The foundations of advanced practice in Britain lay in the late 1960s and 1970s (Castledine, 2002). The Salmon Report ushered in a new clinical nursing hierarchical structure (Ministry of Health et al, 1966), and by the early 1970s, the Royal College of Nursing (RCN, 1975) considered the concept of advanced practice in its New Horizons in Clinical Nursing report. From the 1970s, a perfusion of nurse specialist roles emerged as the Department of Health and Social Security (DHSS) recognised the invaluable contribution nurses could make to health promotion, wellbeing and the prevention of illnesses (DHSS, 1977; Daly and Carnwell, 2003). Those roles evolved into the advanced practice positions seen today.
The advanced practice role developed dramatically during the 1990s, as a response to the growing pressure faced by the NHS to meet the health demands of society (Lindeke et el, 2010). The UK was facing a growing and ageing population, a greater acuity level of patients, many with chronic conditions and multiple co-morbidities, all against a backdrop of rising healthcare costs (Thompson and Astin, 2019). Consequently, during the 1990s, the UK healthcare context expanded politically, environmentally and professionally. The emergence of advanced practice nursing and the development and widening of advanced nursing practitioners' scope of practice was primarily driven by these factors (Ashburner et el, 1997; Dunn, 1997; Frost, 1998; Wilson-Barnett et al, 2000; Department of Health (DH), 2000). The rationale for expanding the boundaries of advanced nursing practice was born out of an absence of appropriate professionals to carry out the tasks in the face of immense demand (Daly and Carnwell, 2003).
Innovation was needed. British nursing took inspiration from American advanced practice, which was already well established by the 1980s. A study from the American Office of Technology and Assessment showed that advanced nurse practitioners (ANPs) ‘possessed the knowledge and expertise to meet the health needs of up to 90% of the ambulatory care patient population’ and that the care provided by ANPs was cost-effective, accessible and to the same standard as doctors (The Office of Technology and Assessment, 1986). This was what the British government wanted. The government and the NHS needed an intermediate level practitioner because of the reduction in junior doctors' working hours, the dwindling recruitment and retention of both doctors and skilled nurses, and the new NHS initiatives in primary care (Daly and Carnwell, 2003). Ultimately, immense pressure was mounting on the health service, but as is common in NHS history, where there is a problem, nurses are all too often the solution. In this case, ANPs were a key part of the solution.
Significant milestones, such as nurse prescribing being introduced in 1994 in England and 1996 in Scotland, marked the growing importance of advanced practitioners and the gaps they needed to fill in healthcare (Bradshaw, 2001). Since the 1990s, most advanced practitioners have been employed in general practice and acute settings (Ashburner et al, 1997). Nurse practitioners developed and honed distinct competencies in several areas, such as:
- Carrying out a full systematic physical investigation
- Taking a comprehensive patient history
- Making complex diagnostic decisions
- Ordering and then interpreting results, ranging from blood tests to x-rays to mental health assessments
- ANPs also developed skills in prescribing treatment and reviewing progress (Read and Roberts-Davis, 2000). These skills have emerged as the hallmark of advanced practice more generally.
Advanced practice positions were established to provide better care for patients through delivering improved services (Jokiniemi et al, 2012). The value of advanced practice has been continuously recognised in a positive light since the 1980s. Stilwell et al (1987), Touche Ross (1994), Coopers and Lybrand (1996) and Dolan et al (1997) all conducted studies on the value of ANPs and found that advanced practice provided quality and effective care to patients. Nurse practitioners were a key contributor to the reduction in waiting times and medical caseloads. Equally, these studies universally agreed that patient satisfaction with advanced practitioners was high, with many patients being as satisfied, or even more so, with nurse practitioners than with their GP.
According to Raleigh and Allan (2017), part of ANPs' success had been their effective blending of the fundamental skills of a registered nurse with medical responsibility. They were praised for their unique ability to form therapeutic relationships with their patients through their tried and tested skills of active listening, looking and reflecting on patients' stories, all to the benefit of patient care. In fact, many studies, including Kinnersley et al (2000), have found little difference between the quality of care provided by ANPs and GPs.
