1. What is Advanced Practice?
Dr Helen Rushforth
Programme Lead
MSc Advanced Clinical Practice
University of Southampton

2. Advanced Nursing Practice
Many presentations start with a definition…

3. Advanced Nursing Practice
We know the concept of advanced practice is one that seems very important to nurses …. But trying to define what it actually is – is rather more complex!

4. Advanced Nursing Practice
Key question:
Is it a concept?
Is it a specific ‘practitioner’ role?
Is it a level of practice?
In some ways is it all of these things?

5. Advanced Nursing Practice – UKCC (1994)
‘Advanced practice is concerned with adjusting the boundaries for the development of future practice, pioneering and developing new roles responsive to changing needs, and with advancing clinical practice, research and education to enrich professional practice as a whole’
UKCC (1994:8)

6. Kim Manley (1997) Three year action research project leading to
‘A conceptual framework for advanced practice’
Expert practitioner
Educator
Researcher
Consultant – comprising the roles of:
Transformational Leader
Collaborator
Change Agent
Role Model
Facilitator
Forerunner of ‘Consultant Practitioner’ role.

7. Late 20th Century Quasi-regulation of Advanced Nursing Practice
Scope of Practice (UKCC 1992)
ENB Higher Award (1993)
UKCC Specialist Practitioner (UKCC 1994)
Higher Level Practice (UKCC 1999)
RCN Accredited Nurse Practitioner Programmes

8. Early 21st Century… Policy Regarding Advanced Nursing Roles
Making a Difference (DH1999)
NHS Plan – 10 Key Roles for Nursing (DH 2000)
Reforming Emergency Care (DH 2001)
Liberating the Talents (DH 2003)
Modernising Nursing Careers (DH 2006)

9. Early 21st Century…
Research Regarding Advanced Nursing Roles
Horrocks et al (2002). – Systematic Review of Whether Nurse Practitioners Working in Primary Care can provide Equivalent Care to Doctors - BMJ Systematic Review
Laurant et al (2005) Substitution of Doctors by Nurses in Primary Care – Cochrane Report.

10. Mantzoukas and Watkinson (2006)
Literature review: generic features of ‘advanced nursing practice’ from various definitions:
Use of knowledge – scientific and intuitive
Critical thinking and analytical skills
Clinical judgement and decision making
Professional leadership
Coaching and mentorship
Research skills
Changing practice
‘…the emerging common goal is that of professional autonomy of the nursing discipline’. (2006:31)

11. NMC (2005-2006) Consultation on Advanced Practice Regulation
Growing concern regarding lack of public protection due to:
Increasing formal regulation of nursing advanced practitioner roles in other Western countries
Contrasting UK position with no formal requirements for education or competency assessment
Proliferation of unprotected titles e.g.:
Advanced Nurse Practitioner/Nurse Practitioner
Clinical Nurse Specialist
Emergency Nurse/Care Practitioner
Nurse Clinician
Community Matron
Consultant Nurse/Practitioner (some title protection)

12. NMC Consultation Advanced Nurse Practitioner Registration (2005)
Proposed Definition
A registrant who ‘has command of an expert knowledge base and clinical competence, is able to make complex clinical decisions using expert clinical judgement, is an essential member of an interdependent health care team and whose role is determined by the context in which s/he practices.’

13. NMC Post Consultation: Agreed ANP Definition (2006)
‘Advanced nurse practitioners are highly experienced and educated members of the care team who are able to diagnose and treat your healthcare needs or refer you to an appropriate specialist if needed.’
Key skills included:
history taking and physical assessment
initiating investigations
diagnosis
treatment/prescribing/referral
working independently within the context of a team 13

14. NMC Consultation Findings - Advanced Nurse Practitioner Registration (2006)
Two other key and important outcomes
Should the title be ‘Nurse Practitioner’ or ‘Advanced Nurse Practitioner’? Response chose Advanced Nurse Practitioner
Should the role be regulated? Overwhelming support for YES

15. Advanced Practice - Skills for Health (2007)
Level Director
Level 8
Consultant Practitioner
Advanced Practitioner
Level 7
Senior/Specialist Practitioner
Level 6
Registered Practitioner
Level 5
Level 7 Experienced clinical professionals who have developed their skills and theoretical knowledge to a very high standard. They are empowered to make high-level clinical decisions.
= advanced practice as a LEVEL of practice
(Based on Skills for Health 2006, 2007 revised 2010)

16. Specialist Practice Expert Practitioner Specialist Practice
Advanced Generalist
Senior Specialist
Specialist Practice
Generalist Practice
Junior Specialist
Junior Generalist
Novice Practitioner

17. Novice to Expert – Benner (1984)
Five levels of practice:
Novice
Advanced Beginner
Competent
Proficient
Expert - includes ‘intuition in clinical situations’; ‘deep understanding and experience’; ‘working beyond rules’; ‘high level proficiency and flexibility’, and ‘dealing with complexity and uncertainty.’
Expert
Novice

18. 2006 - Differing Perspectives
Broad, inclusive view = Level of Practice (Skills for Health)
equates with an expert practitioner,
any one working ‘at a level well beyond initial registration’
i.e. most nurses at band 7/8 (or equivalent), plus many specialists at band 6, are effectively advanced practitioners VS
Narrower, specific view = Role (NMC)
a clearly defined role within the expert domain
independent assessment, diagnosis, treatment and care of those with undifferentiated presentations or deterioration
higher level of professional autonomy in making complex clinical (often medical) judgements
= advanced practitioner

19. Council for Healthcare Regulatory Excellence: (2009)
Government commissioned review of Advanced Practice in response to debate regarding regulation:
‘…advanced practice is a level of practice along a continuum in which practitioners develop their professional knowledge, skills and behaviours to a high level, at which they are capable of safe and effective practice in more complex situations and with greater autonomy, responsibility and clinical accountability…’
(CHRE 2009 ‘Advanced Practice’ pp2-3)

20. So…with regard to regulation
CHRE (2009) concluded that in most instances advanced practice is a higher level of practice
i.e. advanced practice = expert practice
And thus they concluded you don’t need regulation - since why would you regulate ‘expertise’?
Thus they recommended that professional codes of conduct are adequate safeguards for advanced practice in most instances - and therefore that ‘self regulation’ was the way forward.

