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Advanced nursing practice in the United Kingdom



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Chapter 1
The Development of Advanced Nursing
Practice in the United Kingdom
Paula McGee
Introduction 1
Health policies and reforms 2
The UKCC and higher-level practice 4
The interface with medicine 4
The introduction of new roles 8
Modern matrons 8
Nurse consultants 8
Physicians’ assistants 9
Nurse practitioners and the Royal College of Nursing 9
The Nursing and Midwifery Council 11
Conclusion 12
Key questions for Chapter 1 12
References 12
The United Kingdom Central Council (UKCC) defined advanced practice as ‘adjusting
the boundaries for the development of future practice, pioneering and developing
new roles responsive to changing needs and with advancing clinical practice, research
and education enrich professional practice as a whole’ (UKCC 1994:20). To a certain
extent, this definition can be taken to represent the culmination of years of work
and debate in which individual nurses explored and experimented with new ideas
and roles that might enable them to provide both better patient care and meaningful
professional activity. In this context, the Council can be seen as trying to bring some
sort of order to the patchwork of established and emerging roles beyond registration
by issuing a statement about the form these roles should take. Alternatively, the
definition can be regarded as the beginning of a thorough examination of the nature
of post-qualifying nursing practice, about what patients, the profession and society as
a whole want from nursing and the impact this might have on other health professions,
especially medicine.
2Advanced Practice in Nursing and the Allied Health Professions
One of the difficulties in both analyses is that the Council never quite made
clear how the definition of advanced practice would apply to the realities of daily
life in practice. Consequently, there was a great deal of confusion among nurses,
managers, employers and other health professionals as to what the Council intended.
This confusion created a fertile ground for debate, both useful and acrimonious, as
nurses and other health professionals tried to determine the most appropriate way
forward; there was quite a lot of research, some of which helped illuminate the path.
In practice, there was a proliferation of posts and roles that were labelled as advanced
but that were never formally scrutinised to ascertain whether they conformed to the
Council’s ideas (RCN 2008).
In spite of, or maybe because of, the fluidity of this situation, some consensus has
emerged in which there appears to be an agreement that advanced practice should
contain a clinical component, set the pace for changing practice and be underpinned
by formal preparation that is beyond the level of initial registration. There is also an
acceptance that practice is not static and that nursing must continue to move forward.
However, there is far less agreement about the nature of this clinical practice, how
that move forward should be made or even the direction it should take.
This chapter presents an examination of the main issues and influences that have
contributed to the current state of advanced practice in the United Kingdom and
the further developments anticipated. The chapter closes with some key questions to
prompt further discussion.
Health policies and reforms
The health policies and reforms instigated by the Labour government during the late
1990s and early 2000s have had a marked effect on the development of advanced
practice by creating opportunities for innovation both in the development of nursing
roles and in clinical practice. The reforms were intended to improve the quality
of health services by ensuring that they were tailored to meet local needs and
reduce health inequalities (Box 1.1). The reforms were also aimed at valuing staff
and developing a more transparent approach to both the management of information
and the decision-making process (DH 1997, 2000, 2001a). The strategy for nursing
that accompanied the introduction of these policies and reforms made clear that the
profession had an essential role to play because nurses were seen as ideally placed to
promote health, particularly in community settings such as schools and places of work
(Box 1.2). Their skills and expertise could be directed towards early identification and
treatment of health problems and the provision of support for those with long-term
conditions, especially during periods of crisis. Such nurse-led activity could offset
the need for more expensive services including admission to hospital. Where such
admission was necessary, nurses could use their skills to develop care pathways,
promote continuity of care and address specific problems such as infection control
(DH 1999).
The Development of Advanced Nursing Practice in the United Kingdom 3
Box 1.1 Core principles of health policy reforms
Provision of a health service that covers all clinical needs is available to
everyone and is free at the point of delivery
Development of individual packages of care and services that are accessible by,
and which meet the needs of, local populations instead of a one-size-fits-all
Improvements in the quality of care and greater transparency about what is
happening in health-care organisations, both locally and nationally
Creation of a better working environment for staff
Patient and public involvement in service design and delivery
New ways of working, better interprofessional and multi-agency working
Promotion of health and the reduction of health inequalities
Source: Adapted from Department of Health (2000) The NHS Plan. A Plan for Investment.
A Plan for Reform.Wetherby,DH.
