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					Modernising Nursing Careers
Advanced and Specialist Nursing
Practice- a scoping report
Andrew Brown and Kathryn Jones
March 2011


                                  1
      Contents
1.        Purpose and scope.............................................................................................. 3
2.        Definitions of advanced and specialist nursing practice ...................................... 3
     a) Advanced practice:........................................................................................... 3
     b) Specialist practice: ........................................................................................... 4
     c)      Differences between advanced and specialist practice:................................... 4
          Figure 1. Relationship between specialist and advanced practice ...................... 5
3.        Background/ context............................................................................................ 5
4.        Data collection..................................................................................................... 7
5.        Findings from the workshops............................................................................... 8
     Table 1: Summary of workshop findings................................................................. 9
     Table 2. Key considerations formulated within the workshops for preparing the
     advanced practice workforce of the future ............................................................ 10
6.        Findings from the survey ................................................................................... 10
7.        Developing new advanced level nursing roles................................................... 11
8.        Recommendations............................................................................................. 12
     8.1 Recommendations for organisations .............................................................. 12
     8.2 Recommendations for services....................................................................... 13
     8.3 Recommendations for the individual practitioner ............................................ 14
9.        References ........................................................................................................ 15
10.          Appendix 1 ..................................................................................................... 16
11.          Appendix 2 ..................................................................................................... 17
12.          Appendix 3 ..................................................................................................... 18




                                                                                                                              2
    1. Purpose and scope


The purpose of this document is to provide a high level scope pertaining to:
  i.    the range of advanced nursing practice roles within London in both generalist
        and specialist settings
 ii.    the academic preparation of those nurses practicing at an advanced level and
 iii.   the range of activity undertaken by these practitioners.


This high level scope will inform the future workforce planning and education
commissioning agenda in relation to preparation of advanced level practitioners, also
the Continuing Personal and Professional Development (CPPD) that they might
need.


    2. Definitions of advanced and specialist nursing practice



    a) Advanced practice:
  i.    In November 2010 the Department of Health (DH) released a position
        statement on ‘Advanced Level Nursing’ that provides a ‘benchmark to
        enhance patient safety and the delivery of high-quality care by supporting
        local governance, assisting in good employment practices and encouraging
        consistency in the development of roles and posts’ (DH 2010a page 4).
 ii.    Drawing on previous work carried out internationally including the US,
        Canada, Australia and New Zealand, the DH position statement defined
        advanced level nursing practice by building on the standards required of a
        registered nurse on entry to the Nursing and Midwifery Council (NMC)
        register.
 iii.   The DH position statement describes a level of practice rather than a nursing
        role or speciality and so it is generic, it does not constrain itself to specific
        healthcare settings.
 iv.    It proposes twenty-eight elements that encapsulate advanced level nursing
        practice clustered around four themes: clinical/ direct patient care; leadership
        and collaborative practice; improving quality and developing practice;
        developing self and others.

                                                                                       3
v.      The elements define a ‘minimum threshold’ for advanced level nursing
        practice roles and articulate an expectation that nurses working at an
        advanced level will continue to develop their individual practice beyond initial
        competence.
vi.     Finally, the document sets out the expectation that ‘nurses working at this
        advanced level of practice would have achieved this through extensive clinical
        and practice experience and following completion of a master’s level
        education/ learning or its equivalent’ (page 6). The full document can be found
        at the link below.
        http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@
        ps/documents/digitalasset/dh_121738.pdf



     b) Specialist practice:
 i.     The use of the term ‘specialist’ to describe nursing practice is confusing. It is
        often used to describe the clinical specialist roles that some nurses adopt in
        practice, for example, Clinical Nurse Specialist in rheumatology or diabetes.
ii.     However, it also refers to the specialist community public health roles (e.g.
        health visitors, school health nurses, district nurses, and occupational health
        nurses who hold an NMC approved or recordable qualification) on the third
        part of the NMC register.



