Amid the ongoing discussions about the regulation of advanced practice, Helen E Lewis describes what working as an advanced nurse practitioner in primary care means to her, and how she sees the role developing in the future
The Nursing and Midwifery Council (NMC) is currently discussing the regulation of the advanced practice role. If this leads to regulation, it would not only give direction to the role but, in my view, help to protect clinicians and patients in the long term.
The advanced nurse practitioner (ANP) is not a new phenomenon, but there is variation in how advanced practice is described and implemented. Education to masters level and practice across four key pillars are elements included in the Royal College of Nursing’s Standards for Advanced Level Nursing Practice.1
From a personal view, the decision to undertake an MSc in Advanced Practice was exciting, as part of a journey filled with new challenges that has developed me from a personal and professional viewpoint.
This article will offer community nurses information that may be useful if they are considering advanced practice in their professional role.
Advanced practice was first introduced in the late 1980s and early 1990s2 and has continued to develop nationally and internationally.
In the UK, advanced practice was part of the 2019 NHS Long Term Plan, which offered a multiprofessional framework3 outlining the capabilities expected of advanced practitioners working across the four key pillars of education, research, leadership and management, and clinical practice. I have no doubt that advanced practice has been central to the transformation of service delivery in response to the changing demands of 21st century healthcare.
My own journey to ANP started as far back as 2006 when I first entered primary care. I was fortunate that my first role after qualifying was within the community setting, as I already knew my career was not going to be hospital based.
Advanced practitioners are qualified nurses, paramedics, physiotherapists or occupational therapists who have undertaken post-registration training to complete a masters-level degree, to include prescribing in order to be able assess a patient fully in a single episode of care. Autonomy is a key factor to the advanced practitioner role.
Any new day in practice will bring fresh challenges. Some patients are straightforward but others will test, and ultimately enhance, my knowledge. Patients may raise a plethora of concerns during the episode of care.
We encounter anything from sore throats, cough and abdominal pain, to a change in bowel habit, musculoskeletal complaints and minor injuries. All have to be assessed fully, as do mental health conditions, such as anxiety and depression and post-traumatic stress disorder.
Patients will also attend with long-term health conditions such as COPD or diabetes, for a medication review. A care plan review is often required with dementia or debilitating conditions such as MS or Parkinson’s, where the needs of patients and carers will change as the disease progresses.
There are four distinct pillars to advanced clinical practice to which every advanced practitioner must align their practice and subsequent continued professional development:3
- Clinical practice
- Facilitation of learning
- Leadership and evidence
- Research and development.
Clinical practice is the foundation of any episode of care, and advanced practitioners have a high level of understanding of this aspect of patient care.
Team leadership looks at innovative ways of delivering care to patient groups and is borne out of a multidisciplinary approach based on up-to-date evidence. Education is not exclusively related to the education of the advanced practitioner, but encompasses junior staff, which includes practice nurses aspiring to advanced practice, as well as our patient groups.
As an ANP in primary care, I work in a multidisciplinary team of practice nurses, healthcare assistants, advanced practitioners from nursing but also paramedic physiotherapists, along with GP colleagues and district nursing teams. Successful outcomes for patients, their families and the team depend on a collaborative approach.
The team acknowledges the knowledge and skills of everybody within it, which are always changing. The experience gained and the knowledge shared between team members is essential; there is a mutual respect that fosters a shared approach to care.
The team also includes members of the admin staff, who are essentially the gatekeepers to accessing care at the surgery. They are the patient’s first point of contact to schedule an appointment and are essential to the care journey for the patient population.
Work at an advanced level of practice is developed and enhanced by the team around us. Forward planning is seen as an essential part of patient care and one that allows staff to develop and work towards more senior roles, supported and mentored by the team. This ensures consistency, with patient care continued using the same team ethos and standards, and also that individuals within the team feel supported and valued.
The journey to become an ANP is a long one, but it is a role that embodies the years of practice accumulated since initial qualification.