Box 1.2 The role of nursing in health policy reforms
Promoting health in ways that meet local needs
Reducing health inequalities, especially among members of marginalised
Instigating nurse-led initiatives to provide faster access to services and
Expanding roles in primary care settingstoreducehospitaladmissionsand
enable people with long-term conditions to remain at home
Independently prescribing medicines
Expanding roles in secondary care and collaborating with other professionals
to provide specialist care, develop care pathways and promote
evidence-based practice
Providing intermediate care and promoting independence for those with
complex needs
Tackling specific problems such as infection control
Promoting seamless care and inter-agency working
Sources: Summarised from Department of Health (2005) Supporting People with Long
Term Conditions: Liberating the Talents of Nurses Who Care for People with Long Term
Department of Health (1999) Making a Difference. Strengthening the Nursing, Midwifery and
Health Visiting Contribution to Health and Healthcare.London,DH.
4Advanced Practice in Nursing and the Allied Health Professions
The UKCC and higher-level practice
The Council recognised the growing concern about the lack of understanding and
agreement regarding forms of practice beyond registration, both within the profession
and among employers. There was a lack of clarity about the terms advanced, special-
ist, specialism and speciality as used within the Council’s statements about practice
after registration, and practitioners had difficulty in distinguishing between them,
especially with regard to the differences between working in a speciality and being a
specialist. Similarly, distinctions between the roles, responsibilities and preparation of
both advanced and specialist nurses were unclear. This lack of clarity had the potential
to erode public confidence in nursing (Waller 1998).
In response to these concerns, the Council entered into consultation with the
nursing, midwifery and health visiting professions, including practitioners, stake-
holders and professional organisations, about forms of practice beyond registration;
after much deliberation, the Council accepted that these forms were actually levels of
practice but carefully avoided associating these with the term advanced (UKCC 1999).
From this consultation emerged the concept of higher-level practice, which the Council
explained as applying to those nurses who were clinical experts and were able to
apply their extensive knowledge, skills and expertise to develop practice and improve
patient care (UKCC 1999). Following this consultation, the Council pressed forward
with plans to develop higher-level practice, further assisted by 700 volunteer nurses,
midwives and health visitors, from across all four countries of the United Kingdom.
The result was a standard for higher-level practice, incorporating seven domains that
were later taken up by employers to facilitate the development of nurse consultant
posts. The final report from the Council’s working group made 15 recommendations
that were then referred to the then newly constituted Nursing and Midwifery Council
(NMC) in 2002 (UKCC 2002, Castledine 2003).
One of the many problems with the concept of higher-level practice was the inexact
use of terminology; words such as expert require some clarification. There are varying
opinions on what it takes to be an expert, none of which seems to provide a completely
satisfactory explanation (Table 1.1). The Council itself did not venture to explain what
it regarded as an expert, and gradually higher-level practice, expert and advanced practice
were used interchangeably. The Council’s decision to award all the volunteers who
met the higher-level standard the status of advanced practitioners compounded the
situation and subsequently there has been no serious consideration of what these
terms mean for advanced nursing.
The interface with medicine
The introduction of the New Deal and the Working Time (Statutory Instrument
2002) Regulations 2002 created opportunities for advanced nursing by altering the
working lives of doctors through reducing their contracted hours and improving
their training (NHSE 1991). In August 2007 the junior doctors’ contracts stipulated a
maximum working week of 56 hours. This will be reduced to 48 hours by August 2009
The Development of Advanced Nursing Practice in the United Kingdom 5
Table 1.1 Perspectives on expert practice.
Author Definitions Comments
Benner (1984) An expert is one who is able to intuit
the essence of a situation and to
focus accurately on a clinical
problem; is not distracted by
Benner’s work focuses on clinical
practice. The higher-level practice
standard incorporates domains
that are not necessarily
associated with direct practice. It
is not clear whether her views of
an expert performance would
Hamric (2005) Clinical practice is the focus of
advanced practice but there are other
competencies which are also
essential. These include acting as a
consultant for others. The advanced
practitioner is described as an expert
The term expert is not examined
in depth but expert clinical
practice is only a part of
advanced practice. Thus a nurse
may be highly proficient in one
sphere but not advanced
Jasper (1994) The expert must possess a
specialised body of knowledge,
extensive experience, be able to
generate new knowledge and be
recognised as an expert
Jasper does not elaborate on how
nurses acquire such knowledge
the nature of that knowledge,
and whether or how expert
knowledge differs from that of
others. The deeper knowledge of
the higher-level practitioner must
be recognised by others
Zukav (1979,
pp. 345)
The expert is someone who ‘started
before you did’ and ‘always begins
at the centre, at the heart of the
matter’ with the enthusiasm of
acting for the first time
Zukav’s expert has a store of
knowledge on which to draw
and thus may be said to be
dealing with what is known. In
pioneering new roles the
advanced practitioner is entering
into the unknown
Sources: Benner, P. (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice.MenloPark,
California, Addison Wesley.