     c) Differences between advanced and specialist practice:
 i.     The issues around nomenclature are addressed in an online advanced
        practice toolkit produced by NHS Scotland in 2008- see link below. The toolkit
        suggests that ‘increasingly the ‘specialist’ should be considered as one pole of
        the ‘specialist–generalist’ continuum, rather than on the developmental
        continuum from ‘novice’ to ‘expert’. This approach defines ‘specialist’ practice
        as that which is particular to a specific context, be it a client group, a skill set
        or an organisational context’.
        http://www.advancedpractice.scot.nhs.uk/definitions/specialist-and-
        advanced.aspx
ii.     ‘Advanced’ practice, it is argued, is a particular stage on a continuum
        between ‘novice’ and ‘expert’ practice with the ‘advanced’ role profile

                                                                                          4
        characterised by high levels of clinical skill, competence and autonomous
        decision-making, reflecting a particular benchmark on a career development
        ladder as exemplified in the Career Framework for Health (Skills for Health
        2006)’.http://www.advancedpractice.scot.nhs.uk/definitions/specialist-and-
        advanced.aspx
 iii.   The figure below (taken from the toolkit) illustrates the inter-relationship
        between the novice to expert continuum and the specialist to generalist
        continuum.

Figure 1. Relationship between specialist and advanced practice


                                                            ‘Importantly, this figure recognises that the
                                                            developmental pathway towards advanced level
                                                            practice in nursing may be different for individual
                                                            practitioners, with some following a ‘specialist
                                                            nursing’ route through focus on high-level skills
                                                            and decision-making within a particular client
                                                            group or clinical context, while others will develop
                                                            a portfolio that reflects high-level assessment,
                                                            decision making and autonomous practice across
                                                            a greater breadth of practice’
                                                            http://www.advancedpractice.scot.nhs.
                                                            uk/definitions/specialist-and-
                                                            advanced.aspx




        The full tool-kit can be found at the link below:
        http://www.advancedpractice.scot.nhs.uk/home.aspx




    3. Background/ context



  i.    Development and regulation of advanced practice roles is a long standing
        point of debate within the nursing profession. There have been several
        attempts over the past decade to define and then to begin to regulate
        advanced practice without success. Despite this, nursing roles have been




                                                                                                            5
       developed to meet service needs which incorporate a range of advanced
       practice activities.
 ii.   This development has been due to a range of factors including: political
       directives, for example, the European Union Working Time Directive (EWTD)
       of 2004; the shift to care being provided in increasingly non-traditional
       settings, for example, community care; streamlining care activity to improve
       patient experience and reduce the overproduction of care, for example Darzi’s
       right care, right person, right time (DH 2008); as well as responding to the skill
       shortages in other professions.
iii.   One of the nursing professions strengths has been the ability to adapt and
       respond to the changing landscape of healthcare delivery. The range of
       expertise and talent has been acknowledged and now nurses are leading and
       delivering a range of generalist and specialist services across a diverse range
       of health care settings.
iv.    There has been a significant shift in the way that care is delivered. New
       models of care provision often utilise and rely on a multi-professional team,
       including those working with enhanced or advanced skills, to: treat, refer,
       order diagnostics, prescribe medications and deliver courses of treatment,
       which have previously been the domain of medical professionals.
 v.    Alongside this role development, there has been a growth in role descriptors
       and job titles. In particular, the plethora of advanced and specialist job titles is
       of concern to practitioners, regulators and the public alike. There is limited
       understanding of the meaning of the titles and what can be expected from
       those practitioners using them. Job titles themselves do not consistently
       reflect the educational preparation or level of competence of practitioners.
vi.    Although the DH position statement does not tackle the regulation or
       protection of titles (which is the role of the regulator) it does take the first step
       in describing a standard of educational preparation and describing the
       elements for a practitioner working at an advanced level (refer to section 2a).
vii.   Further,   the   command      paper    ‘Enabling    excellence:    autonomy     and
       accountability for health and social care’ (DH 2011) was published in February
       2011. This paper sets out a strategy for reforming and simplifying the system
       for regulating health and social care workers in the UK with the ambition of a
       more simplified ‘right touch’ regulation that does not incur further costs to
                                                                                          6
        registrants. ‘The government will not support the health professions regulators
        in taking on new responsibilities or roles which add to the costs to their
        existing registrants without providing robust evidence of significant additional
        protection or benefits to the public’(DH 2011 page 11).
viii.   Whilst there maybe professional support amongst the nursing community for
        the introduction of measures such as advanced practice registers, the paper
        requires ‘a compelling case’ to be justified before taking further regulatory
        action. A system of voluntary registers has been proposed as a preferred
        option rather than a statutory approach (DH 2011 page 18).


