Advanced nurse practice originated in the USA and Canada in the 1960s and Barbara Stillwell is credited with both importing the role to the UK in the 1980s and collaborating with the Royal College of Nursing (RCN) to establish nurse practitioner degree programmes (Rogers and Gloster, 2020). Internationally, there is a robust network to support advanced practice nurse development, the International Council of Nurses Nurse Practitioner Advanced Practice Nurse Network (ICN NP/APNN). The UK, however, is moving towards multidisciplinary advanced practice (Health Education England (HEE), 2017; Department of Health (DoH), 2019; Welsh Government (WG), 2020; Scottish Government (Scot Gov), 2021). There is an abundance of evidence to support the effectiveness of advanced practice nurse roles (Laurant et al, 2018; Evans et al, 2020; Hooks and Walker, 2020), which is reassuring but also indicates a continual requirement for validation of this role.
Advanced practice development in the UK across the professions aligns to focus on four pillars of practice (NHS Education for Scotland (NES), 2018). These pillars of practice are detailed as clinical practice, facilitation of learning, leadership and evidence, and research and development. Exact terminology regarding these pillars may vary slightly across the UK.
Current advanced practice titles tend to indicate a concentration on clinical aspects of advanced practice, for example use of the title advanced clinical practitioner. There remains, however, a requirement to demonstrate capability across all four pillars. To add further confusion, across the UK a variety of titles are used to denote advanced practice.
This article will focus on the importance of education and development for advanced practitioners, but will start by providing some detail of the background development of advanced practice in the UK to justify the focus on ongoing achievement of capability across the four pillars. To avoid confusion with the range of titles used in the UK aligned to advanced practice, the term advanced practice and advanced practitioners will be used.
Background to advanced practice nurse development
During the 1990s, regulation of nurses was provided by the United Kingdom Central Council (UKCC). The UKCC undertook a number of consultations and identified growing support for regulation of ‘higher level practice’ (Castledine, 1998). Castledine (1998) advised this was required because a confusing array of titles such as nurse practitioner, advanced practitioner and specialist practitioner were being used without clearly defined roles and there was lack of understanding about the knowledge and skills required to practice in these roles. There was widespread agreement that it was the level of practice rather than the title of the role that required clarity and the UKCC consequently employed the term ‘higher level practice’. During this time, the UKCC developed proposals to regulate this higher level practice and proposed outcomes against which practice could be measured (Norman, 2000). These seven outcomes have been further refined into what we now refer to as the four pillars of practice. In 2001, the Nursing and Midwifery Council (NMC) replaced the UKCC. The NMC continued to support regulation of higher level practice, but work on this ceased in 2009 when it was advised that additional regulation was not required (NMC, 2009). The higher level practice work, however, guided the development of an advanced practice toolkit. This toolkit was originally developed as a Scottish resource, but as its relevance was UK-wide, it was subsequently endorsed by Chief Nursing Officers across the UK (NES, 2018).
In 2021, the Scottish Government produced paper 7 of the Transforming Roles programme, which specifically identifies dedicated time for advanced nurse practitioners (defined as 10% per week pro rata) to support development across the three non-clinical pillars. As this is a newly published paper, embedding this requirement in practice is at an embryonic stage and specific to Scotland. At the time of publication, there have not been similar indications from the other three UK countries in terms of specified time that should be dedicated to non-clinical development.
Advanced practitioner education
UK advanced practice programmes offer education that aligns with the four pillars, and a requirement to demonstrate capability across these pillars is required for health professionals developing in advanced practice roles. Of interest, however, is the terminology used when defining educational requirements for advanced practitioners. The National Leadership and Innovation Agency for Healthcare (NLIAH) (2010), DoH (2016), HEE (2017) and Scot Gov (2017) have all indicated that masters level education is a prerequisite for advanced practitioners, but have stopped short of indicating a full masters award is required, although it is recommended. The International Council of Nurses identified in 2001 that a full master's level award was required for advanced nurse practice, and in the USA and Canada there have been moves towards doctoral preparation for advanced practice nurse roles. Gloster and Leigh (2021) argue that the failure to complete a full master's programme may leave advanced practitioners vulnerable and potentially under prepared to demonstrate capability across the four pillars.
