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Nurse practitioners: where do they stand now?

Cheryl I'Anson
BA(Hons)
Acting Editor
Nursing in Practice

There has been deep concern from the nurse practitioner (NP) camp following the recent Medical Care Practitioner (MCP) Competence and Curriculum Framework public consultation,(1) as many NPs are anxious about the introduction of a role that appears to be identical to the one they are currently performing. MCPs will, according to the consultation document, be able to obtain full medical histories and perform appropriate physical examinations, and diagnose, manage (including prescribing) and treat illnesses within their competence;1 responsibilities that nurse practitioners are currently undertaking. Many NPs are now questioning why a huge amount of public spending is being used on creating duplicate roles, when it should be spent on developing existing ones.

History of nurse practitioners
The role of nurse practitioner has changed dramatically in the last few years; during the 1990s NPs were represented as individuals working in a primary care environment, however, these days NPs are just as likely to work in secondary care settings and across established healthcare boundaries.(2)
In primary care, NPs handle a caseload, which is dealt with between colleagues working in the same area of practice, or referred on to colleagues in more specialist areas. Primary care NPs have an extensive range of skills, a wide foundation of knowledge, and the ability to deliver specific aspects of care. However, these skills can be supplemented by specialists, including district nurses, health visitors and practice nurses. It is their ability to employ this wide-ranging skill base that sets them apart from other healthcare practitioners and defines them as NPs. They are not doctor substitutes or cheap medical labour, but a complementary body that works alongside colleagues and offers patients the opportunity to consult an alternative healthcare practitioner.

Raising the profile
So why, then, are their valuable skills being overlooked in favour of new talent? Benny Harston, chair of the Nurse Practitioner Association, is behind a campaign to raise the profile of NPs and is asking why the government is introducing a new breed of healthcare practitioner instead of investing in the existing workforce. She is keen to point out that the public at large and colleagues in other healthcare settings should be familiar with the training NPs undertake, and that developing a post-registration standard is the only way this will happen. She says: "If only the Nursing and Midwifery Council (NMC) had regulated the role when it was first developed 10 years ago. I feel that if we had been seen to be taking our roles as NPs and nurse prescribers seriously and set firm high standards, ie, by linking all our educational attainments, then we would be on firmer ground now."
The development of NPs in primary care has evolved and been led by nurses often with no additional resources, but in recognition of gaps in services. Nurses have been developing their roles in innovative ways to improve patient care and offer greater choice.

Creating a new standard
The lack of regulation has caused an air of uncertainty surrounding the role of NPs, and has led to nurses working at a level beyond initial registration, and also  to misuse of the title nurse practitioner.(3) The NMC, however, is now attempting to remedy the situation with their Consultation on a Framework for the Standard of Post-registration Nursing.(4)
There is concern that patients do not understand the level of care they should expect because of the varied job titles within nursing. The NMC maintains that the competence and knowledge implied by these titles sometimes does not match the actual degree of care received by the public. They argue that, although many nurse practitioners will have undergone rigorous assessment to validate their skills and training, others won't have, leaving dangerous gaps in the levels of patient care. The standard will therefore be a tool for validating the education and training of registered practitioners, with a view to clarifying the role of advanced nurse practitioners.
The current Nursing and Midwifery Council Order 2001 requires that the register is divided into parts by the Privy Council.(4) The NMC is proposing a subpart to the nursing section to cover advanced practitioners, which would require approval from the Privy Council and further development of legislation. The consultation process involved a questionnaire that was available for all registered nurses to take part in, and a consultation package was sent to a targeted audience, including a selection of registrants, government health bodies and health regulators. Once the register has been established in legislation, guidance will be produced by the NMC to support nurses who want to access the register and those who want to gain NMC approval for programmes of preparation for Advanced Nurse Practitioner. The timescale for implementing this new standard has provisionally been set for August 2006.
The government has been encouraging and pushing the boundaries for nursing but unfortunately the NMC has been slow to respond and support new roles with clear legislation and codes.