The basis of any advanced practice role is the education and training that has come before it, and for me this included qualification as an RGN followed by qualification as a midwife.
When I started as a practice nurse, I was aware that education and training were going to be key to success within the role. Undertaking courses for ear syringing, cytology and chronic disease management were an essential part of the learning curve. Childhood immunisation, once the domain of health visitor colleagues, also became part of the practice nurse role.
I undertook the community degree with a focus on minor illness nearly 10 years before starting the masters degree for advanced practice.
The Department of Health and Social Care describes an advanced practitioner as someone who can undertake a full assessment of a patient, request and interpret investigations, and prescribe medication.
Primary care is the gatekeeper to secondary care, and having knowledge and understanding of a patient from a holistic point of view informs appropriate referral, or admission into hospital where needed.
ANPs are fundamental to a modern healthcare service so holistic care needs to be introduced at an early stage of our collective training. The knowledge and skills we develop are adjusted and enhanced throughout our career.
As far as regulation is concerned, though, the role itself remains in the wilderness.
The NMC acknowledges that public understanding of the role remains unclear, but that experienced nurses and midwives are increasingly taking on complex autonomous and expert roles under the umbrella of advanced practice.
Specific regulation needed
While the NMC does not specifically regulate advanced nurse practice now, it has committed to considering additional regulation as part of its 2020-25 strategy. It commissioned the Nuffield Trust to look at existing literature on regulation of advanced practice, given the variation in how the role is interpreted across the UK. The study found that the ‘consensus’ among stakeholders, which included nursing leaders at the highest levels, was that some form of specific regulation is needed for advanced practice in nursing.4
And in an update in October, the nursing regulator said it would likely present a ‘preferred option’ for regulation by early 2024.5 It stressed it wanted to avoid the risk of any future regulation confusing the public or disengaging members of the profession.
The regulation of health and social care professionals is a practical way to protect those using services from harm and to enhance trust in healthcare professionals. Student nurses are made aware of their responsibility to be patient advocates, to understand our limitations and to work within the healthcare regulatory framework.
The same is true for advanced practice. In my view, regulation is essential – to protect the public but also to acknowledge our educational attainment.
My MSc in Advanced Practice was the start of a new journey and each day there is still something new to learn, an understanding to gain, and a patient to support using the knowledge and understanding I have developed. I have often told patients that there is no such thing as a silly question, but we should always ask questions of our own practice too. It is this ever-questioning approach that ultimately provide the blocks of knowledge we need as advanced practitioners to adopt a truly holistic approach to our patients.
In the UK, there are 716,100 registered nurses and 40,900 midwives on the NMC Register.6 Nurses and midwives working at an advanced level enhance the patient experience and we bring a greater understanding of practice developed through experience and educational attainment. This contribution enhances the profession we are all very proud to be associated with.
Nurses and nursing need to use a collective voice, and enhancing our knowledge – working within the four pillars of advanced practice – will allow that voice to be heard more clearly across healthcare and political forums, and also support and encourage the next generation of advanced practitioners.
Helen E Lewis is a Queen’s Nurse and an independent nurse practitioner based in South Wales
1 Royal College of Nursing. RCN Standards for Advanced Level Nursing Practice. tinyurl.com/RCN-ANP-standards
2 Leary A et al. The evolution of advanced nursing practice: past, present and future. Nursing Times 2019; 115:10:18-19. tinyurl.com/NT-advanced
3 NHS. Multi-professional framework for advanced clinical practice in England. tinyurl.com/HEE-advanced
4 Palmer W et al. Independent report on the regulation of advanced practice in nursing and midwifery. Nuffield Trust, 2023. tinyurl.com/Nuffield-advanced
5 Ford M. NMC looking for ‘sweet spot’ on advanced practice regulation. Nursing in Practice, 5 October 2023. tinyurl.com/NIP-advanced
6 Rolewicz L. Past, present and future of NHS nurse numbers. Nuffield Trust, 2023.