Over the past 15 to 20 years the role of the advanced nurse practitioner (ANP) has evolved within general practice, as well as secondary care.
These roles are known by a variety of titles, each defined by different competencies, qualifications and indemnity cover. As such this has created confusion for employers, fellow healthcare staff and patients.
Framework for advanced clinical practice
In November 2017 a framework for advanced clinical practice in England was launched. There are also similar frameworks in Scotland, Wales and Northern Ireland.
These frameworks define advanced practice and four areas, or pillars, of practice. Health Education England (HEE) describes advanced clinical practice as delivered by experienced registered health practitioners with a high degree of autonomy and complex decision-making. It requires a master’s or equivalent qualification that includes the following four pillars:
- Clinical practice.
- Leadership and management.
- Education and research.
- And a demonstration of core capabilities and specific clinical competence.
All ANP degrees will have elements of each of the four pillars, teaching theoretical knowledge and practical skills to the same standards. But the focus on each pillar will vary based on the context of the individual’s scope of practice, their role and professional background. This quality of training will ensure the ability to make high-level decisions and manage medical complexity.
Advanced practice in primary care
With a growing shortage of GPs, more complex care being delivered in primary care and an increasing patient demand, there is a huge need for more clinicians. The General Practice Forward View (2016) highlighted the need for workforce development to combat these issues.
Research consistently shows that a multi-professional team working together delivers better outcomes for patients as well as more effective and satisfying work for clinicians. It requires flexibility in attitude and behaviour, and for healthcare professionals to value and respect the distinct contribution of each clinician.
Primary care will benefit from the development of multi-professional teams in delivering high-quality care to patients. How these teams develop will depend on the needs of the local area, the existing staff and skill mix, and the funding available to educate, supervise and develop new roles. Smaller practices have to balance the needs of developing staff while still providing existing services to patients. This can mean that practice nurses will have to work some of the week in their existing role and the rest in developing as an ANP, meaning it could take longer to be competent in managing the variety of presentations required to develop more broad-based generalist competencies.
The ANP role and what it involves
Many senior practice nurses have advanced skills, often in a specialist area such as long-term conditions. Some have built on these skills to see patients presenting with minor illnesses. I define an ANP as a nurse who sees patients with undifferentiated and undiagnosed conditions, both acute and chronic presentations, and who requires a generalist skill set.
An ANP will exercise autonomy and use clinical reasoning to make complex decisions in the context of uncertainty and varying levels of risk. They are accountable for their decisions.
If you are interested in an ANP role, consider whether there is a need for this in your practice. You will need the support of your employer and an identified clinical supervisor. Think about how the role will be supported. You will need debrief sessions after each surgery, tutorial and workplace-based assessment. This may be familiar for teaching practices, where the trainee ANP can slot into existing educational sessions under the supervision of the GP trainers. In non-training practices this may be more challenging.
Daily debrief sessions are a necessity, not only to ensure patient safety by checking that patients have been dealt with appropriately, but they also serve an important educational purpose. Feedback relating to patient presentations is much more likely to be remembered, as it is pertinent to patient needs and your own educational needs. You should identify your educational needs, include them in your personal development plan (PDP) and address them by a tutorial, educational meeting or other method.
Trainee ANPs should undergo regular assessment, using approaches such as consultation observation tools and case-based discussion (CBD), much in the same way as foundation- and registrar-level doctors do.
COT assessment can be achieved either by shadowing a surgeon during surgery or by reviewing a pre-recorded one. Recording a surgery requires patient consent, so a scanned copy of the form should be in the patient’s notes. For CBD, you should provide your supervisor with two to three cases, so they can select the case they feel would be most beneficial to discuss. A selection of cases will be needed to show a variety of competencies.
Examination and procedural skills carried out as part of the ANP role should be assessed in practice. Obviously, these vary depending on where you work. Intimate examinations are not covered in detail by many higher education institutions, so before any are carried out you will need to be assessed. You should understand:
- Anatomy and physiology.
- When you should or should not carry out the procedure.
- Informed consent.
- The examination process.
To demonstrate competence there should be a number of directly-observed procedures.
Some areas have their own requirements. Derbyshire has identified a model called the advanced clinical practitioner (ACP). This is defined as a generalist role that can work in a variety of settings, including acute, primary and community care. The Derbyshire ACP must meet a core set of competencies, and then meet specific capabilities depending on the area of practice.
The aim is to ensure standardisation and that all ACPs have some core transferable skills. All ACPs in Derbyshire must have a full MSc degree. You must check the qualification requirements in your own area.
A master’s-level education is identified as key in all the frameworks, so you need to find what advanced practice programmes are offered by local universities. Many MSc modules require a specified number of supervised practice hours to assess competency.
There are likely to be some core modules, such as advanced assessment and diagnostics, pathophysiology and prescribing. If your practice requires you to see children, you should undertake a paediatric module. Funding for these modules varies from area to area.
As well as passing MSc-level modules, you will need to compile a portfolio of evidence to demonstrate your competencies. Currently a capability framework is being devised and a pilot project is underway looking at how best to assess competency. There are plans for a digital portfolio for advanced practitioners. Until this is agreed, you will need to maintain a paper portfolio.
It is good practice to include the following in your portfolio:
- A PDP identifying SMART objectives.
- Your educational attainment and a record of MSc modules.
- A record of assessments, to include case-based discussions, consultation observations and directly-observed procedures.
- Quality improvement projects or audit.
- Information relating to leadership and management.
- Information about any educational roles you have.
- Any patient compliments and complaints.
- Significant event analysis.
- A learning log detailing evidence of competency. There should be a couple of learning log entries a week, reflecting on cases where you have demonstrated competency or identified learning needs.
Also ensure your job description is correct and up to date.
It is also very important to ensure you have the appropriate indemnity cover. If you are an ANP you cannot be covered on a practice group scheme. Send your job description to the indemnity company of your choice to ensure you have the adequate cover.
How to get started in your training
- Understand the framework in your part of the UK and keep an eye on national developments.
- Discuss the need for an ANP role in your practice.
- Identify appropriate, good-quality clinical supervision and how this can be delivered in practice.
- Identify any requirements or guidance about advanced practice in your area.
- Identify MSc programmes on offer from universitiesin your area.
- Maintain a portfolio of evidence.
- Always work within your scope of practice.
- Ensure you have an accurate job description and adequate indemnity cover.
Developing as an ANP is challenging. Generally, it will involve a senior registered nurse leaving their comfort zone to learn and take on new knowledge, competencies and skills. With the correct training and support, the ANP role can be exciting, providing job satisfaction and excellent patient care.
Julia Taylor is an advanced clinical practitioner at Lister House Surgery in Derby, and a GP trainer and lead for general practice with the Advanced Practice Strategy Group in Derbyshire