News

IMPORTANT IMPLICATIONS FOR REGULATION OF ADVANCED PRACTICE

Dear Colleagues

I have been part of the collaboration that has produced an important piece of research which highlights misuse of titles such as Advanced Nurse Practitioner and Advanced Practitioner.  The Health Service Journal ran a pre-article which has been picked up in the Nursing Press etc.  Please read the full article for details.  The NMC has responded and the implications of the research are being discussed at the CNO meeting.  Hopefully an important stepping stone to reconsidering the need for regulation.

 

LSBU STUDY OF NHS NURSING JOB TITLES ACROSS UK HIGHLIGHTS NEED FOR GREATER REGULATION OF STANDARDS AND QUALIFICATIONS WITHIN THE PROFESSION

‘Variation in job titles within the nursing workforce’- a new study published today (7 September 2017) in The Journal of Clinical Nursing, warns of a significant risk to patient safety that threatens to undermine public confidence in the nursing profession and highlights the need for greater regulation of standards and qualifications within the sector.

The report is produced by researchers at London South Bank University (LSBU) who analysed in detail a cohort of around 18,000 (17,960) specialist nursing posts over a ten-year period (2006-2016) within NHS trusts across the UK.

Results of their analysis show that just under 600 (595) different specialist job titles are currently in use– a practice that is not only confusing for the public, medical professionals and commissioners of healthcare services- but is arguably posing a serious risk to patient safety.

The International Council of Nurses recommends that advanced level nurses who often prescribe drugs and manage a caseload have at least a Masters degree level qualification but of 8064 posts looked at, for which educational data was obtained, 323 (4%) were recorded as holding titles such as ‘Advanced Nurse Practitioner’ and ‘Specialist Nurse’ while having no formal first level nursing qualification registered with the Nursing & Midwifery Council (NMC).

This four per cent group of unregistered nursing support workers employed by NHS trusts in England are most prevalent in London and the North East of England.

In this group that were not registered with the NMC all of the low paid workers featured in this sample (100 per cent) were women earning in the region of £17-22k (Pay band 3 and 4).

Of these, the majority use the term ‘Advanced Nurse’ or both ‘Advanced’ and ‘Nurse’ in their job title. Examples include, ‘Advanced Practitioner’ which was the most common (83) followed by ‘Specialist Practitioners (69) and ‘Advanced Nurse Practitioner’ (52). They primarily worked in emergency care, pre-assessment, theatres and cancer.

These job titles were cross-checked further on the NHS Jobs website during April-May 2017 using the search terms ‘advanced’ and ‘nurse’ (and applying a pay band 1-4 filter) revealed advertised posts for which registration with the NMC as a registered nurse was not required.

Those who were registered nurses using the title specialist or advanced had a variety of qualifications which ranged from none to Masters and PhDs.

As there is currently no regulation of specialist advanced nursing practice in the UK employers and post holders drive the labelling of posts. The report recommends that harmonisation would help to curb the unnecessary proliferation of nursing job titles, introduce much needed clarity and possibly enhance patient safety.

The report also suggests that regulation of protected job titles is particularly important for the international community in countries outside of the UK that are developing these roles.

Alison Leary, LSBU Professor and Chair of Healthcare and Workforce Modelling, one of three LSBU research staff who co-authored this report said: “What the results of this study clearly show is that advanced nursing practice needs regulation to help protect the public. Lack of consistency has implications for the wider perception of advanced specialist practice in the worldwide community and the workforce more generally.

 “If the current system is allowed to continue unhindered, then there is a real risk posed to patient safety. Public trust also risks being undermined by NHS trusts applying professional job titles to low-paid carers who are not fully qualified nurses.

“In some instances, there is evidence that these post holders are being expected to treat members of the public and are missing diagnoses altogether, which could lead to patients becoming seriously ill or worse.

 “This study also demonstrates that previous assumptions by the Council for Healthcare Regulatory Excellence that advanced practice labels are associated with career progression are unsound and should be addressed by the regulator. 

“The lack of a common framework across England is an issue. Future role development and education from a common framework should be considered.”

HEE Advanced Clinical Practice framework to be published by end of May 2017

Further to the updates below:

The HEE Local Offices ACP working group met on Wednesday 22nd March 2017 to review the progress that was being on the Advanced Clinical Practice framework.   This is currently being prepared to build on the definition and case studies that have already been published on their site.   We will share the framework as soon as we can via this site.