    4. Data collection



   i.   To inform the advanced practice work stream two workshops were conducted
        in autumn 2010. An email invitation was sent to Directors of Nursing
        requesting nominations from a range of clinicians who felt they worked at an
        advanced level. These nominations (n=18) formed two workshops. The roles
        of those who attended were based in a variety of settings including acute and
        specialist, but also in the community as well as roles that cut across settings
        and followed a patient pathway. Also, those who provide advanced practice
        education attended.
  ii.   Interviews were also held with stakeholders where advanced practice was
        explored and their personal and organisational experience discussed.
        Appendix 1 provides a list of those who participated in the workshops as well
        as those consulted individually.
 iii.   To validate the findings of the workshops and also to inform the content of this
        paper, an expert reference group was formed and the findings reviewed.
        Appendix 2 lists the membership of this reference group.
 iv.    To broaden stakeholder engagement and ensure greater depth in the data
        source, a workforce survey was prepared to better understand existing forms
        of advanced practice. Based on an original survey conducted by NHS
        Scotland (2007), a 54 item questionnaire was constructed to capture the
        scope of advanced practice nursing roles within London. Also, the clinical
        areas where those considering themselves to be advanced practitioners were

                                                                                      7
       practicing and their education preparation for role. A link to the survey was
       disseminated by a number of networks in December 2010 including the
       London Directors of Nursing and NHS organisation education leads. The
       survey drew great interest and resulted in a survey response of 362.
v.     Appendix 3 is an embedded file of the NHS London survey questionnaire.



     5. Findings from the workshops



 i.    The consensus within the workshops was that nurses working at an advanced
       level required a minimum period of broad experience to consolidate their
       nursing skills and knowledge, before moving into an advanced practice role.
ii.    There was also consensus that practitioners working at an advanced level
       required a formal qualification to support and underpin their clinical practice.
iii.   Those present supported a core set of competencies for advanced practice,
       with supervision, reflective practice and gaining clinical competence also
       considered key elements of an advanced practice role.
iv.    In relation to the development of advanced practice roles, often they were
       described as ‘ad hoc’ or ‘organic’ in development. Roles had been developed
       with little forward planning in response to workforce shortages. Advanced
       practice was frequently considered to be led by an individual practitioner
       seeking to broaden his/her knowledge and competence, rather than as a
       service development to expand staff roles.
v.     To help gain clarity around roles and titles it was felt important to recognise
       that some roles within specialist settings are not practiced at an advanced
       level, and that clarity was needed at an operational level to determine levels
       of practice. To note, it is not the intention to devalue the specialist role, but
       within a culture of transparency and public protection it is important that
       patients, clients and their families understand the level of skill of those who
       treat them.
vi.    Also, for some, role boundaries were not clearly defined leading to limitations
       or confusion. For example, several participants cited occasions whereby other
       professionals had not accepted their authority or competence to act and to
       refer. To overcome these issues clear patient-centric service redesign needs

                                                                                          8
        to take place that includes identification of the scope, boundaries and
        legitimacy of advanced practice roles.
vii.    Some discussion took place about whether the ‘building blocks’ of advanced
        practice could be included in pre-registration training, for example physical
        assessment skills.




