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Enduring ambiguity: the ANP role

The Royal College of Nursing appears clear on what an advanced nurse practitioner (ANP) is supposed to do. ‘Advanced practitioners are educated at master’s degree level in advanced practice and are assessed as competent in practice, using expert knowledge and skills. They have the freedom and authority to act, making autonomous decisions in the assessment, diagnosis and treatment of patients.’

But in reality, it remains unclear what qualifies a nurse to have ANP status. It appears the possibilities of the role are endless.

Much of the confusion over the ANP role stems from lack of regulation. Nurses without an MSc but with a wealth of experience may describe themselves as ANPs. So can nurses without the necessary prescribing skills.

Paula Spooner, ANP and general practice nurse consultant at Wakefield CCG, who has an MSc, says: ‘It’s not set what an ANP is. We’re all from different backgrounds because there is no regulation. This is not a protected title and any nurse can call themselves an ANP. So, at the moment, an ANP is whatever anyone wants it to be.’

There have been efforts to address this lack of regulation. The RCN has made attempts at semi-regulation, introducing ‘credentialing’ for advanced-level nursing practice in 2017, although there is an initial cost of £275 for a nurse to be included on the database of credentialed nurses and £125 every three years after that.

The Nursing and Midwifery Council (NMC) has said it will look at its role in regulating advanced practice later this year. An NMC spokesperson told Nursing in Practice that the organisation was ‘currently in the final stages of launching our strategy for 2020-25.

‘Exploring whether advanced practice nursing is something we should regulate will be part of our work to meet the themes and priorities of that strategy,’ the NMC spokesperson says, adding: ‘The council won’t be making any formal decisions on ANP until after the launch of our new strategy, which is expected in the middle of the year.’

Other bodies have also attempted to bring clarity to the ANP role. In January, the not-for-profit organisation Skills for Health published a framework, commissioned by NHS England and NHS Improvement, to identify the core role of the ANP (see box below). The organisation recognises in its framework: ‘Primary ACP (primary care nurse) roles, within general practice/primary care have so far developed without a set standard, and this has led to varying levels of attainment, resulting in disparity. This has created confusion for employers, fellow healthcare staff and people because of variations in titles, qualifications and competency.’

The Skills for Health ANP framework

 

Capabilities in the Skills for Health framework cover everything from communication and consultation skills, practising holistically and personalised care, to working with colleagues and in teams. The framework is intended to ensure ANPs work to an ‘advanced level’. It is also designed to support them to ‘demonstrate and evidence their capabilities to service commissioners, employers, people utilising healthcare and the public’. Many existing primary care nurses will have areas for development and may need to top up their academic knowledge or capabilities in order to demonstrate the core requirements in this framework, says Skills for Health.

It also believes its 13 capabilities can help employers use the framework to agree the scope and content of their role in the multi-professional team. ‘Nurses may have differing starting points, and this will help them and their employers to identify and address any educational [or] training needs; it can be used as part of the appraisal process,’ it explains.

The Skills for Health framework details 13 capabilities, which it claims ‘set a standard regarding the academic knowledge, skills and behaviours required to enable the highest standards of practice within primary care and general practice’.

Health Education England is currently developing the Academy for Advancing Practice, which is intended to standardise routes into advanced clinical practice. Skills for Health says the academy should provide an opportunity for practitioners to prove their ability to work to the ‘advanced level’, as set out in the framework. ‘Work is now under way to look at how best to support commissioners, employers and nurses to implement it,’ a representative at Skills for Health says. These measures could help clarify what an ANP is meant to be.

But what ANPs are not supposed to be are replacements for GPs, the RCN believes. Marie-Therese Massey, RCN professional lead for general practice nursing, says: ‘Those advanced nurse practitioners should not be seen as a long-term strategy to fill the GP gap and should not be asked to work beyond their professional competencies.

‘Without urgent investment in primary healthcare services, the pressures on these vital nurses is only likely to increase, putting services and patient access to care at risk.’

Benjamin Scott, an ANP working at Conisbrough Group Practice and the clinical director of Doncaster South PCN, stresses the importance of not comparing ANPs with doctors because ‘ANPs are here to complement medics. We are nurses who have a passion to do more for the patients in our care, and have studied hard to provide this.

