Features

Setting the bar: how advanced practitioners are being recognised for transferable skills

Nurses, paramedics and other professionals working at advanced-practice level in emergency care can now obtain credentials that are nationally recognised, giving them pride and recognition in their roles and enabling them to easily transfer their skills

Amy Cawthorne, an advanced clinical practitioner in emergency care in Leeds, is one of the first emergency nurses in the country to reach a national standard for her role.

Ms Cawthorne spent nine months going through the new credentialing scheme for emergency care advanced clinical practitioners (ACPs) devised by the Royal College of Emergency Medicine (RCEM) and Health Education England (HEE).

The UK-wide approach has been developed to provide standardisation and consistency on the work and ability of ACPs to improve patient safety and enable transferability between employers. It is open to nurses, paramedics and other professions who may work at an ACP level.

The role of emergency advanced clinical practitioners

Advanced clinical practitioners can look after patients with

...

Amy Cawthorne, an advanced clinical practitioner in emergency care in Leeds, is one of the first emergency nurses in the country to reach a national standard for her role.


Advanced clinical practitioner Amy Cawthorne (right) in a weekly multidisciplinary training session
with consultant doctor Mohit Arora and staff nurse Nyasha Mujaji

Ms Cawthorne spent nine months going through the new credentialing scheme for emergency care advanced clinical practitioners (ACPs) devised by the Royal College of Emergency Medicine (RCEM) and Health Education England (HEE).

The UK-wide approach has been developed to provide standardisation and consistency on the work and ability of ACPs to improve patient safety and enable transferability between employers. It is open to nurses, paramedics and other professions who may work at an ACP level.

The role of emergency advanced clinical practitioners

Advanced clinical practitioners can look after patients with a wide range of pathologies from the life-threatening to self-limiting conditions. They can:

  • Identify people who are critically ill and injured, providing safe and effective immediate care.
  • Provide expertise in resuscitation.
  • Establish diagnosis and differential diagnosis rapidly, and initiate and plan for definitive care.
  • Work with all inpatient specialties as well as primary care and pre-hospital services.
  • Identify who needs admission and who can be safely sent home.

 

Credentialing is a way of showing that a nurse or other professional has reached the competencies defined by the RCEM for the role.

Demanding but worthwhile

Gathering the required evidence was demanding but worthwhile, says Ms Cawthorne, who works at Leeds Teaching Hospitals NHS Trust. She already worked as an ACP, alongside ten colleagues, in a locally agreed role.

Some of the other ACPs are going through the credentialing process now and all trainees will work towards this standard.

‘Day to day I am functioning the same at work, as I was already assessing, diagnosing, treating, prescribing and discharging or admitting patients,’ Ms Cawthorne says.

‘But credentialing gives us that national recognition and clear standard for everyone to be able to work towards. It made me really push myself in all the required areas and gives colleagues and patients a better understanding of the role. It is also important that it comes from the royal college, as we work closely as part of the emergency care team.’

Debated at RCN

Concerns about how to ensure that training and levels of competence are properly established for advanced nurses in all specialties have been discussed in the nursing profession for some time. This included a debate at RCN congress in 2010, and calls for the Nursing and Midwifery Council to record in some way the standard reached by those at an advanced level.

RCN credentialing

The RCN is about to launch its own national scheme to recognise nurses working at an advanced level.

Those completing the UK-wide credentialing for nurses in any field will go on an RCN database and receive a certificate and a badge.

According to the RCN, gaining a credential will be an opportunity for nurses to enhance their career prospects and reassure patients and the public about their level of expertise and skill.

About 50 nurses have been going through the pilot process to be awarded the RCN advanced-level nursing practice certificate.

Applicants need to be working at an advanced level, have a prescribing qualification and be educated to master’s level. For the next three years there will be a transitional arrangement for those without master’s degrees.

The certification will be valid for three years, after which nurses will need to renew though a more ‘light-touch’ version of the system, the RCN says.