Advanced practitioners have been remarkably flexible in accommodating the demands on the NHS. The expedited nature of the role's creation meant that advanced practice's scope of professional practice was never clearly defined for fear of being too restrictive and to ensure advanced practice could remain versatile (Castledine, 2000). Therefore advanced practitioners have partially circumvented crippling shortages of doctors by assuming highly skilled roles in a variety of settings – general practice, A&E, and in acute medicine – and they have proven to be effective clinicians, therefore, fulfilling the initial aims of the creation and development of advanced practice. For this reason, by the turn of the millennium, advanced practice emerged as the ‘engine room’ of the NHS (Holyoake, 1996).
Modern advanced practice
Historically, there has been confusion surrounding the level of academic attainment, skills acquisition, knowledge and role identity that defines advanced nursing practice. However, more recently, attempts have been made to offer greater clarity and structure to the progression of advanced clinical practice. In terms of regulation relating to advanced nurse practitioners, The Code of Professional Practice (Nursing and Midwifery Council (NMC), 2018) refers to prescribing practice and indemnity, and therefore, the addition of ACP to the NMC register was deemed not required. This was the result of previous documentation from the Council for Health Regulatory Excellence in 2009, and later in 2011, the Enabling Excellence Command paper allowed recognition of self-regulation (Council for Health Regulatory Excellence, 2009; 2011). Revalidation followed, which was introduced by the NMC (2018). This required each registered nurse to practise in relation to The Code and provide evidence of the ability to practise safely and effectively, through a series of approved documentation for revalidation.
The NMC were not the only nursing organisation to acknowledge the requirements of advanced clinical practice. The RCN produced the Standards of Advanced Level Nursing Practice, the most recent being in 2018, which offered a resource to identify the requirements for advanced level practice (RCN, 2018). This, along with the opportunity to credential one's achievements relating to advanced clinical practice with the RCN, necessitated evidence of working at an advanced level. In 2020, the RCN stipulated that for those nurses who did not possess a master's degree, but who could evidence a level of autonomous practice that included critical thinking, high levels of decision making and problem-solving, value-based care and evidence of improving practice, the mapping to master's level descriptors could be made to facilitate credentialing. Although this remains time limited, ending March 2023, when a relevant master's degree will be required (RCN, 2020).
Recognising advanced clinical practice and defining its purpose and level of ability is reflected in the competencies and capabilities indicated by the Department of Health (DH, 2010) and Health Education England (HEE, 2017). The four pillars of advanced practice are also evident in the Advanced Clinical Practice Apprenticeship Degree, which was agreed in 2018 by the Institute for Apprenticeships and Technical Education (2018) England. This required Higher Education Institutions (HEIs) to collaborate with employers to develop a programme of study that would facilitate the development of the knowledge, skills and behaviours required for advanced clinical practice, with the addition of supervision in the workplace. In addition, the International Council of Nurses (ICN, 2020) produced Guidelines on Advanced Practice Nursing to help clarify the issue. Acknowledgement of specialist capabilities related to specific advanced practice roles also emerged. Competencies related to emergency medicine (Royal College of Emergency Medicine, 2015), primary care (Royal College of General Practitioners, 2015) and the Faculty of Intensive Care Medicine (2015) were developed to address the specific needs associated with advanced level practice. Other core capabilities have since been developed into a framework, which focuses on the requirements of advanced clinical practice within the community and reflects the application of advanced practice in primary care (HEE, 2020a). Work by HEE also involves the ongoing development of structured learning units to address workforce progression and enhance the capabilities of advanced practitioners. HEE (2021a) have provided open-source documents, that will be delivered by education providers, to help standardise learning outcomes and experiences and increase advanced practice capability and capacity.
Clinical supervision to support such clinical knowledge and skills has also been developed by HEE in work undertaken by Dr Deborah Harding. A multi-professional approach to clinical supervision and a structured method to its implementation has been outlined in the Workforce Supervision for Advanced Clinical Practice document (HEE, 2020b) to improve its effectiveness. Although related to medical education, Crossley (2014) states of high-quality clinical supervision and allows the transformation of the learner from indecision to self-assurance and certainty. These requirements for quality clinical support and guidance are transferable and equally important in the development of ACPs in their transition to advanced clinical practice.