Once the framework is published, other resources will in added as a “toolkit” approach.  This will include patient-focused information.

https://hee.nhs.uk/our-work/developing-our-workforce/advanced-clinical-practice

AAPE UK Annual Conference 2017 report

“Innovations in Advanced Practice Education:

The Time is Now”

Our annual conference was hosted this year by the University of the West of England Bristol on Friday 3rd March 2017.   We were delighted to welcome approximately 80 delegates from across all four countries of the UK, and two academics from Norway.

We will provide the slides from many of the presentations through Slideshare, however I thought it would be useful to provide a brief review of the day for those people who were unable to join us.

I opened the conference and reflected on the significant expansion of AAPE UK since the original meeting of Nurse Practitioner course providers in 2001.  Membership is currently stable around 35 HEI’s with new ones joining as advanced practice education provision expands.

Professor Steven Neill, Pro-Vice Chancellor and Executive Dean of Health and Applied Sciences, UWE Bristol, welcomed us and observed that the need for advanced practice knowledge and skills has never been higher in the health service.

The three themes for the day were Policy updates, Innovation in education and the Impact of education.

Policy updates

We noted that Scotland, Wales and Northern Ireland were all in the implementation phase of the advanced practice policies, with dedicated funding streams.

Health Education England has been providing a dedicated workforce development funding stream for advanced clinical practice since 2015, however this is likely to cease due to financial challenges.  They established an Advanced Clinical Practice work stream with a Steering Group in 2016 chaired by Mark Radford (Director of Nursing for Improvement, NHS Improvement) and Charlotte Beardmore (Director of Professional Policy, Society and College of Radiographers (SCoR).  Ruth Pearce (University of Nottingham, former Chair AAPE UK) is a member of this group representing AAPE UK. I am a member of the Working group which includes representation from all of the HEE Local Offices.

Mark Radford had been invited to provide an update on the work to date but was unfortunately not able to join us.  Therefore Ruth and I reviewed the outputs to date – definition and case studies which are now available on the website page – and the plans to release the core capabilities and other guidance within a framework document in the near future.

https://hee.nhs.uk/our-work/developing-our-workforce/advanced-clinical-practice

Discussion with delegates focused on the importance of emphasising the need for Masters education, with emphasis on all 4 pillars of advanced practice, and rigorous assessments.   Concerns were raised that funding pressures could lead to in-house quick fix training and the resultant loss of the safe, effective, value-added approach demonstrated by our graduates.

Innovation in education

Lynn Sutcliffe (University of Cumbria) then provided an overview of their distance learning provision utilising e-learning to the full for their  UK and internationally based student group.  Lynn noted this approach does not suit the learning style for all students.  She highlighted it requires more staff resources than face-to-face teaching, however it has proved a very successful flexible approach with increasing student numbers.

Another example of innovation was reviewed by Annabella Gloster (University of Salford) and Anna Jones (Cardiff University).  Both HEI’s have replaced their traditional Dissertation module with a substantial Portfolio.  They had to make strong cases to argue that this approach retained academic rigour and enabled demonstration of critical thinking, analysis and synthesis across the required components with accompanying reflection.  Each had different requirements  and timescales for collation of the evidence but both resulted in portfolios that demonstrated all four pillars of advanced practice.  Annabella noted that more students had gone on to publish related material than had previously following the Dissertation.  Many also continued to maintain and update their Portfolio following graduation.

Anna Jones (Cardiff University) and Emma Thomas (Service Improvement Manager, 1000 Lives Improvement Service) shared their exciting collaborative venture to link the advanced practice students service improvement project dissertation option with a Wales-wide initiative to embed the “Improving Quality Together learning programme” into the development plans for all health service staff.  Students need to link with the Local Health Board and consider how to implement sustainable changes.  The results have been impressive and enable students to gain the Silver award in recognition of their achievements.

http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Quality%20Improvement%20Guide%20-%203rd%20edition%20%28IQT%29%20WEB.pdf