There was controversy when the RCN announced that it would cost nurses £350 to receive accreditation, but the figure is under review due to concerns that it is too high.


Shirley
Reveley

RCN associate consultant for credentialing Shirley Reveley says: ‘Patients will see that badge, and know that these nurses are working at an advanced level and have gone through a period of education and training. The nurses will be able to demonstrate education, experience and competence.’

The RCN has backed the emergency care ACP curriculum, devised by the Royal College of Emergency Medicine and Health Education England.

Rob Crouch, who led the RCEM working party developing the ACP curriculum and co-chaired the group for the credentialing scheme, says elements of the two different credentialing schemes are complementary, and that the RCN scheme is more generic.

 

In 2009, the Council for Healthcare Regulatory Excellence report recommended, however, that there was no need for additional regulation of advanced practice in nursing and that employers should be responsible for the governance and regulation of these roles.

Nurses working at an advanced level are increasingly important in filling medical workforce gaps in emergency departments (EDs) and are often put on junior doctor rotas. With attendances and waiting times increasing in EDs with too few medical staff, the need for ACPs is clear.

But there have been concerns that roles and skill levels vary from employer to employer.

Vital to patient safety

The RCN, which supports the RCEM scheme, is currently also testing its own generic scheme for credentialing advanced nursing practice.


Rob Crouch

Rob Crouch, consultant nurse in the University Hospital Southampton NHS Foundation Trust ED and honorary professor of emergency care at the University of Southampton, led the RCEM working party developing the ACP curriculum and co-chaired the group for the credentialing scheme. He says improving the standardisation of the role is vital to patient safety.

While universities provide high-quality master’s level courses in advanced practice, these do not include specialty-specific competencies or nationally defined curricula, he says.

‘The emergency nurse practitioner model has developed over the last couple of decades but there is no definition of what one is and huge variation in terms of education, preparation, competency, scope of practice and role,’ Professor Crouch says.

Professional protection

‘Credentialing is important for patient protection, patient safety and professional protection. This system clearly states the level of your practice.

‘ACPs are working under the delegated authority of the consultant, and part of the delegation requires the doctor to have a good understanding of their knowledge and competence. It is a really important piece of work in that we now have a national standard for ACPs in emergency care.’

The RCEM work began after HEE published a report in 2013 on ED workforce challenges, which highlighted the shortage of doctors. One of the recommendations from the document, called Emergency Medicine: Background to HEE Proposals to Address Workforce Shortages, was to develop the role of the ACP.

‘There was a recognition that we needed to look to different workforce models in the future, and what contribution advanced practitioners could bring to carry part of the workload,’ Professor Crouch says.

Evidence of competence

The national ACP curriculum has been based on the medical curriculum for junior emergency medicine doctors and draws on the junior doctor model of assessments and care. It was also used to identify groups of patients that could be cared for by ACPs.

The curriculum, published in 2015, lists the competencies that should be reached by ACPs, with separate routes for those in adult care, children’s care and a combined care pathway for adult and children's care.

This curriculum can be used to train new ACPs and to award credentials to those who are already working at an advanced level. Those who wish to meet the standard will have to provide evidence that they have achieved each competency in the curriculum.

Would-be ACPs, who are training, will gather the evidence for their RCEM e-portfolio as they go through their course, rather than having to compile it subsequently like those who are already working at an advanced level.

Once in a career

A wide range of assessments, including at least 20 consultant assessments, and the completion of a recognised life-support course are also required as part of the evidence.

A trained panel will assess the e-portfolio to decide whether the nurse or other professional has achieved the required competencies.

Once credentialed, the professional will receive a certificate and their name will be added to an RCEM register. Credentialing will only need to be completed once in their career.

The first three ACPs, two nurses including Ms Cawthorne and a paramedic, have been credentialed, and a wider pilot scheme was is to finish in April.

Demanding process

Professor Crouch says it is a demanding process that takes about nine months to complete. ‘The burden is quite considerable in terms of the evidence that is required to show you are functioning at that level of practice,’ he says. ‘It is a significant amount of work.’