Hamric, A., Spross, J. and Hanson, C. (eds) (2005) Advanced Nursing Practice. An Integrative Approach,
3rd edn. St Louis, Elsevier Saunders.
Jasper, M. (1994) Expert: a discussion of the implications of the concept as used in nursing. Journal of
Advanced Nursing.
Zukav, G. (1991) The Dancing Wu Li Masters. London, Rider.
(DH 2007). Alongside these contractual changes is a move away form the traditional
apprenticeship system for training junior doctors towards a new, competency-based
scheme. All junior doctors now enter a 2-year foundation programme that equips
them with ‘basic practical skills and competencies in medicine and will include: clinical
skills; effective relationships with patients; high standards in clinical governance and safety;
the use of evidence and data; communication, team working, multiprofessional practice, time
management and decision-making and an effective understanding of the different settings
6Advanced Practice in Nursing and the Allied Health Professions
in which medicine is practised’ (DH 2004a, p. 8). Those who successfully complete the
foundation programme may enter a further programme to become either a general
practitioner (GP) or a hospital specialist. Inevitably, implementing these programmes
has affected the amount of day-to-day work that junior doctors are able to do, a
situation that has been complicated by the number of senior practitioners who are
approaching retirement. A flexible retirement scheme was introduced to encourage
hospital consultants to continue in post beyond the age of 65 and financial incentives
were offered to GPs for each additional year that they deferred retirement (The Lords
Hansard 2002).
The implications of the reduction in the availability of doctors were not lost on
the British Medical Association (BMA), which proposed that, in primary care, nurse
practitioners (NPs) could act as the first point of contact for most patients and
refer them on to doctors or other health professionals if necessary. Similarly, in
hospitals, specialist nurses could act as care coordinators (BMA 2002a, b). Even
prescribing by nurses and pharmacists was accepted provided that it was ‘limited and
in line with the individual’s training and experience’ (BMA 2006). The BMA was thus
supportive of new roles in nursing to the extent that its members expressed frustration
at, as they saw it, the failure of both employers and the NMC to bring about a change,
which resulted in ‘the undermining and de-valuing of nurses with extended roles’
(BMA 2004).
This justifiable criticism is not new. The history of advanced practice shows that
some doctors have been very influential in spearheading new developments, often
providing a vision of what could be achieved. For example, in 1957, in North Carolina,
Dr Eugene Stead envisaged an NP’s role that was between nursing and medicine
and found a nurse to share this vision but was opposed by both the senior nurses
in the local university and the National League for Nursing, which refused to accredit
the necessary postgraduate training course because doctors would have had to teach
much of the content. As a result of this failure, the university instituted a physicians’
assistant (PA) course. In another example, Loretta Ford, one of the most well-known
NPs, worked with Dr Silver setting up a postgraduate course in paediatric care for
poor rural children in Colorado but the American Nurses Association would not
support this, preferring to concentrate on preparing nurses for teaching or manage-
ment. In both examples, the doctor provided or helped to provide a significant vision
through which particular health needs might be met; it was nursing’s professional
bodies that appeared to have difficulties. Unsurprisingly, the doctors concerned lost
interest and moved on (Dunphy et al. 2004).