A Global Survey of Clinical Education of Advanced Practice Nurses has been conducted by the Education sub-group of the International Council of Nurses (ICN) Nurse Practitioner/Advanced Practice Nurse network.  Linda East (University of Nottingham) shared some interesting reflections.  Many countries have a set number of hours which students need to demonstrate to gain the final award.  The underpinning principle is obviously the need for sufficient experience to develop competence and confidence but the quality of the time may be an important factor to consider.  The USA develops their students through placements but with increasing numbers, they are having to reconsider this approach.  Many countries in the survey use the UK model where students undertake the course part-time whilst working in a setting within which their practice can develop. There are challenges with this approach; the quality of the setting cannot be controlled so rigidly and it relies on supportive employers and volunteer mentors, however it does open the programme to a wider range of students.  The 10th ICN NP/APN conference is in Rotterdam, The Netherlands 27-29 August 2018.  This should be an exciting event and a fantastic opportunity for networking considering the last conference in Hong Kong attracted 900 delegates!

Impact of education 

During the day, we heard from the three advanced practice graduates who were invited to share reflections on the way in which their education had developed their practice.

Jimmi Ronaldson is an Advanced Retrieval Practitioner, with the Emergency Medical Retrieval Service in Scotland.  He gained 60 credits with Glasgow Caledonian University through use of a work-based learning contract approach, with a designated supervisor.  This enabled him to develop the specific competencies he needed for the scope of practice in his job description. He used the NHS e-portfolio to gather the evidence to demonstrate achievement of all 4 pillars.  This strategy was clearly effective for achieving the balance for gaining both generic and specialist advanced level knowledge and skills to prepare him for his current and future practice.

Rob Harvey is a Advanced Practitioner Pharmacist in General Practice in Bournemouth.  He recently joined Bournemouth University as a Lecturer/Practitioner.  He shared is experience of using the combination of his advanced practice education and pharmacy background to see patients presenting with undifferentiated problems.  NHS England are promoting this development, which goes beyond the medication advice/review role.

https://www.england.nhs.uk/gp/gpfv/workforce/cp-gp/

Rob also shared the Royal Pharmaceutical Society Roadmap to Advanced Practice which was launched in November 2016.  This uses the Faculty approach to recognise experience in the workplace, competence and the ability to manage complexity.

http://www.rpharms.com/what-s-happening-/news_show.asp?id=4148

I added another aspect of Pharmacist development which is in Emergency Care.  An evaluation has been positive with more HEE pilots currently taking place.

https://hee.nhs.uk/sites/default/files/documents/PIED%20National%20Report.pdf

Finally Stuart Wildman, Nurse Consultant Major Trauma, Salford Royal Foundation Trust, reflected on his progression from Advanced Clinical Practitioner to Consultant.  He acknowledged the term Consultant had reduced challenges to his referrals and decision making, but felt that his advanced practice education and experience was absolutely fundamental to his effectiveness at this.  This had enabled him to be the “glue” for the trauma service to ensure an effective service focused on the patient with injuries, rather than the fragmented specialist-specific injury focused approach  that was previously evident.  He was now supporting new advanced clinical practitioners (nurses) but hoped to develop a physiotherapist into this role to utilise multi-professional backgrounds and expertise.

We finished the day with the AGM.  The minutes will be made available on this website.

We are evaluating the day but initial feedback was very positive.

The next conference will be Friday 1st March 2018 in Glasgow.  We will start planning soon so if you want to suggest any speakers or topics, please let me know.

Katrina Maclaine

Chair of AAPE UK & Associate Professor Advanced Practice, London South Bank University

maclaik@lsbu.ac.uk

Update – DEVELOPING ADVANCED PRACTICE IN NHSSCOTLAND – Scottish Government report June 2016

Interesting developments within Scotland has seen a commitment from the Scottish Government CNO office to support the development of 500 Advanced Nurse Practitioners (ANPs). The report from the working group has set out a robust vision for ANPs education, key competencies and an agreement that MSc qualification will be the minimum to be considered an ANP. Governance structures within health boards will require collating numbers of existing ANPs and specialty (this is already done in some health boards) and standard job descriptions. Many of the recommendations are already being achieved and HEIs are covering the majority (if not all) of the core areas of education in their existing MSc programmes.

Clinical assessment

Clinical reasoning, judgement and diagnostic decision making

Anatomy and pathophysiology

Non medical prescribing- V300

Leading, delivering and evaluating care

Practice learning/transferable work based learning processes.

