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Developments in advanced practice nursing roles: UK perspective

Dr Kim Manley CBE

Learning & Development Manager: Resources for Learning & Improving, Learning & Development Institute, RCN

Visiting Professor Bournemouth University

Overview Overview

  Nursing   Political context   Modernising Nursing Careers   NHS & RCN Career framework   What is advanced practice?   Competences

Value-addedness of nursing

Nursing is about:

  caring values;   focusing on relationships with individuals, groups and

populations;   managing/facilitating the context of care;   enabling co-ordination and continuity of care;   using knowledge of patients as people with concepts and

implications of health and illness to inform assessment, interventions, evaluation, patient education and health promotion (Manley 2000).

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A conceptual framework for nursing expertise in the UK (Manley et al 2005)

Professional artistry

Holistic practice

knowledge

Knowing the patient/client

Moral agency

Saliency

Skilled know-how

Enabling factors

Two key parameters to expertise in nursing

• Developing EXPERTISE in all OTHER FUNCTIONS necessary for continuing to provide quality services –developing person-centred systems

• Developing EXPERTISE in the practice of nursing for a particular client group

LEARNING & DEVELOPMENT

• Personal and people development (Core 2)

• Learning and development (G1)

PERSON-CENTRED, EFFECTIVE & SAFE NURSING PRACTICE

• Assessment and care planning to meet health and wellbeing needs (HWB2)

• Promotion of health and wellbeing & prevention of adverse effects on health & wellbeing (HWB1)

• Protection of health and wellbeing (HWB3)

• Enablement to address health and wellbeing needs (HWB4)

• Assessment and treatment planning (HWB6)

• Provision of care to meet health and wellbeing needs (HWB5)

• Interventions and treatments (HWB7)

• Communication (Core 1)

• Health, safety, security (Core 3)

• Equity, diversity and rights (Core 6)

KNOWLEDGE & INFORMATION

• Information processing (IK1)

• Information collection and analysis (IK2)

• Knowledge and information resources (IK3)

MANAGING CARE & SERVICES

• Procurement and commissioning (G3)

• Financial Management(G4)

• Services and project management (G5)

• People management (G6)

• Capacity and capability (G7)

• Public relations & marketing (G8)

QUALITY, IMPROVEMENT,

INNOVATION

• Development and innovation (G2)

• Service improvement (Core 4) • Quality (Core 5)

Competences for Nursing (Based on KSF dimensions)

Political Context   Consultation on Non Medical Regulation – Foster

Review

  “Trust, Assurance and Safety – The regulation of health professionals in the 21st century ” (DH, 2007)

  “The Government believes that existing professionals should be subject to a system of regulation that is proportionate to the risks and benefits entailed” (p81)

  Supports UK wide standards for higher levels of practice for advanced practice in nursing, AHP’s and healthcare scientists

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Trust, Assurance and Safety: The Regulation of Health Professionals

  “patient, public and professional confidence in the health professionals' watchdogs,

  improving patient safety and ensuring the fair treatment of health professionals’. The key changes include:

  standardising the level of advanced practice across health professions

  measures to ensure healthcare professionals are revalidated throughout their career and remain up to date with clinical best practice.

Extending Regulation Group   Existing roles e.g. clinical psychologists, health care support

workers   New roles e.g. surgical care practitioners   Advanced practice

Changing context in UK: Service competence frameworks

  Competency frameworks for the service are being developed that identifies all the competences expected to be delivered by health care team

  Staff groups then identify which competences relevant to them

  Areas of overlap and flexibility   Gaps in competency provision

–  Advanced practitioner –  Assistant practitioner

A High Quality Workforce: NHS Next Stage Review

  National standards for advanced and autonomous roles

Towards A Framework for Post Registration Nursing Careers (MNC)

  Consultation November 2008   Content, structured career approach,

defined levels and competencies   5 domains proposed   Widespread support for standardising

an advanced level of practice   Match patient need to numbers of

nurses at different levels

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Modernising Nursing Careers: Coming from Going towards  First post in hospital

 Early specialisation

 Often no link between job titles and level of competence

 Confusion and role overlap between generalists and specialists

 First post in community or a mix of both

 Pathway careers, built on portfolio of Competencies

 Nationally recognised standards for post-registration practice, and job titles that denote the level and seniority of the holder

 Clarity about the division between generalist and specialist roles in the workforce and how they complement each other

Moving from and to….. Cont.