Table 1: Summary of workshop findings
    • Broad base nursing experience is required to underpin advanced practice
        roles (suggested minimum of 5 years)
    • Masters level qualification should be the minimum education requirement
    • Advanced practice needs a standardised set of competencies that can be
        applied to all advanced practice roles across London (and indeed the country)
    • Supervision is essential to monitor delivery of advanced practice
    • Advanced practice roles need to be planned, not just evolve
    • The scope of the advanced practitioner needs to be defined in collaboration
        with and supported by the wider multi professional health team
    • There is a need to define what is advanced and what is specialist practice
    • A strategy for advanced practice is required (both at organisational and pan
        London level)
    • Funding needs to support the development of new advanced practitioner roles
    • Research is an integral part of advanced level nursing
    • Assessments of new advanced practitioners should include patient feedback
    • Understanding the public health profile of a population is important to support
        service development (the why and how do you provide a service).




viii.   The changing landscape of the NHS, as described in the recent white paper
        (DH 2010b), with a shift towards GP commissioning consortia was discussed
        within the workshops.    In order to respond to the changing dynamic in
        healthcare, additional skills may also be required for advanced practice
        including an understanding of finance, incorporating public health information



                                                                                    9
           into service development plans, leadership and change management skills,
           commissioning and business skills.
 ix.       It was considered that London was unique in its ability to develop the next
           generation of advanced practitioners. To support this it was suggested that a
           strategy to develop advanced practitioners should be created to help
           coordinate and support new advanced practice roles.
 x.        This was echoed by members of the reference group. But experience of
           providing advanced practice education was often that individuals present to
           develop their own practice, rather than being selected and supported as part
           of a coordinated service development approach.
 xi.       Finally, many of those who attended the workshops cited access to funding
           and study leave as a key area of concern. The inequity of this provision when
           compared to the experience of medical colleagues was also noted.



Table 2. Key considerations formulated within the workshops for preparing the
advanced practice workforce of the future
       • Finance, business skills and management skills are crucial, with the
           commissioning process understood by all
       • Leadership skills and change management skills are required to support the
           development of new ways of working and creating new services
       • Provision of study leave needs to be protected, and supported if possible with
           ‘back-fill’ Structured mentorship and supervision are required at both a clinical
           and professional level
       •   Effective succession planning should be used as a mechanism to identify
           future candidates for advanced practice programmes



       6. Findings from the survey



  i.       362 nurses responded to the survey, of whom 312 identified that they worked
           in London.
 ii.       The survey data revealed the most usual demographic profile for an advanced
           practitioner as White female, aged 40 -49 (n=124). The majority of

                                                                                         10
            respondents (n=186) had been in role for longer than 5 years. The largest
            number of respondents (n=141) were from Agenda for Change (AfC) Band 7,
            with the next largest group from Band 8a (n=78) within a range of Band 5-9.
     iii.   Respondents were asked to identify where they worked geographically, with
            information grouped by NHS London sectors. The largest cohorts came from
            the North Central sector.
  iv.       Of those who responded, just over a half (n=196) held an undergraduate
            degree, just over a quarter (n=97) a completed Masters award and one a
            professional doctorate. Also, a quarter (n=92) held some masters credits but
            not a whole award. Two fifths (n=143) of respondents were currently studying
            for an academic qualification- of these 15 were engaged in study at doctorate
            level and 78 were studying for a Masters award. Of those who reported it,
            two-thirds (n=186) of the qualifications held were attained at a London Higher
            Education Institute.
     v.     The survey identified 198 individual job titles. The titles were filtered using
            specialist (n=71), practitioner (n=33) consultant (n=11) and other (n=83).
  vi.       The survey data is currently being further analysed to better understand the
            role remit of the advanced practitioner in London. A full findings report will be
            available by the beginning of April 2011.


