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Advanced practice: the implications for nursing

Christine Smith
PhD RGN MN RCNT RNT
Director of Primary Care/Community Nursing
Cardiff University

Dianne Watkins
RN RM HV RNT MSc
Director of Educational Developments
Cardiff University

The modernisation of the NHS has aimed to provide a service where patients and the public have greater choice and a greater voice. Opportunities to provide more secondary care in community settings is considered the way forward for the future.(1)
Throughout the UK, the NHS is facing increased pressure to provide acute hospital beds. As a result, the importance of maintaining people independently in their own homes is extremely important. In addition, the General Medical Services (GMS) contract is extending the nursing role from clinical to the more business aspects of practice.(2) The contract allows nurses to become partners in the practice and therefore providers of services. As practices are able to opt out of providing additional and out-of-hours services, initiatives such as nurse-led walk-in centres and minor injuries clinics, will provide alternative access points to primary healthcare. These new roles will require a higher level of practice and education.(3) The vision for primary care nursing is for more integration with secondary care and:

  • To be based on the needs of informed patients.
  • To be responsive to those needs.
  • To have an extended range of local services.
  • To operate across organisational barriers.

In order to meet the above, there will need to be:

  • Greater emphasis on a flexible team approach.
  • More opportunities for nurses to become equal members of the practice.
  • Greater skillmix.
  • Opportunities to develop the services that local practices have opted out of providing.

What is advanced nursing practice?
The substantial changes that have occurred in the health service over the last decade have been supported by the nation's renewed interest and concern for a more relevant and flexible healthcare service. The Nursing and Midwifery Council (NMC) has defined advanced practice as: "highly experienced and educated members of the care team who are able to diagnose and treat a patient's healthcare needs or refer them to an appropriate specialist if needed".(3) This definition has now been extended by the NMC to include: "to provide patients, their carers and other healthcare professionals with more detailed information about what they can expect of an advanced nurse practitioner".(4,5) More details regarding these discussions are available from the NMC website (see reference list).
The NMC has established a framework and standards for advanced nursing practice.(6) There has been a mapping of the NMC's approved competencies against the Knowledge and Skills Framework (these are still to be agreed by the council).(7) The NMC website offers a lot more detail on the issues regarding advanced practice.

The policy drivers
Primary care now plays a central role in the NHS and has become a major focus of health policy, shifting the emphasis from secondary care and placing primary care at the centre of healthcare development, commissioning and public health. Changing interprofessional relations and organisational structures may provide opportunities for developing better networks of communication within nursing. The blurring of patients' and carers' roles is linked to wider issues in which policy has an increased involvement.(1)

New ways of working for community nurses
Community nurses have extended their roles, but consideration needs to be given as to whether or not community nurses work at a higher level of practice, and what education is best suited for them to function autonomously in that role. Opportunities to maximise  this autonomy may require "new ways of working" in community nursing practice in the future.
In Wales, during May 2005, the Welsh Assembly  published Designed for Life: Creating World Class Health and Social Care for Wales in the 21st Century.(8) This describes how by 2015 the people of Wales will benefit from "world class healthcare and social services in a healthy, dynamic country". This will involve:(8)

  • Access - enabling patients to see a GP by appointment on the day they wish to be seen.
  • Chronic disease management - reducing unplanned episodes of care.
  • Health communities - bringing communities together in order to improve their quality of life.

The strategy encapsulates the government's vision of transforming the NHS "from the national illness service it currently is into a truly national health service", and it is underpinned by three themes (see Figure 1).(8)

Expected growth in primary care
Essentially, the expected growth in primary care activity over the next decade means that much of the work traditionally carried out by GPs may need to be undertaken by highly trained community nurses, working at an advanced level of practice. Through training, education, support and mentorship they can develop the following attributes that will help equip them to be effective commissioners of health:

  • The ability to translate clinical experience and knowledge into key health messages that capture the attention of commissioning colleagues.
  • Political awareness.
  • Presentation and communication skills.
  • Networking skills.
  • Credibility.
  • Problem-solving skills.
  • A sense of financial reality.
  • Commitment to working with user groups and other agencies to confront social deprivation.
  • Knowledge and understanding of national and local health- and social care structures.With these skills nurses can provide:
  • A service where patients and the public have a greater choice and a greater voice.
  • Opportunities for more secondary care in community settings.
  • Extended nursing roles, including taking on some work currently done by GPs.
  • 24-hour first-contact care across a range of settings.
  • A major role in delivering national service frameworks.
  • A greater voice in decision-making.
  • A focus on prevention and tackling inequalities.
  • Greater skillmix and leadership opportunities.
  • Required education to match changing roles.

[[NIP30_fig1_19]]

Clarifying advanced nursing practice
Daly and Carnwell try to differentiate between terminology and practice, and the education required for the different roles that we currently find in the clinical field.(9) They suggest that practice falls into:

  • The elementary nurse practitioner.
  • The clinical nurse practitioner (or clinical nurse specialist).
  • The advanced nurse practitioner (or nurse consultant).