 Restricted career options

 Preparation for higher levels of practice away from the workplace, in academic institutions

 Career in NHS within traditional hierarchical structures

 Opportunities to major in one pathway or sector, while attaining basic competencies across the spectrum

 Modular programmes, underpinned by experiential learning

 Careers spanning sectors, with opportunities for entrepreneurialism and self-employment

Towards A Framework For Post Registration Careers

The starting point

  Develop clear career pathways for nurses from first registration through to advanced practice

  Align nursing career pathways with the patient care pathway, health care needs for nursing expertise, and how health care services will be managed and delivered in the future

Modernising Nursing Careers: Post-registration pathways

  Children, family and public health   First contact, access and urgent care   Supporting long term care   Acute and critical care   Mental Health and psychosocial care

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National Career Framework/RCN

RCN BENCHMARKS

Health care Assistants

Competent nurse

Experienced proficient nurse

Senior practitioner/Expert nurse

Consultant nurse

NATIONAL CAREER FRAMEWORK

Health Care Assistants (Level 4)

Practitioner (Level 5)

Senior practitioner/ Specialist practitioners (Level 6)

Advanced practitioners (Level 7)

Consultant practitioners (Level 8)

•  General Practice settings, alongside GPs and Branch surgeries •  PMS (Personal Medical Services) sites [GP-led or Nurse-led] •  GMS contract •  Practitioner with Special Interests •  Partnership •  Out of hours services •  NHS Walk-in Centres •  Homeless/refugees/asylum seekers & rural health care •  Nurse-led initiatives eg Intermediate Care Facilities •  “NP Limited” !

Building on NP developments : Primary Care

Examples : NPs in A&E/MIU’s, Night NPs, Out-reach critical care, Children’s NPs, NPs in cancer care, acute medicine, respiratory, urology, opthalmology etc etc

Stimulated by : •  European Working Time Directive •  Hospital at Night, Hospital at Day •  Lack of continuity of patient care •  Need for acute assessment units •  Greater awareness of contribution of nursing ???

Building on NP developments : Secondary & Tertiary Care Clarity on advanced practice

  A defined level of practice, not a role or job title   A national and 4 country agreed standard   A level of competence which can be measured in relation to

both: –  direct patient/client care –  systems of care

  A transferable skills base   Consistent with National, European & International literature   A widely supported integrated toolkit (Scottish MNC)   Terminology which is understood across health professions

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1.  Assessment and Management of Patient health/illness status

2.  The nurse-patient relationship

3.  The education function

4.  Professional role

5.  Managing and negotiating health care delivery system

6.  Monitoring and ensuring the quality of advanced health care practice

7.  Cultural competence

Domains of Advanced Nurse Practitioner practice (NMC, 2005; RCN, 2008) RCN competences (2008)

  Mapped to the KSF   Linked to the NHS career framework   Recognised by the NMC   Linked to ICN   Potential for use in other disciplines

“Advanced nurse practitioners are highly experienced, knowledgeable and educated members of the care

team who are able to diagnose and treat your health care needs or refer you to an appropriate specialist if

needed”

Further “ANP’s are highly skilled nurses who can :

•  take a comprehensive patient history

•  carry out physical/mental examinations

•  use their expert knowledge and clinical judgement to identify the potential diagnosis

Definition of an Advanced Nurse Practitioner

“The Scope of Practice, Standards and Competencies of the Advanced Practice Nurse” (ICN, June 2008)

“The APN is a registered nurse who has acquired the expert knowledge base, complex decision-making skills and competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice” (ICN, 2002)

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Expert Practice

Specialist Practice

Generalist Practice

Novice Practice

Professional Accreditation

  Advanced practice programmes in 10 Higher education institutes against 15 standards focussed specifically on assuring quality of provision and standards of practice for graduates of advanced practice programmes

Revalidation - ?RCNs role for future   Establishing quality and standards unit

  Resources and experience in individual accreditation against standards and competences

  Use of e-portfolio to collect multiple sources of evidence against standards and competences with compatibility to e-KSF to enable professional and academic accreditation

Key messages   Advanced practice is a level of practice not a role

  Advanced practice needs to be linked to the quality agenda –  Person-centred care –  Effective and Safe care –  Context of care to sustain these

  Advanced practice is about developing expertise in a number of competences primarily around nursing practice with greater responsibility and autonomy in decision- making

  Advanced practice is about developing expertise in the systems required to sustain quality systems

  Consultant nurses are expected to have expertise in both advanced practice as well as in the systems to sustain quality

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Professional artistry as a kaleidoscope

  RCN definition, competences and guidance (2002, updated 2008) www.rcn.org.uk

  RCN accreditation of ANP programmes