‘We are experienced, holistic-independent, autonomous practitioners who have care at the centre of our hearts, who complement teams just like our other allied health professionals. Everyone has their individuality and can create magic within teams,’ he says.

Jenny Aston, an ANP for Granta Medical Practices in Cambridge, says of the role: ‘We are complementary to GPs – not a replacement for them – and if everybody uses the right skills at the right time, this works really well.’

For Ms Spooner, ANPs are ‘not mini-doctors – they are maxi-nurses’. She explains that this ‘maxi-nurse’ could be working at the top of their capabilities with advanced skills and qualifications, seeing the patient from the start to the end of their journey, assessing them, diagnosing them, and planning and implementing care. And while they might not be mini-doctors, ANPs are ‘taking the strain off doctors’ by seeing patients that would traditionally have been seen by a GP, she says.

Helen Lewis, an ANP based in general practice in south Wales, does not believe there is anything wrong with nurses taking the strain off GPs, ‘as long as they’ve got the necessary qualifications and knowledge’. Since qualifying as an ANP in 2019, her workload has gone up 50%, ‘reflecting the confidence GPs have in my work’, Ms Lewis says. She runs full clinics, and her responsibilities include looking at blood results, referring patients for X-rays and ultrasound scans, and discussing results with them.

The role of ANPs is constantly evolving, so ‘you can’t allow the grass to grow under your feet’, says Ms Lewis. But as yet, she says it lacks clarity, which she believes ‘will come when the NMC makes a decision on the role’.

Mr Scott adds that it is not just healthcare professionals who are confused about the role but also patients. ‘Patients at times are not aware of the role and what care we can provide, so initially feel deflated. But like anything, with a little discussion about me and my role, it can all be resolved.’ He finds the role itself ‘personally amazing; I am able to provide the holistic care from my nursing background and combine my extra skills to be the right clinician at the right time,’ he says.

But Ms Lewis expresses concern that nurses could potentially be ‘working outside their remit’. This has inevitably led to concerns about patient safety – and the levels of pay received by ANPs.

Ms Lewis suggests nurses could be under pressure from a doctor or from a healthcare team to extend their role to meet patients’ needs. Their qualifications might not meet their job description, or that description might not tally with their qualifications.

In the absence of current regulation, the way nursing is evolving it ‘has to be right that a nurse working at an advanced level should have, or be working towards, an MSc’, says Mr Scott. ‘If the title is wrongly used, it has to be the individual’s responsibility. Our code is quite explicit about nurses recognising and working within the limits of our competence,’ he says.

Ms Spooner does not believe RCN credentialing and checks by employers are enough to protect patients. ‘I don’t think employers know about RCN credentialing so are not asking nurses if they have this.’ She adds that the £275 fee makes RCN credentialing expensive for nurses, and there is no incentive to take part because nurses are still able to get work irrespective of whether they’ve gone through credentialing.

ANPs say that having the NMS regulate and protect advanced practice is the way forward. Ms Aston hopes that will involve nurses having ‘high levels of skills to be able to practise safely’. And Ms Lewis would like the NMC to make the ANP role ‘a recordable qualification that is then reflected in our revalidation – that you are continually working to that level, rather than just getting a title but actually not working to that level consistently’.

As the landscape of healthcare changes, with the potential for ANPs to take on more clinical work, and with new roles such as nursing associate coming into general practice, Ms Spooner predicts practice nurses will upskill and take on more advanced roles. But with these added responsibilities should come financial rewards as well, she believes. ‘Nurses should be substantially rewarded for their skills, and if they do similar training to GPs and become credentialed, they should be rewarded as valuable members of the workforce with a wage to reflect that.’

Whatever the NMC decides about the role and the regulation of ANPs, and whatever shape that takes, nurses will continue to be passionate about opportunities to use their knowledge and experience to benefit patients while working as part of a healthcare team. ‘Fundamentally, we are all one team trying to get to the same place,’ says Mr Scott, ‘and that is to deliver the best patient care we can in the environments in which we work.’

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