This notion of a transitional journey from comfortable ability to the challenges of being a trainee ACP can be complex and damaging to self-esteem (MacLellan et al, 2015). According to Wenger (2006), a community of practice where people come together who have a common interest in something they are involved in, and by interacting with one another develop the knowledge and skill to improve and help the members overcome challenges, is worthy of consideration to support the transitional phase (Reynolds and Mortimore, 2021). Through a sense of community ACPs can share their knowledge, foster relationship building, and help create a sense of support for each other, to nurture development and prevent the uncertainty that transitioning can bring (Murphy and Mortimore, 2020). The authors suggest that when ACPs are supported through transition, there is consistency in patient care through the provision of teamwork, leadership and assistance with workload, with Glendinning and Walker (2019) concluding that the ANP is a great asset and assists in healthcare transformation.
Expert advanced nurse practitioners
The four pillars of advanced practice – clinical, leadership, research and education (HEE, 2017) –provide the foundation of advanced level practice. From Glendinning and Walker's (2019) findings, the ANP demonstrates expert clinical qualities and the ability to work within teams and autonomously (HEE, 2017). These qualities provide the opportunity for advancement and progression for many advanced clinical practitioners, to levels beyond Benner's (1982) ‘expert’.
The Derby Model (Mortimore et al, 2021) identifies two further levels of expert, which indicates how ACPs can contribute to evidence-based care and care on a national and international level, thereby surpassing Benner's (1982) level of ‘expert’. The model supports ACP progression, and it is hoped that this will identify and motivate ACPs and offer a greater focus on the research, leadership and education pillars. This may help address the point made by Lawler et al (2020) that career advancement for ACPs should be planned and communicated, using the ACPs clinical acumen, skills and addressing their proficiency related to all the pillars of advanced practice. This collaborative approach to the development of ACPs and ACPs beyond ‘expert’ level offers a career pathway that reflects the advanced level skills practised by ACPs. This creates an opportunity for embracing innovation as long as it is not stifled by bureaucracy and management. Therefore, appropriate governance and supportive frameworks responsive to the continuing professional development and the unique contribution of ACPs to future health service provision is essential.
Future developments
A supportive and structured approach to the development of advanced clinical practice is the way forward. However, regulation related to this level of practice remains unclear, with a policy project commissioned by the Health and Care Professions Council (HCPC) in June 2020, identifying that increased regulation of advanced level practiced was not indicated (HCPC, 2020). What did emerge from the project was a need for greater definition related to this advanced level of practice (HCPC, 2021).
In addition, implications from the NHS Long Term Plan (2019) necessitate the implementation of improved and up-to-date pathways of care that ensure patient safety. The ACP will be integral to that development, with their education and development monitored by the Centre for Advancing Practice (HEE, 2021b). Developing the workforce to meet the needs of the future NHS is captured in the NHS People Plan 2020/21 (2020), which refers to the transformation across the NHS to improve patient care. Opportunity for progression to advanced clinical practice is also seen in the role of first contact practitioners who help optimise the patient pathway in fields such as musculoskeletal, via agreed road maps of practice (HEE, 2021c). There is also future opportunity for research, innovation, flexibility, leadership, education and the ability for multi-professional teams to learn and work together (NHS, 2020).
Conclusion
It would seem there is current and future opportunity for advanced level practice to progress, and potential for forthcoming structures to enable transition and advancement. Overall, for advanced level practice to continue to thrive it appears that appropriate governance, organisation, and support are required if ACPs are to feel valued and able to evolve. These interventions may help support retention and improve job satisfaction and be the subject of current and future research in the field of advanced clinical practice.
KEY POINTS
- Advanced practice remains fluid to be able to respond to the demands of the changing health care needs of the nation
- National policy and professional bodies will be required to respond to the needs of advanced practitioners in the face of such demands placed upon them, to ensure safe and effective practice is maintained
- Advanced practitioners need an infrastructure that provides support for transition, progression and continued professional development (CPD)
- Standardisation of education, competence and capability continues to evolve through the work of Health Education England
CPD REFLECTIVE PRACTICE
- What do you need to do to develop beyond the expert level as an advanced practitioner?
- What support and governance do you feel should be in place to facilitate your development?
- What can you do to support the transition of trainee advanced practitioners to trained status?
- What key issues within the policies effect your professional development as an advanced practitioner?