          7. Developing new advanced level nursing roles



i.          In the context of developing new ways of working, advanced level nursing
            roles are clearly being developed and implemented across a range of
            disciplines and clinical settings. However, as cited above, the development of
            these roles has emerged organically and often with out proper planning or
            vision.
ii.         Effective workforce planning and service redesign are essential steps in
            creating new (or developing existing services) that are focused on the needs
            of the patient and provided by staff with the required skill set and matching
            scope to meet those needs.




                                                                                          11
iii.      A service needs analysis tool developed by NHS Education for Scotland
          (2010) provides a systematic approach to developing and implementing
          advanced practice roles.
          http://www.advancedpractice.scot.nhs.uk/media/20207/service%20needs%20
          analysis%20tool%20revised%20final%20ver%201.3%20june10.pdf



       8. Recommendations



          To support the development and implementation of advanced practice roles, a
          range of recommendations are outlined below:




       8.1 Recommendations for organisations
          To provide strategic assurance in relation to development of advanced
          nursing practice organisations should:

       • Identify a board level champion who will drive role and service redesign
             o Ensure a consistent methodology for service redesign
             o Ensure services are redesigned with a patient focused approach
             o Consider a strategy for benefits realisation
             o Ensure patient-centred workforce planning embraces advanced
                 practice roles
       • Provide strategic oversight to ensure the necessary operational infrastructure
          is in place to support new ways of working
             o Ensure underpinning operational infrastructures are in place to support
                 implementation of new roles
             o Address levels of accountability and authority to act
             o Ensure governance and board assurance frameworks are developed
                 and that auditing and monitoring of advanced practice takes place
             o Ensure that risk analysis and issues logs for advanced practice are
                 developed and regularly reviewed
             o Ensure structures are in place to support advanced practitioners



                                                                                     12
        o Provide assurance that advanced practitioners engage in self
            regulating activities
  • Provide oversight to ensure that the momentum of service redesign and
     implementation is maintained
        o Make explicit links between workforce planning and education
            commissioning to support the implementation of advanced practice
            roles and ongoing succession planning
        o Ensure      consistency    of   practice   and    alignment   of   roles   and
            responsibilities within all parts of the organisation.



8.2 Recommendations for services
     To provide operational infrastructure to underpin advanced nursing practice
     roles, service leads should consider the following when planning or
     redesigning services:
  • Use consistent methods to assess service need and to identify new ways of
     working
        o Ensure that key external stakeholders including patients, service users
            and their families are engaged with and inform service redesign
            processes
        o Ensure that key internal stakeholders including medical staff and the
            wider health care professions are engaged with and inform service
            redesign processes
        o Ensure that the wider professions are aware of and support the
            practice of advanced practitioners
  • Identify resources to underpin advanced level practice
  • Define mechanisms to gather feedback from patients and service users to
     evaluate advanced practice interventions
  • Plan for auditing advanced level practice and the services in place
  • Implement supervision and reflective practice within the service area
  • Ensure all CPPD plans and individual Personal Development Plans reflect
     service needs




                                                                                     13
   • Ensure advanced practice is aligned with the DH position statement enabling
      all aspects of practice to be undertaken (leadership, research, education and
      clinical practice)
   • Assess individual staff members currently working at advanced practice level
      to ensure they meet the DH elements
   • Review job descriptions and person specifications to ensure they reflect the
      advanced practitioners role and scope of practice
   • Ensure that advanced practice is concordant with local operational policies
      and governance frameworks.



8.3 Recommendations for the individual practitioner
   The individual advanced practice nurse should:

   • Ensure own practice aligns with the 28 elements set out in the DH position
      statement
   • Ensure own practice is aligned with organisational operational policies
   • Maintain own competence
   • Audit own practice to demonstrate clinical efficacy, value for money and
      improved patient experience
   • Scope the support for own advanced practice within the workplace
   • Identify operational structures that support own advanced practice
   • Align practice with governance and assurance frameworks
   • Source structured feedback on the services provided from both internal (e.g.
      patients and service users) and external stakeholders (e.g. wider health team,
      medical teams and commissioners)
   • Engage with structured peer supervision and reflection to self regulate
      practice
   • Engage with CPPD activity to support continuously developing                  skills,
      knowledge and competence
   • Develop business critical skills to ensure continuing relevance in the future
      health     economy   (e.g.   business   skills,   finance   skills,   understanding
      commissioning).