21. DH (2010) – Front Line Care Active NMC ‘lobby’ of government
Ongoing concern about proliferation of roles and titles related to advanced practice
Share NMC concern that advanced nurse practitioner regulation remained unresolved
Support minimum qualifications for advanced practice roles
‘Front Line Care: Report by the Prime Minister's Commission on the Future of Nursing and Midwifery in England’.

22. Department of Health (2011) Enabling Excellence White Paper
‘the health professions regulators will need to demonstrate that measures such as advanced practice registers, which have some professional support but where a compelling case for further regulatory action has yet to be made, are an appropriate and proportionate use of registrants’ fees’. (DH 2011 clause 2.8) i.e. there was insufficient evidence of risk for regulation – and self regulation was clearly the way forward….

23. Advanced Level Nursing – A Position Statement: DH (England) (2010)
Nationally agreed standard for self regulation
Also ‘applicable to other healthcare practitioners’
28 benchmark statements in 4 practice domains
Advanced practice is ‘a level well beyond initial registration’ – incorporating complex reasoning, critical thinking, reflection and analysis to inform assessments, clinical judgements and decisions in challenging situations. (p7)
Masters level education viewed as key
Individual and employer responsibility to ensure competence to practice.

24. Similar support for ‘self regulation’ of Advanced Practice across the UK
NLIAH Wales (2010) ‘Framework for Advanced Nursing, Midwifery and Allied Health Professional Practice in Wales’
NHS Education for Scotland ( )‘Advanced Nursing Practice Toolkit’ and ‘Post Registration Career Framework for Nursing, Midwifery and Allied Health Professionals’
DHSSPS Northern Ireland (2014) ‘Advanced Nursing Practice Framework’

25. Advanced Practice: Four Key Domains/Pillars
Clinical Practice/ Direct Care
Research/
Improving Quality/ Developing Practice
Leadership/ Management/
Collaborative Practice
Education/ Developing Self and Others
The Scottish Government (2012, 2014), NLIAH (Wales) (2010) DH (England) (2010) , DHSSPHNI (2014)

26. Levels of practice - Exemplars
Increasing autonomy
Novice to Expert

27. Current Situation
Growing support for Advanced Nurse Practitioner Roles
Particular focus on primary and community care
Driven by shortfall in medical and GP recruitment
Growing multi professional focus for Advanced Practice

28. BUT… is self regulation working….
…or is there still a need and a case to continue to fight for the regulation of Advanced Practice…

29. The case for regulation?
…CHRE (2009) also stated that ‘if the nature of practice changes so significantly that a practitioners scope of practice is different from initial registration – rather than gradually evolving – then action to assure fitness to practice may be required… (CHRE 2009:1)
Scope to argue that Advanced Nurse Practitioners – if we focus on those in specific ANP roles – fulfil this criteria…

30. ANP – Hybrid role model? Medicine ANP Nursing
…yet there are no agreed, mandatory competency assessments, educational standards or protection of the title…
Brook and Rushforth (2011)

31. Expert Nursing Practice
(Advanced Practice as a level of practice)
= LOW RISK
Novice

32. Advanced Nurse Practitioner
= HIGHER RISK
Nursing
ANP
Medicine

33. Advanced Nurse Practitioner
= HIGHER RISK
..but very limited evidence of this risk exists…hence CHRE and DH argue there is no current case for regulation.
Nursing
ANP
Medicine

34. Revalidation and Scope of Practice
Initial thoughts that revalidation might offer some form of advanced practice regulation
Initial links to a persons scope of practice in pilot phase
Post pilot – increased clarity that revalidation was NOT about fitness to practice
However revalidation DOES relate to current practice roles – so is at least it offers a vehicle for some discussion, reflection and potentially adjustment of a registrants role and scope of practice…

35. The Future… workforce redesign
Addresses medical under recruitment as a key driver
Solution lies with current non medical workforce.
Advanced Practice ROLES seen as key - alongside extended roles and increased support staff and physicians associates.
Medics as ‘master diagnostician and clinical decision maker’.

36. The future - credentialing
Royal College of Nursing – Piloting Advanced Nurse Practitioner Credentialing. Full launch 2017
Open to nurses who can demonstrate they are working at an advanced level, who have a Masters qualification (or equivalent) and non medical prescribing qualification.
Formal recognition of advanced level of expertise and skill in clinical practice, leadership, education and research
Credentialed practitioner will be:
on a register
badge and certificate.
Pay registration fee
Update every three years

37. The future…agreed frameworks
Health Education Wessex Advanced Practice Framework - published Oct 2016
Draws heavily on Welsh NLIAH ‘pillars’ of practice and Scottish Toolkit.
Strong multi-professional focus
Includes portfolio template and guidance
Masters education ‘by experience’ as an option – debatable!
Link to national work by Health Education England on National Framework – key meeting 30th November.

38. Any questions?
If you have any further questions about any aspect of this presentation, or what to know more about Advanced Nurse Practitioner educational opportunities, please don’t hesitate to get in touch. Dr Helen Rushforth –