Consultation
The analysis and recommendations of the consultation were presented in a meeting in June 2005 held by the NMC. They highlighted the considerable support from the nurses who took part, and demonstrated that a significant proportion of nurses already considered themselves to be working at the advanced level. The consumer and patient organisations that responded also indicated a good level of support. As a result, the NMC has agreed that a level of practice beyond initial registration should be set and registered, and that the title for this should be Advanced Nurse Practitioner.(3) Following approval by the Department of Health, the NMC hopes to establish this standard by 2006.
Katrina Maclaine, RCN Nurse Practitioner Adviser, said: "The decisions that the NMC Council made at this meeting are extremely welcome, and something that we have been pushing for for many years."

So why the need for MCPs?
In light of the implementation of this regulatory standard, which will finally clarify and acknowledge the extensive skills of the NP's role, the confusion surrounding the introduction of medical care practitioners seems justified. There is already in place a good evidence base for safety, effectiveness and patient satisfaction for NPs; and as autonomous practitioners they are able to prescribe not just medication but also plans of care. Nurse practitioners are also authorised to order various investigations, including X-rays, and can refer patients for consultant opinion and even admit them acutely to hospital. The argument against MCPs is that there is no similar evidence base of efficacy and safety, and MCPs will be "mini-doctors" who need constant supervision when prescribing, creating extra costs in terms of time and expense. Nurse practitioners point out that there does not seem to be much evidence for the need for a new role when all proposed areas of care are already being adequately covered, particularly in view of the extended nurse prescribing powers recently granted by the DH.
Nigel Sparrow, Vice Chairman of the RCGP, claims that there is a call for the introduction of MCPs, which has been based on a model of physician assistants developed in the USA in the mid-1960s. He says: "We believe that there is a need for a broadly based new healthcare professional who can contribute to holistic patient-centred care in both primary and secondary care settings, but that it is essential to define the role and scope of practice and the standards for education and assessment in order to ensure that practice is to a uniformly high standard."(5)
The British Medical Association is more sceptical. Dr Hamish Meldrum, chairman of the General Practice Committee, says: "We will always consider anything that will help to improve access to services and the speed and effectiveness with which patients get treatment. However, we have already got skilled nurse practitioners in primary care who have taken over a lot of the more routine tasks from GPs.
In terms of more complicated tasks, such as dealing with complex illnesses, I would need a lot of convincing that medical care practitioners would be of added benefit and would not confuse patients as to who exactly was treating them. GPs would want to be assured that the introduction of MCPs into primary care would improve both the quantity and quality of care available to patients."(6)
Whatever the reasons behind the development of this new breed of health practitioner, the MCP consultation closed in February, and NPs will be awaiting the results with interest.

Staying strong
Nurse practitioners come from an ethos where the essence of nursing is the therapeutic relationship that allows them to connect with their patients, understand their experience of their illness and respond to their needs. They are "maxi-nurses" as opposed to mini-doctors, which is more than just semantics, and the difference is significant. There is much research evidence to show that they deliver safe and effective healthcare, and in this patient-centred climate their good communication skills mean that patients prefer consulting them to visiting their GP.
Following the NMC's implementation of the post-registration standard, the position of nurse practitioner will hopefully continue to remain strong within the NHS, providing even greater opportunities for training and qualifications.
For more information and to stay up to date on all developments visit www.nursepractitioner.org.uk

References

  1. NHS Modernisation Agency. MCP competence and curriculum framework public consultation. Available from http://www.wise.nhs.uk
  2. RCN. Nurse practitioners - an RCN guide to the nurse practitioner role, competencies and programme approval. Available from http://www.nursepractitioner.org.uk
  3. Maclaine K. News letter. Available from http://www.nurse practitioner.org.uk
  4. NMC. Consultation on a framework for the standard of post-registration nursing. Available from http://www.nmc-uk.org/a FrameDisplay.aspx?Document ID=933
  5. DH. The competence and curriculum framework for the medical care practitioner. Available from http://www.dh.gov.uk/assetRoot/04/12/25/86/04122586.pdf
  6. BMA. Press release 4 November 2005. Available from http://www.bma.org.uk/pressrel.nsf/wlu/STRE-6HTJMC?OpenDocument&vw=wfmms

Resources
Nurse Practitioner UK
W:www.nurse practitioner.org.uk

Nursing and Midwifery Council
W:www.nmc-uk.org