Nursing theorists are keen to point out that advanced practice is about developing
nursing and not about taking over medical work, but the interface between the two
professions is not clear cut. Advanced NPs diagnose and treat illness – activities that
are perceived by patients to be part of the doctor’s repertoire of skills. There is
certainly an area of overlap between the two roles. For example, the advanced NP
and the doctor may diagnose repeated and severe tonsillitis but it is the doctor who
will have the skills required to perform a tonsillectomy and the nurse who will be best
equipped to manage the post-operative period. Both will draw on the same research
and use the same decision-making and problem management skills but in different
ways (Hunsberger et al. 1992) (Figure 1.1). Thus the two roles are complementary
The Development of Advanced Nursing Practice in the United Kingdom 7
Medical expertise Advanced nursing expertise
Research and evidence-based practice,
interpersonal, diagnostic and
decision-making and treatment/care skills
Fig. 1.1 The interface between advanced nursing and medicine (based on Hunsberger
et al. 1992).
rather than competitive, allowing both to concentrate their efforts where they are
most needed. Moreover, the holistic orientation of the advanced NP allows for greater
consideration of factors that may impinge on the patient’s recovery, for example,
social circumstances or psychological problems. Patients often do not like to, as they
see it, bother the doctor with such details but are likely to reveal them to an advanced
This notion of complementarity leads naturally to the idea that the two roles of
advanced nurse and doctor meet as equals in the practice setting. While individual
practitioners in both camps may agree with this, as a body, doctors clearly disagree.
The BMA’s support for advanced nursing roles was qualified by their capacity ‘to
improve the working lives of doctors’ (BMA 2004). Nurses might extend their roles
but only within ‘a defined field answerable to a medically qualified doctor’ (BMA
2005). The subordination of nursing to medical expertise was, therefore, to continue
and there was strident protest when nurses attained positions in which this balance of
power was overturned. Thus the BMA found it ‘outrageous and totally unacceptable
that a nurse consultant has been appointed as the lead clinician in occupational
health and that she, with the assistant director of human resources, will perform the
annual appraisal of the occupational health consultant’ (BMA 2005).
It would seem, therefore, that the interface between advanced nursing and medicine
is highly ambivalent. Individual practitioners may develop pioneering partnerships
based on mutual regard for each other’s expertise but formal relations between the
two professions still require considerable effort on both sides. In practice, it is usually
the advanced nurse who must make the first move, involving medical staff from the
start of any initiative so that they understand what is happening and the reasons for
it and can begin to see the potential that advanced nursing practice can bring to their
own sphere of work.
8Advanced Practice in Nursing and the Allied Health Professions
The introduction of new roles
Modern matrons
The managerial roles of matrons were introduced in hospitals as part of a range
of initiatives to improve the quality of service. Other initiatives included tackling
standards of cleanliness, improving the quality of hospital food, the introduction of
the Patient Advisory Liaison Service and benchmarking. The title of matron emerged
following public consultation that revealed a preference for the presence of a clearly
identified and authoritative presence, in each setting, to whom patients and relatives
could turn for help, advice and to complain. Matrons were to take charge of a group
of wards and resources to ensure that patients received the best possible care and that
support services fulfilled their responsibilities to the highest standard and to provide
leadership (NHSE 1999, DH 2001b).
More recently, matrons’ roles have been exported to primary care settings as
part of the strategy for supporting patients with long-term conditions (DH 2005).
The intention is to enable patients to receive the help they need from primary care
services and, therefore, reduce the number of admissions to hospital. Community
matrons were intended to use case management strategies to identify patients’ needs
and formulate care plans based on multi-professional working to enable patients to
become as independent as possible (DH 2005).
The managerial orientation of matrons’ roles tends to place them outside the
advanced nursing sphere. Advanced nurses are primarily practitioners engaged in
direct patient care; their roles do not include responsibility for managerial issues such
as staffing, budgeting or resources. Matrons, on the other hand, are concerned with
precisely these factors as a means of creating environments in which patients can be
between the two roles and research is needed to examine this unexplored territory.
What is certain is that, to be effective, the advanced nurse, like the matron, must
have the status, power and authority to act and to direct others when necessary.
Consequently, the advanced practitioner must ensure that these issues are clearly
addressed in the development of any new post.
Nurse consultants
The idea of nurse consultants is not new. In the 1970s, it was envisaged that the
development of a consultant’s role would provide clinical leadership but would be
free from the demands of managerial responsibilities (Ashworth 1975). The health
service reforms introduced in the late 1990s facilitated the introduction of nurse
consultant posts (DH 1999, 2000, 2001c, NHSE 1999). Consultants were expected to
be clinical experts who spent at least half their working time in practice, working
directly with patients and acting as focal points for professional advice, education
and research, activities similar to those required by advanced practitioners. Many of
the attributes of advanced nursing practice can be found within the consultant’s role
and a number of advanced practitioners have gravitated towards nurse consultant
The Development of Advanced Nursing Practice in the United Kingdom 9
The introduction of nurse consultant posts was of considerable significance because,
for the first time, nurses seeking to develop their careers did not have to leave the
practice setting. Previous generations of nurses had been faced with two options,
management or education, both of which meant leaving practice. The opportunity to
remain in the practice setting not only offered satisfaction to those nurses who took it
up but also ensured that the much-needed expertise remained in patient care.