This pragmatic approach to ANP education focussing on the clinical pillar of advanced practice reflects the current service needs of the country. However, the report does stress the importance of all 4 pillars of AP.  How HEIs ensure that they are able to accommodate these increased numbers and how a standard approach on clinical pathways of MSc programmes is met is something that we at AAPE UK are aiming to address via our AAPE Scottish sub- group which should be discussing these developments with the working group. Interestingly, the focus here is on nursing whilst the rest of the UK appears to focusing on AP across disciplines. However, these are exciting times which could see the most coordinated approach to ANP education across the whole of Scotland. I recommend reading the whole report. transforming-roles-advanced-practice-paper-june-2016

Dr Evelyn McElhinney (UK Committee, AAPE Scotland sub-group lead)

 

AAPE UK response to announcement that RCN is to credential ANP’s.

AAPE UK have noted the announcement that the RCN is to credential Advanced Nurse Practitioners with the aim of improving the consistency related to the use of this title.

Demand for advanced level knowledge and skills is at an all time high in the UK as our health care systems face significant challenges.  Nevertheless, the public and employers are asking for clarity and assurance about the appropriate use of titles, underpinning education, rigour of assessment and governance framework needed for the burgeoning number of posts.

AAPE UK representatives are currently participating in top level discussions related to advanced clinical practice policy, standards and implementation strategies in England, Scotland, Wales and Northern Ireland.  Whilst the specific priorities vary in each country, there is a common recognition that advanced clinical practice roles have expanded beyond nursing to include allied health professionals and pharmacists.

AAPE UK hope that the production of standards for advanced practice by the professional colleges will support and facilitate the further expansion of advanced practice roles and not result in an incoherent, fragmented approach.

We look forward to hearing more of the RCN work at the launch in November.

Update on Health Education England Advanced Clinical Practice Project (August 2016)

Background

In the latter part of 2015, Health Education England started a project in relation to Advanced Clinical Practice aiming to establish an agreed framework with a common definition and core principles with a multidisciplinary application.  A Steering Group was established.  The opportunity was taken to utilise an existing group of LETB representatives and advanced practice health professionals who had been already meeting for a year to share local advanced clinical practice frameworks and guidance.  This group has become the working reference group for the HEE project.

AAPE UK have representation on both groups:  Ruth Pearce (former Chair of AAPE UK) is a member of the Steering Group and Katrina Maclaine (Current Chair of AAPE UK) is on the working group.

Meetings of both groups are being held regularly with good attendance and enthusiastic participation.  The time line for the project has recently been extended from 1 year to 2 years in recognition of the scale of the project, however it is hoped that a definition with principles will be produced as on of the interim outputs.

Thoughts from Katrina Maclaine on themes from recent working group meetings:

The enthusiasm for this project has been high with lots of discussion and debate on issues that have vexed everyone involved in advanced practice for many many years.  As a result achieving a consensus has been challenging but a very interesting process.

For example is the intention to set a standard for advanced clinical practice as a level of practice or rather to define the role advanced clinical practitioner. We have agreed the former (using the reasoning already well articulated in the Welsh Advanced Practice policy) however anxiety in the practitioners in the group remains regarding how this will help the multitude of titles and consistency of terms for patients and colleagues.

Another key aspect that many of us have emphasised is the need to not reinvent the wheel, with high quality UK and international and profession specific work to draw on.   We undertook an exercise where multiple definitions of advanced practice were mapped and key common words highlighted.  This enabled us to synthesis a draft definition which will be put to the Steering group for consideration.  In this we particularly emphasised the importance of the four pillars, not only as separate key aspects of advanced practice but also as integral to and underpinning each other to ensure that the level of practice is significantly different from the standard of a newly qualified health professional.

The most contentious issue has been whether there should be a set standard for educational preparation and if so what this should be.   Some members want “masters level thinking” focusing on demonstrating experiential learning, while others of us are strongly pushing for a full MSc award with the curriculum based around all 4 pillars.

There was some email debate following the last meeting so I thought it might be worth sharing what I contributed (see below).  I would welcome your thoughts to enable Ruth and I to reflect your opinions as AAPE UK members in the group discussions. 

As I said at the meeting I strongly advocate a full MSc ACP for the future standard with agreed themes for content based around the 4 pillars that form part of our proposed definition.

