and knowledge.’
New ways of working
A framework published last year by Health Education England (HEE) signalled a changed direction for advanced practice.
Described by HEE as a ‘new and bold vision’, the framework sets out a consistent description of advanced clinical practice to apply across all health and care professions and in all settings.
HEE says a driver for the implementation of advanced clinical practice is ‘to enable practitioners to practise to their full potential’, paving the way for new ways of working and new models of care.
The RCEM’s curriculum for ACPs is a manifestation of that vision and Mr Phipps says development of the ACP role is welcome.
‘Where traditionally staff would go into management – become a matron or be in overall charge – this gives them the option to go down the clinical route – become a senior clinician or senior clinical decision maker – and develop their clinical leadership skills.
‘It gives the person the option to stay in clinical care or direct patient contact as a senior clinician.’
Mr Phipps adds: ‘From a nurse’s perspective, the ACP role is fantastic. If an ACP’s base registration is a nurse, they’re still a nurse but they have an additional skill set.’
Laura Jukes, lead advanced nurse practitioner at Poole Hospital NHS Foundation Trust, says the HEE framework and the so-called ‘four pillars’ on which it is built – clinical practice, leadership and management, education, and research – are already beginning to influence education programmes, but this itself can be confusing.
‘You can be an advanced practitioner working at an advanced clinical practice level, but is this the same as the advanced clinical practitioner role as detailed by the RCEM? It is confusing.
‘A recordable qualification is a must, with parameters of what you need to have achieved to be awarded the qualification.’
‘I think the ACP role in the purest form blurs the boundaries between nursing and medical roles’
Ms Jukes’ department was part of a Wessex-wide development programme that looked at developing a majors role in emergency settings.
‘It wasn’t accredited but from a regional perspective it provided a marker of what majors practitioners should look like and be competent in.’
After two intakes it was decided, first to follow the RCEM framework for ACPs, and then to adopt an in-house programme that takes elements from the Wessex and the RCEM programmes but focuses on common presentations.
‘I think the ACP role, if adopted by EDs in the purest form as outlined by the RCEM portfolio, blurs the boundaries between nursing and medical roles.’
She adds: ‘This is not necessarily a bad thing but may be more suited to bigger centres.
‘And ANPs working in my department who see majors patients but without RCEM credentialing are still working at an advanced clinical practice level.’
Perhaps the main question arising from this debate about job titles, professional boundaries, and credentialing versus registration is whether any of it, ultimately, affects patient care.
‘This is difficult,’ says Ms Jukes. ‘It is important for patient safety that, if you claim to be working at an advanced level, you have an underpinning level of knowledge and expertise to support this.
‘That’s important for patients and for our professional identity.’
The NMC said it does not regulate advanced practice and it would not comment further.
What’s in a name?
Advanced nurse practitioners (ANPs) are educated at master’s level, and use expert knowledge and skills.
The RCN describes ANPs as ‘having the freedom and authority to act, making autonomous decisions in the assessment, diagnosis and treatment of patients’.
A more detailed definition in a Department of Health 2010 position statement says the role includes decision making, leadership, management and quality improvement, as well as an understanding of the ‘social, political and economic aspects of healthcare’.
Emergency nurse practitioners (ENPs) are usually senior emergency department nurses specially trained to treat minor injuries. They are able to assess, diagnose, treat and discharge some patients without reference to a doctor. Without regulatory and educational frameworks in the UK, ENP roles have developed in accordance with local need.
Advanced clinical practitioners (ACPs), according to Health Education England (HEE), ‘enhance capacity and capability within multi-professional teams by supporting existing and more established roles’.
HEE defines advanced clinical practice as: ‘A level of practice characterised by a high degree of autonomy and complex decision making. It includes the analysis and synthesis of complex problems across a range of settings, enabling innovative solutions to enhance people’s experience and improve outcomes.’
Find out more
- NHS Education for Scotland (2012) Advanced Practice Toolkit.
- Lansley A (2011) Enabling Excellence: Autonomy and Accountability for Healthcare Workers, Social Workers and Social Care Workers.
- Health Education England (2017) Multi Professional Framework for Advanced Clinical Practice in England.
- Department of Health (2010) Advanced Level Nursing: A Position Statement.
Read more about the debate online
- Case M (2018) Is there a need to define myself as a nurse? Emergency Nurse.
- Rumley-Buss M (2018) Bigger Picture: ‘One size does not always fit all’. Emergency Nurse.