Physicians’ assistants
This is a separate, non-nursing role that developed in the United States. A PA trains
at undergraduate level for at least 2 years and is able to assess patients, diagnose and
treat common ailments, undertake routine laboratory work, minor surgical procedures
and administrative matters such as billing insurance companies. PAs work within a
medical framework and for a doctor (Castledine 1998). However, their roles may at
times overlap with those of other health-care professionals.
In Britain, a small number of nurses began working as PAs in the 1990s. The first to
do so was Suzanne Holmes who was employed to conduct vein harvesting and other
procedures at the Oxford Heart Centre. The development of these posts was quite
haphazard and many were initially not paid as nurses but as medical technicians.
The PA’s role was eventually formalised as that of ‘anew health-care professional
who, while not a doctor, works to the medical model, with the attitudes, skills and
knowledge base to deliver holistic care and treatment within the general medical
and/or general practice team under defined levels of supervision’ (DH 2006, p. 3).
Those wishing to become PAs must now gain a recognised qualification based on a
degree-level course, located in a medical school, of at least 90 weeks, followed by a year
of supervised practice. It is anticipated that a professional register will be opened.
The PA’s role is open to anyone with the appropriate entry qualifications, which
include a first degree in a relevant science. The work involves activities, which, in
some ways, appear broadly similar to those of the advanced practitioner: assessing
patients and formulating diagnoses, requesting appropriate investigations, formu-
lating treatment plans and prescribing medication (DH 2006). The main difference
is that the PA is not a professional in his or her own right; a PA works for and is
supervised by a doctor even though, on a day-to-day basis, a fair degree of apparent
autonomy may be allowed. In contrast, an advanced nurse practitioner is a member
of a recognised profession and is responsible and accountable for all aspects of the
care she or he delivers to patients. Nevertheless, it is probable that, as PAs become
more widely available in the National Health Service (NHS), patients will have some
difficulty in distinguishing them from advanced nurse practitioners and, possibly,
other roles. Advanced nurse practitioners will, therefore, need to explore ways of
conveying the nature of their role to patients.
Nurse practitioners and the Royal College of Nursing
Nurse practitioners were introduced, by the Department of Health (DH), in the early
1990s as part of the strategies to reduce junior doctors’ working hours. There was
10 Advanced Practice in Nursing and the Allied Health Professions
no overall plan regarding their role and consequently several parallel developments
took place. A survey of the North Thames Region identified four categories of NPs in
hospitals: those who performed specified procedures, those in charge of pre-admission
clinics, designated posts in accident and emergency departments or minor injuries
units and nurses who had extended their skills in order to perform certain tasks for
their caseload of patients (Kendall et al. 1997). In contrast, a study of NPs in primary
care showed them acting as the first point of contact with the health service and thus
having assessment and diagnostic responsibilities similar to prototype NPs’ roles
in the 1980s (Burke-Masters 1986, Stillwell et al. 1987, Ashburner et al. 1997). The
huge variety of posts was reflected in employment conditions. There was no national
agreement about grading and in primary care NPs were initially employed by GPs
rather than by the NHS.
A recent postal survey by the Royal College of Nursing (RCN) for the Nurse
Practitioner Association (NPA) showed that NPs (n=1021) are typically women
in their mid-forties; two-thirds work in primary care; are highly qualified – 35%
at Masters level and view the core elements of their role as making autonomous
decisions, assessing the health needs of patients, undertaking physical examinations,
making new/initial diagnoses and formulating a diagnosis. The grading of posts
varied from F to H, bands 68. Of the NPs, 44% reported that referrals to other
clinicians and for X-rays were refused. The numbers were higher among those
working in general practices. They reported feeling that their jobs were under threat,
especially those who worked in hospitals. This feeling was fuelled by the introduction
of the PA’s role (Ball 2006).