This does not stifle creativity and can be outcome focussed with recognition of prior and experiential learning optimised.

I looked that some of the other Local office standards and also the Scottish, Welsh and Northern Ireland, RCEM and international work.

MSc Advanced Practice is now the common proposed standard and I think any suggestions for England not to act similarly would be a serious mistake in terms of reputation and its impact on reducing inter-country barriers for a mobile global workforce.

Their rationale does refer to international comparisons, however they also importantly emphasise:

  1. The need to establish consistency to sustain the future of advanced clinical practice with a single framework to support employers, service leads and senior clinicians to articulate the role, its function and the education requirements.
  2. Recognition of the level of practitioner that will result from a full MSc with a specific curriculum designed to fully optimise the knowledge, skills and competencies that are characteristic of advanced clinical practice, will be higher than that for a lower masters level award such as a module, PgCert or PgDip.   This is key for delivering the future policy agenda nationally and locally in England.

I know there may be a perception that as an HEI we have a vested interest in advocating for a full MSc, however my experience from the being on the UKCC Higher Level Steering Group (1994) piloted a standard for trying to regulate advanced nursing, subsequently as part of the NMC working group on regulating Advanced Nurse Practitioners (2004), and then on the Department of Health group to define Advanced Nursing (2010) has demonstrated to me that “masters level thinking” is not sufficient to provide a the single standard needed to enable us to move on from the constant debate about the standards needed for preparation of health professionals for advanced practice.

The issue of affordability came up last Thursday.  This is a challenging one but I don’t think we should modify our goals based on this.

I realise there are other views but wanted to share my thoughts so they could be included in information for the Steering group to consider.

Katrina’s contact email is maclaik@lsbu.ac.uk 

We will provide further updates on this work.  

Our conference in March 2017 will also include a presentation from Mark Radford who is co-chairing the Steering Group for this important project. 

Nuffield Trust release Reshaping the Workforce

The Nuffield Trust have released their report titled: Reshaping the workforce to support new models of care. Their executive summary states it ‘is a huge opportunity, but
also a huge organisational development challenge – particularly with regard to the
non-medical workforce. We argue that organisations need to begin with a deep
understanding of patient needs, and then train, recruit and skill the workforce to
meet those needs. This report explores how organisations can do this, and the benefits
that would result.’

Click on the link to access the report

For HEI’s it state that advanced practice roles should ‘typically’ have a two year Masters qualification. The Health Education England National Framework also gets a mention and the need for ring fenced funding. See below:

The report states there are a number of important areas where national support is needed. Based on
their research they would recommend the following:
– the Health Education England budget and specialist workforce planning expertise
should be protected by ring-fencing monies to support local workforce redesign
– national competence frameworks are needed for staff in extended and advanced
roles
– there should be a dialogue between the professional regulators and system
regulators to ensure that there is no ‘regulatory gap’ and that new and extended
roles have safe governance arrangements
– Health Education England should work with NHS Improvement and the Care
Quality Commission to ensure that planning assumptions, new workforce models
and inspection requirements are aligned and clearly communicated
– the Department of Health should review the current legal indemnity
arrangements for primary care staff with new and extended roles to find ways to
make legal indemnity easier to obtain and more affordable
– the underlying needs analysis for, and impact of, workforce redesign should be
a national research priority
– Health Education England should consider how it can support the dissemination
of good practice examples.

As Chris Inman from Birmingham City University points out there are parts of the report that read is if the Nuffield Trust has just come up with these roles and rather typically, when AP is mentioned, there is scant attention paid to regulation. However, it’s good to see a call for the DH to review legal indemnity for primary care staff.

AAPE UK Conference 2016 programme

 AAPE UK Annual Conference 2016

 “The Impact of Inter-Professional Advanced Practitioners on Service Design and Health and Social Care” 

 Friday 4th March 2016, 9am – 4:00pm

The Old Fire Station, University of Salford,

Council Chamber G05, The Crescent, Salford, M5 4WT

 Location: Visit http://www.salford.ac.uk/conferencing-at-salford/our-venues/the-old-fire-station

Nearest train station – Salford Crescent Station (3 minute walk – turn left out of the station and cross at the pedestrian crossing – venue is facing you)