                                                                                      14
9. References


• Department       of   Health   (2011)   Enabling   excellence:   autonomy   and
   accountability for health and social Care.
• Department of Health (2010a) Advanced Level Nursing: a position statement.
• Department of Health (2010b) Equity and excellence: liberating the NHS.
• Department of Health (2009):
   http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Managingyour
   organisation/Workforce/Workforceplanninganddevelopment/Europeanworking
   timedirective/DH_077304 (accessed 7.02.11).
• Department of Health (2008) High quality care for all. NHS Next Stage Review
   Final Report.
• NHS Scotland (2007). Review of advanced practitioner and specialist nursing
   posts.


   Please forward any enquiries about this report to Kathryn Jones, Programme
   Director Modernising Nursing Careers: kathryn.jones@london.nhs.uk




                                                                              15
   10. Appendix 1
Attendees of the Advance Practice Workshops



Name                       Organisation
Janet Catt                 Royal Free Hospital
Karen Bodamn               Oxleas NHS Foundation Trust
Chris Shaw                 Barts and the London NHS Trust
Jane Williamson            NHS Tower Hamlets
Ruth Trout                 Bucks University
Grace Vanterpool           NHS Hammersmith and Fulham
Andrew Frazer              Newham University Hospital
Tracey Ward                Royal National Orthopaedic NHS trust
Nicola Dunlor              Moorfields Eye Hospital NHS Foundation Trust
Aine Feeny                 Moorfields Eye Hospital NHS Foundation Trust
Carol Lincoln              Middlesex University
Ann Maloy                  Imperial College Health Care NHS Trust
Doug Wilson                Camden & Islington NHS Foundation trust
Heather Naylor             Imperial College Health Care NHS Trust
Kate Potter                Bucks University
Janet Murat                Tower Hamlets CHS
Kara Renno                 Tower Hamlets CHS



Individual consultations

Ursula Gallagher           Director of Quality and Clinical Leadership, NHS Ealing


Katrina Maclaine           Principal Lecturer Advanced Nursing , London South Bank
                           University & Executive Committee Member of Association
                           of Advanced Nurse Practice Educators
Rebecca Longmate           Divisional Director of Nursing, Royal Free Hospital



                                                                                     16
   11. Appendix 2
Expert reference group membership


Name                Title                    Organisation

Sarah Connor        Professional             Kingston Hospital NHS Trust
                    Development Lead
Debbie Smith        Head of Workforce        St Georges Hospital NHS Trust
                    Development
Jacquie             Programme Leader         Royal Marsden School of Cancer
Woodcock                                     Nursing and Rehabilitation
Chris O'Connor      Head of Nursing and      South West London Mental Health
                    Practice development     Trust
Jacky Harrop        Head of Nursing &        NHS Westminster
                    Quality
Fiona Dickson       Service Manager.         Greenwich Teaching PCT
                    Contraception & Sexual
                    Health Service
Julie Latmier       Learning and             Macmillan Cancer Support
                    Development
Claire Anderson     Course Director          London South Bank University
                    Children's Advanced
                    Nurse Practitioner
Julie Irwin         Principal Lecturer for   Bucks University
                    Student Experience and
                    Quality Enhancement
                    MSc Advanced Practice
                    Programme Leader
Judith Birch        Clinical Learning &      NHS Enfield
                    Placement Co-ordinator




                                                                               17
12. Appendix 3


A copy of the workforce questionnaire is found embedded below




  MNC survey questions.zip




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