In response to widespread concern about the employment of NPs and the roles
that they were expected to fulfil, the RCN began to investigate what was happening
frombothatradeunionandaprofessionalperspective. The College drew on the
expertise of members and a wide range of other sources, which included the National
Organisation of Nurse Practitioner Faculties (NONPF), to develop a definition of
an NP as ‘a registered nurse who has undertaken a specific course of study of at
least first degree (honours) level’ and who practised in seven core domains each
of which was accompanied by a set of competencies (NONPF 1995, RCN 2002). In
2008, the College revised and updated its position. The definition issued in 2002
was applied to advanced practice. Thus, according to the College, an advanced NP
is ‘a registered nurse who has undertaken a specific course of study of at least
first degree (honours) level’ (Box 1.3) (RCN 2008, p. 3). The College went on to
identify seven domains for advanced nurse practitioner practice, each of which was
accompanied by a set of competencies to be achieved. For example, the first domain,
assessment and management of patient health/illness status, has 32 competencies that
include critical thinking, assessing and intervening to assist patients in complex,
urgent or emergency situations, performing and interpreting common screening and
diagnostic tests (RCN 2008). Finally, the College set out 15 standards and criteria
for courses that prepare nurses for advanced practice. These standards and criteria
form the basis of a system of accreditation that enables educational institutions
to ensure that their courses are ‘up-to-date, of the highest quality, effective in
educating nurses and the wider health care family, and to promote best practice’
(RCN 2008, p. 21).
The Development of Advanced Nursing Practice in the United Kingdom 11
Box 1.3 Characteristics of the advanced NP
Professional autonomy and accountability over one’s caseload
Diagnostic skills that include the ability and authority to initiate investigations
and referrals to other agencies
Collaborative working with patients, other professionals and disciplines
Extended knowledge and skill base for providing treatment and care
Counselling and health education
Clinical and professional leadership
Source: Summarised from Royal College of Nursing (2008) Advanced Nurse Practitioners. An
RCN Guide to the Advanced Nurse Practitioner Role, Competencies and Programme Accreditation.
The Nursing and Midwifery Council
The NMC received the work of the UKCC’s higher-level practice project but made
little progress on the issue of advanced practice for some years. Finally, the Council
undertook its own consultation about a post-registration nursing framework and was
able to state that ‘advanced nurse practitioners are highly experienced, knowledgeable
care needs or refer you to an appropriate specialist’ and who carried out a specific
range of activities (NMC 2005, p. 3) (Box 1.4). Furthermore, the Council agreed that
advanced practitioners should be registeredandthattheroleshouldbedenedina
way that was meaningful for patients and the public. Advanced competencies were
to be mapped against the Knowledge and Skills Framework (DH 2004b). The Council
also agreed that a policy was needed to accommodate nurses thought to be already
working as advanced practitioners (NMC 2005, p. 3).
Box 1.4 The NMC’s first view of advanced nursing practice
Advanced NPs are highly skilled nurses, with extended skills and knowledge,
who can do the following:
Examine patients physically, initiate investigations and diagnose health
Initiate and make decisions about treatment and care, prescribe medication or
refer patients to other sources of help.
Evaluate and alter treatment and care as appropriate.
Provide leadership and ensure that patients receive high standards of treatment
and care.
Source: Summarised from Nursing and Midwifery Council (2005) Implementation of a
Framework for the Standard of Post Registration Nursing Agendum 27.1 C/05/160. December
2005. Available at
12 Advanced Practice in Nursing and the Allied Health Professions
In 2006, the NMC tried to obtain approval from the Privy Council to open a
further sub-part of the nurses’ part of the register in order to register advanced NPs.
A letter was sent to the Privy Council in December 2005 with additional information
being sent in January 2006. The Privy Council has been seeking the views of the
Department of Health (England), which takes the lead on regulatory matters relating
to health-care professions across the NMC (2006). In 2007, some slight progress was
evident in the White Paper Trust, Assurance and Safety – the Regulation of Health
Professionals in the 21st Century, which stated that ‘the Department with ask the
Council for Healthcare Regulatory Excellence to work with regulators, the professions
and those working on European and international standards to ... the development
of standards for higher levels of practice in nursing, AHPs and healthcare scientists’
(NMC 2007). However, at the time of writing, no further progress has been made and
the situation remains unresolved.