The elementary nurse practitioner is undertaken by a large number of nurses who extend their roles by undertaking task-related competencies, for example intravenous additive training. The role is generally undertaken by a staff nurse postqualifying and does not fall into the domain of advanced nursing.
The second level is called the "clinical nurse practitioner" or the "clinical nurse specialist". It is suggested that these nurses are not advanced nurse practitioners, although in practice these roles are probably blurred.(9) The clinical nurse practitioner has expanded their role in some way and has greater responsibility and autonomy, although the core of their work remains similar to that of the elementary nurse practitioner. District nurses and health visitors who hold a specialist qualification fall into this category.
The advanced nurse practitioner or nurse consultant works autonomously, and the nature and scope of their practice has been developed compared with the previous two categories mentioned. They usually have 5-10 years experience, and a minimum of a master's degree.(9) In Wales, consultant nurses are encouraged to work towards a doctorate, and the role encompasses education, research, leadership and expert practice.
McGee and Castledine suggest that the advanced nurse practitioner is:(10)

  • Autonomous.
  • Experienced and knowledgeable.
  • A researcher and evaluator of care.
  • An expert in health and nursing assessment.
  • An expert in case management.
  • A consultant, educator and leader.

These categories complement those outlined by the NMC in its implementation for advanced practice. The NMC states that nurses should be able to take a comprehensive patient history and carry out a physical examination. Nurses should be able to make a preliminary diagnosis and refer the patient for appropriate investigations, before making a final diagnosis.(10) They should be able to plan and undertake treatment, inclusive of prescribing, and plan, assess and evaluate care in partnership with the patient. Such nurses should be able to work independently and as part of a team, provide leadership in their area of expertise, and ensure that care and treatment is based upon the best available evidence.

Education for advanced practice
The NMC suggests that advanced nurse practitioners are highly skilled nurses who will have achieved competencies mapped by the NMC (in consultation phase at present with privy council) to be able to function as advanced practitioners.(4-6) However, nurses will require education to enable them to undertake full clinical examinations of patients and to make a differential diagnosis. This includes being able to interpret investigations, treat and prescribe. A full holistic assessment that includes screening for disease and risk factors is essential, as well as being able to plan, implement and evaluate care. Management of long-term conditions such as diabetes, asthma, hypertension and respiratory conditions will in the future be undertaken almost entirely by nurses. Although this is currently happening in some areas of practice, education and assessment of competence to undertake such roles will become mandatory in the future.(6) The competencies have been aligned with the Knowledge and Skills Framework to reflect an advanced level of practice.(6)

Clinical and professional leadership
Education in transformational leadership is essential in any education programme that prepares nurses for advanced roles. This is about teaching nurses to be visionary, to develop skills in empowering others, to value the contribution all can make to healthcare, to manage barriers, to challenge professional boundaries and pioneer innovation. It relates to the four "Es" - envisioning, enabling, empowering and energising - creating a vision and a plan, choosing the right people to take it forward and communicating that vision with passion and charisma.

Consultancy, research and education
The role of education is also to prepare nurses for consultancy, to be a consultant to clients, patients, members of the multidisciplinary team and colleagues. The key here is to teach nurses to work in partnership with others. It is also about developing the skills for nurses to become critical thinkers, to use their professional judgement and to evaluate and research practice, particularly in areas where the evidence for this is scarce. They must also be able to facilitate learning in others and communicate nursing issues to the wider population. 

Conclusion
The developments in Wales are beginning to reflect the shift from secondary to primary care, and there is collaborative working with the Welsh Assembly, the local health boards who are responsible for identifying needs and commissioning healthcare, NHS trusts and higher education institutes.(8) This move will open up new opportunities for community nurses to develop their roles and move into the realms of advanced practice. The health and social needs of the population of Wales is changing, and practice and education must work hand in hand to meet this ever-changing agenda.

References

  1. Department of Health. Liberating the talents: helping primary care trusts and nurses to deliver the NHS plan. London; DH: 2002.
  2. Department of Health. General Medical Services (GMS) contract. London: DH; 2005.
  3. Nursing and Midwifery Council. Report of the higher level of practice pilot and project. London: NMC; 2002.
  4. Nursing Midwifery Council. Advanced nursing practice - update.4 July 2006. Available from: http://www.nmc-uk.org/aArticle.aspx? ArticleID=2068
  5. Nursing and Midwifery Council. Advanced nursing practice - update. 4 May 2006. Available from: http://www.nmc-uk.org/aArticle. aspx?ArticleID=2038
  6. Nursing and Midwifery Council.Implementation of a framework for the standard for post registration nursing. London: NMC; 2005.
  7. Department of Health. The NHS knowledge and skills framework (NHS KSF) and the development review process. Wetherby: DH; 2004.
  8. Welsh Assembly. Designed for life: creating world class health and social care for Wales in the 21st century. Cardiff: Welsh Assembly; 2005.
  9. Daly W, Carnwell R. Nursing roles and levels of practice: a framework for differentiating between elementary, specialist and advanced nursing practice. J Clin Nurs 2003;12:158-67.
  10. McGee P, Castledine G, editors. Advanced nursing practice. 2nd ed. Oxford: Blackwell Publishing; 2003.