Continual education and development
Healthcare practitioners are required to competently provide care that is ethical, safe and effective. Lifelong learning is a mandatory requirement for revalidation for healthcare practitioners, who must demonstrate and evidence continual development in their area of practice. In the absence of specific regulation for advanced practice, the UK policy documents aligned to advanced practice (NLIAH 2010; DoH 2016; HEE, 2017; Scot Gov, 2017) indicate ongoing professional development as a requirement for advanced practitioners. In order to ensure public safety, the regulators such as NMC, Health and Care Professions Council (HCPC) and General Pharmaceutical Council (GPhC) make this specific compulsory requirement for all registered practitioners regardless of role. This demonstration of ongoing capability aligns with a robust governance approach, which is required not only for the regulator but also the employer and, arguably, the practitioner who should feel assured that they continue to meet requirements.
Figure 1. Four pillars of practice.
Buchan et al (2019) argue that budget cuts and lack of support to undertake continuing professional development (CPD) requirements have had an adverse effect on achievement of revalidation requirements. The global COVID-19 pandemic has further challenged the opportunity and capacity of staff to ensure continuous development requirements are attained. In addition, variation in roles across the UK due to lack of regulation has led to disparity in roles and support available (Wood et al, 2020). Regulation of advanced practice is very topical currently due to the NMC's pending review, but is seen as a potentially controversial move due to the organic growth of this area of practice across the UK. Lifelong learning, however, remains a crucial and mandatory requirement for advanced practitioners and efforts to achieve these requirements can be met in a variety of ways.
As identified above, there remains an obligation for advanced practitioners to align their practice and subsequent CPD with four pillars. Arguably, this represents a reductionist approach, which does not fully encapsulate the complexity of advanced practice (Gloster and Leigh, 2021). Overall, as a group, nurses tend to focus less on the research pillar, but there are clear directions in the UK to support a collaborative approach to advanced practice developments. Practitioners looking to maintain and develop research capability should embrace any opportunities to do this. With the developing governance arrangements across the UK comes potential opportunities for collaboration in research. Additionally, advanced practitioners could seek support from their local educational institutions to collaborate. In Scotland, for example, the recently developed national advanced practice newsletter (Henderson and Graham, 2021) highlights opportunities for involvement and encourages collaboration in research.
As an autonomous practitioner, individuals should consider the evidence required to demonstrate achievement and maintenance of capability across the four pillars. Gloster and Leigh (2021) argue for equivalent concentration across the pillars to verify effective practice. To demonstrate capability, practitioners should consider the evidence required to reflect the specific pillar, for example for the clinical pillar case-based discussions or patient feedback could be utilised as evidence. The research pillar evidence might include publications or collaborative projects. It may be the evidence supports achievement of more than one pillar. To contextualise learning needs to individuals and areas of practice, self-direction of ongoing competence and capability is encouraged. However, networking and sharing ideas with colleagues who are also seeking to ensure their own ongoing capability would be of benefit.
Learning in practice
There are core requirements in advanced practice programmes across the UK for practice supported learning and assessment. One example of this is the non-medical prescribing (NMP) programme, which has specific regulatory requirements. For access to advanced practice programmes and NMP, students are asked to demonstrate organisational support from managers and have identified named practice assessors (exact terminology varies between professional groups), who may or may not be from the same professional group as the student. This indicates an encouragement to develop robust support networks in practice, which can be maintained beyond programme completion. The ability to choose an appropriate assessor with whom a trustful rapport has been established supports an effective learning experience. Additionally, this collaboration in learning is seen as essential to enable safe practice (McCormick and Downer, 2012; Gloster and Leigh, 2021) and maintenance of these robust collaborations should be considered for ongoing support.
Multidisciplinary support
With the UK multidisciplinary focus on advanced practice developments comes opportunities for practitioners to work together, promoting collaboration and inspiring new ways of thinking. When considering the development of multidisciplinary networks, practitioners should be cognisant of and embrace professional culture variations. Hall (2005) advises that professional cultures are rooted in historical development and have values and customs linked to the homogeneousness of that profession, but that are concealed from other professions and this can affect interprofessional collaboration. She indicates for example, nurses favour teamwork while medical practitioners seek to adopt leadership roles. Consideration of these cultural variations has the potential to impact negatively on professional development where collaboration is promoted. Homeyer et al (2018) and West et al (2020) confirm effective interprofessional collaboration supports the establishment and efficiency of good teamwork, healthy working environments and empowered staff. Nationally, partnership and collaborative working are promoted as key components across the UK (Welsh Government, 2018; NES, 2019; NHS England, 2019) and should therefore be endorsed.