This chapter has presented a discussion of the main influences on the development
of advanced practice in the United Kingdom. This development has been rather
haphazard, with new roles introduced to expedite the achievement of particular
policies, such as the reduction in junior doctors’ working hours or as a response to
public opinion about how the NHS should function. The lack of an overarching plan
can be seen as providing an opportunity for experimentation but it has also served
to hinder the coherent development of advanced practice and to differentiate it from
other new roles. There is an urgent need for progress to allow the title of advanced
practitioner to be protected and to ensure that only those who have the appropriate
qualifications and experience are allowed to use it. The following key questions are
intended to promote discussion about potential ways forward.
?Key questions for Chapter 1
In your field of practice:
(1) What strategies might be useful in educating the public about the advanced
nursing role?
(2) How might you explain the advanced nursing role, as opposed to that of
doctor, matron or PA, to patients?
(3) Assuming that the NMC will be able to register advanced practitioners, what
further action, if any, should the Council take and why?
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Care. The Extent of Practice and Research. Keele University, Centre for Health Planning and
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Ashworth, P. (1975) The clinical nurse consultant. Nursing Times 17 (15) 57477.
Ball, J. (2006) Nurse Practitioners 2006.The Results of a Survey of Nurse Practitioners Conducted on
Behalf of the RCN Nurse Practitioner Association. Hove, Employment Research Ltd.
British Medical Association (2002a) The Future Healthcare Workforce. HPERU Discussion Paper
No. 9. Available at
British Medical Association (2002b) BMA Response to Consultation on Unfinished Business.
Available at
British Medical Association (2004) Junior Doctors’ Policy Group. Available at http://www.
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Burke-Masters, B. (1986) The autonomous nurse practitioner: an answer to the chronic problem
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Castledine, G. (1998) Clinical specialists in nursing in the UK: 1980s to the present day. Chapter
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Department of Health (1999) Making a Difference. Strengthening the Nursing, Midwifery and Health
Visiting Contribution to Health and Healthcare.London,DH.
Department of Health (2000) The NHS Plan. A Plan for Investment. A Plan for Reform.Wetherby,
Department of Health (2001a) Involving Patients and the Public in Healthcare. A Discussion
Document. London, DH. Available at
Department of Health (2001b) Implementing the NHS Plan – Modern Matrons. Strengthening the
Role of Ward Sisters and Introducing Senior Sisters. Health Service Circular 2001/10 April.
Available at
Department of Health (2001c) More NHS Nurse Consultants. News Desk. 10.9.01. Available at
Department of Health (2004a) Modernising Medical Careers.The Next Steps.The Future
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... Later, other countries, such as Canada, also adopted this pathway Kaasalainen et al., 2010). In the United Kingdom, the "new nursing" movement has been working for some years toward greater autonomy for nurses (Feroni & Kober, 1995), and advanced practice has become operational (Mc Gee & Castledine, 2003). In France, these professional roles do not exist in the same way, nor is there the advanced nursing practice that has generally developed in other countries, such as the United States (Donelan, DesRoches, Dittus, & Buerhaus, 2013;Rigolosi & Salmond, 2014), where the Nurse Practitioners Modernization Act will take effect on January 1, 2015. ...
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In France, medical practitioners are aware that the practice of the delivery of primary care by nurses occurs in other countries. However, there is disagreement about how to implement this practice. This aspect of the issue of front line care has not yet been studied in France. In this article, our aim is to identify to what extent the delivery of primary care by nurses is considered acceptable by doctors and nurses working in hospital emergency departments and in public and private health centers. The results of our research provide a picture of opinions that exist among doctors and nurses. These opinions highlight practices that are outside the current regulations and present perspectives, which range from conditionally in favor to unfavorable. Such opinions contribute to our knowledge because they are derived from the professionals directly involved and describe what is acceptable in this particular context.
... When new and radical ways of working have been identified, it is the application of these that is referred to as 'critical practice' (McGhee and Castledine, 2003). To make the guidance a reality, a number of further steps were necessary, as follows: l Sign-up from all agencies l Launch of new way of working l Training sessions and workshops l Review systems. ...
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The Healthy Child Programme, the national universal public health programme for all children and families in the UK, requires health visitors to carry out a health review for children between two and 2.5 years. Similarly, the revised Early Years Foundation Stage statutory framework now places a new requirement on early years practitioners to review a child's learning and development through a progress check at two years. While work is being undertaken nationally for the two-year health review to be delivered jointly by health, early years and early intervention services, this paper discusses the development of an innovative, integrated local model that not only ensures better reach of two-year-old children in Harrow but also ensures best use of professional resources and expertise, and a more joined-up service for children and families.