Those already working at an advanced level in an emergency team may ask why they should put themselves through the challenging process of becoming credentialed.

‘The advantage is that they have reached a national standard,’ Professor Crouch says. ‘For them and their employer, there is an assurance around their level of knowledge, experience and clinical sign-off in practice, which is really important.

‘This is one of the few examples where there is a structured national programme. In the future it will help with transferable skills and knowledge.’

Not without critics

Professor Crouch hopes that employers seeking ACPs in the future use it is as a requirement in job descriptions.

But the scheme is not without criticism. Alastair Gray, senior lecturer in emergency and advancing practice at Coventry University, agrees that credentialing advanced practice can improve patient safety, but feels that the RCEM-HEE model is too geared towards ACPs replacing doctors.


Alastair Gray

‘It will give them competencies that relate to medical practice that will provide a certain level of safety and security and assurance to trusts employing staff to act in a quasi-medical capacity,’ he says. ‘But that is only one dimension of advanced practice, and that is where my concern lies – I want to see advanced nursing practice, and not just nurses fulfilling medical practice.’

While helping alleviate the shortage of doctors is one of the factors driving advanced practice, Mr Gray says that meeting the needs of people with long-term conditions and complex problems is also crucial.

Essential elements missing

‘There isn’t really a medical cure so in that sense a medical replication model does not address the problem,’ he says. ‘In terms of addressing long-term conditions, we need practitioners to be able to bring their particular skills to long-term condition management to keep people out of hospital, maximising health and enabling patients to manage their own conditions.’

He also fears other essential elements of advanced nursing such as education, innovation, leadership and research are not included in the medical replication model of training. Opportunities for nurses to integrate and develop services could be lost if their focus is on hands-on clinical work, he says.

But Ms Cawthorne has no doubt that becoming a credentialed ACP is worthwhile. She is particularly pleased that it gives nurses and other care professionals a chance to advance while remaining focused on clinical care.

‘Credentialing gives us something to work towards that is still clinical. Most nurses and paramedics can get so far then have to move into management. That is why I wanted to be an ACP in the first place – to stay with patients and really advance my skills and knowledge.’

Case study: Paramedic Els Freshwater has found that credentialing has boosted her knowledge, confidence and credibility

Els Freshwater: ‘The main thing about credentialing is that it is a benchmark.'

Ms Freshwater, who works in the emergency department at University Hospital Southampton NHS Foundation Trust as an advanced clinical practitioner, says credentialing sets an important standard.

‘The main thing about credentialing is that it is a benchmark,’ says Ms Freshwater, who has 15 years’ experience as a paramedic. ‘It provides a recognised standard. There is a lot of confusion about advancing practice and different roles used, in EDs and elsewhere.

‘We work with our medical colleagues, seeing patients alongside junior doctors, so to have the recognition of our knowledge and skills by the college is really important.’

Ms Freshwater encourages other nursing and paramedic colleagues to undertake ACP credentialing, but warns them to expect a challenge. ‘The trickiest part was collecting the evidence for the portfolio,’ she says. ‘It is sizeable but it needs to be, to encompass the whole range and breadth of conditions that we encounter in emergency care.’

Being credentialed has increased her clinical knowledge and skills, while providing valuable evidence and clarity to delegating medical consultants about her scope of practice, an important factor in clinical governance.

‘It has improved my skills and knowledge, which are transferable,’ she says. ‘It has given me more confidence and credibility too, as a lot of these roles are quite new and it helps to know that I have been independently assessed and have all the evidence to demonstrate it.’


Further information

Want to read more?

Subscribe for unlimited access

Enjoy 1 month's access for £1 and get:

  • Full access to emergencynurse.com
  • Bi-monthly digital edition
  • RCNi Portfolio and interactive CPD quizzes
  • RCNi Learning with 200+ evidence-based modules
  • 10 articles a month from any other RCNi journal

This article is not available as part of an institutional subscription. Why is this?

Jobs