CPD requirements
Karas et al (2020) undertook a scoping review of CPD requirements for UK health professionals. They found variation in CPD requirements across professional groups, which, arguably, will challenge the ability to be explicit for advanced practice. For example, the authors report a focus on the practitioner identifying their own learning needs and planning ways to address these needs. Peer supported learning is essential for both NMC and GPhC registrants, but is only suggested for HCPC registrants. Reflection is identified across the regulators, but it is not specified whether this should be used to develop a learning plan or reflect after a CPD activity. The NMC are unique in requiring post-CPD activity to be discussed with another registrant. Reflection is a core requirement across most professions, but the authors argue prospective reflection, which is key for CPD, is not a requirement for regulation (Karas et al, 2020). Interprofessional learning is not identified as requisite for all professions and effective CPD activity is regarded as being ambiguous. Karas et al (2020) indicate that group and peer learning are successful in guiding professional behaviour, but how this should be achieved is open to interpretation and not required by all regulators. The authors argue that with a focus on integration and team working, interprofessional education (IPE) should be a core tenet. IPE is not, however, required CPD, and this, they argue, may adversely affect the development and provision of integrated care.
Wallace and May (2016) propose an outcome-based approach to CPD activities is vital to ensure benefits to practice and support an improvement to healthcare outcomes. The authors indicate the focus should be on interaction, reflection, facilitated skills development and repeated opportunities to practice and simulation could form part of this. Although this article relates to a review of CPD in medical education, it has relevance for advanced practice. This outcome-based approach is in contrast to traditional approaches, which support a more didactic approach to learning, such as conference or workshop attendances. This traditional approach to CPD is known to provide little improvement on practitioner performance (Wallace and May, 2016) compared to activities that enable interaction, reflection and identification of variation between performance and standards. The latter having resulted in considerable changes to practice and improved patient outcomes (Wallace and May, 2016).
An outcome-based approach aligns with the suggestions above of practitioner responsibility for individual needs and lifelong learning and could include activities such as audit and feedback. This will aim to ensure demonstration of the impact of learning on individual practice. Wallace and May (2016) support identified staged approaches to CPD, which includes reflection on practice, identification of individual learning needs, undertaking appropriate CPD to meet these needs and measuring impact. They propose one method of measuring impact could be through patient and colleague feedback. Mini clinical examinations, peer review and simulations are some of the activities that can be used to facilitate ongoing learning and development and advanced practitioners should be aware of this from advanced practice education requirements. These activities will support ongoing clinical practice development, but we must also be cognisant of achievement of capability across the non-clinical pillars. Transforming roles paper 7 (Scot Gov, 2021) supports the use of metrics for advanced nurse practitioners to determine and communicate impact and the detail provided in this paper would be useful to review.
Advanced practitioners could consider the possibility of honorary contracts with local higher education institutes. This would support development of capability in both education and potentially research. The availability of e-learning opportunities has increased as a result of the COVID-19 pandemic and opportunities to network with colleagues in similar roles across the UK are readily available and should be encouraged.
Conclusion
Across the UK, Government policy directives advocate for the development of multidisciplinary advanced practice roles. There is a wealth of evidence to support advanced practice nurse roles, but a continuing requirement to evidence the impact of these roles. Advanced practitioners should demonstrate competence and ongoing capability across the four pillars and look to develop robust support networks in the workplace. Interprofessional collaboration and has been shown to be effective in ensuring good teamworking and empowered staff and opportunities to undertake IPE should be encouraged as this will support the provision of integrated care.
Further reading
The links to the policy documents referred to in this article are identified in the reference list and will provide useful reading. In addition, the following webpages should be of interest.
- The Association of Advanced Practice Educators UK: http://aape.org.uk/
- The International Council of Nurses Nurse Practitioner/Advanced Practice Nurse Network: http://icn-apnetwork.org/
- The Advanced Practice Toolkit: https://www.advancedpractice.scot.nhs.uk/
- Health Education England Advanced Practice: https://www.hee.nhs.uk/our-work/advanced-clinical-practice/what-advanced-clinical-practice
- Royal Pharmaceutical Society Advanced Practice: https://www.rpharms.com/recognition/all-our-campaigns/shaping-the-future-of-pharmacy-education/advanced-practice
KEY POINTS
- Lifelong learning is a regulatory requirement
- Continuing professional development (CPD) requirements across professional groups vary, but advanced practitioners should demonstrate ongoing capability across the four pillars of practice
- Opportunities for interprofessional learning should be embraced to support partnership working and integrated care
CPD reflective practice
Reflect on your practice and consider the following:
- What are your learning needs in relation to the four pillars?
- What impact might cultural variations have on your professional development?
- How might you measure the impact of CPD on your practice?