... The stimulus for GPs to employ practice nurses and thus expand practice nursing commenced in 1990 with the GP contract, which paid doctors to provide chronic disease clinics and to meet population target rates for vaccinations and cervical screening. 11 Most of this health promotion work is organised and delivered by nurses and the introduction of these nurse-led services, throughout the 1990s, resulted in reduced inequalities in health and health care provision in England. 12 With regard to chronic disease management, positive outcomes have been found for nurse-led services in: secondary prevention of ischaemic heart disease, 13 asthma care, 14 chronic heart failure 15 and hypertension. ...
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Hoare is a lecturer working between the Goodfellow Unit and School of Nurs-ing, at the University of Auckland. She was the executive nurse of a primary care group in the UK and has worked as a public health nurse in New Zealand. Wendy Fairhurst-Winstanley is a nurse practitioner and nurse partner at Marus Bridge Practice in Wigan, UK. She was one of the first nurse practitioners in primary care in the UK and has been instrumental in establishing the education and develop-ment of the role. ABSTRACT 'There's more than one way to skin a cat' is a strange old saying which could be applied to the employment of nurses in general practice. Changing practice nurse employment from GPs to Pri-mary Health Organisations is a 'red herring' and may not achieve the main aim of the Primary Health Care Strat-egy – a reduction in health inequali-ties, in the way that some nurse lead-ers have suggested. Lessons from the UK suggest that nurses organising themselves into peer groups, remunera-tion of general practices for the attain-ment of positive patient health out-comes and a statutory duty of clinical governance contributed to the devel-opment of practice nurses' roles and expansion of numbers of nurse practi-tioners in general practice. Nurses have become partners with GPs in general practice in the UK, a much preferable alternative for some than employment by a Primary Health Organisation.
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What constitutes advancing professional practice has been widely debated, as the term ‘advanced practice’ is associated with a range of nursing roles. Sharin Baldwin considers the skills, competencies and attributes required to advance health visiting practice.
The current political healthcare economy is blurring traditional professional bound aries, and national agendas are requiring nurses to take on more roles and tasks previously undertaken by doctors. The emergency nurse practitioner’s expanding scope of practice has moved beyond managing the care of patients with minor injuries, to include those with ‘minor’ illnesses and indeed beyond that to the management and care of those with increasingly complex, acute and chronic conditions. The process of conjugation between the two disciplines has been driven by the demands and pressures on the health economy. Given the unprecedented and increasing overlap in practice between the domains of medicine and nursing, it is time to re-examine differences between them and clarify the issues which divide them. There is a need to benchmark infrastructure and standardize the education and development of nurses undertaking advanced practice roles. There is also a need for continued debate on the future of the health care workforce, informed by research, to facilitate correct and cost effective decision making.
IntroductionPatient historySigns of liver diseaseLaboratory testsDiagnostic studiesComplications and considerationsChapter summaryIllustrative case study
IntroductionAdvanced practiceThe context of pain management: definitions and prevalenceAdvancing practice in pain managementBringing together advanced practice and pain managementConclusions References
BackgroundThe Nursing and Midwifery Council (NMC), the regulatory body in the UK, is in the process of opening a new part of the register for Advanced Nurse Practitioners. This presents a potential opportunity for clinical research nurses within cancer care.ObjectivesTo explore the role of the clinical research nurse in cancer care whilst considering whether the role can be performed at a level that could be considered advanced practice. Consequently, a developmental model to enable the clinical research nurse to work towards an advanced level of practice is explored.MethodA literature review of the clinical research role in cancer care and analysis of published frameworks of advancing practice in nursing.DiscussionAdvanced practice is not defined by the role but by the level of skill to which it is performed. There is scope within the role of the clinical research nurse to practice at a level beyond initial registration. A framework for development towards advanced practice within the cancer clinical research nurse role is suggested.ConclusionAdvanced practice within clinical research nursing is possible and provides a further level of career development that may facilitate movement between research and clinical practice. This could aid awareness, recruitment and retention of research staff within cancer care and other specialities.
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We surveyed 655 health professionals affiliated with tertiary level neonatal intensive care units in Canada and the United States to define an expanded role for nurses in neonatology and to determine the educational requirements for the role. The role, comprising advanced clinical practice, educational, research, and administrative responsibilities, is a blend of nurse practitioner and clinical nurse specialist activities. Based on survey findings, a neonatal stream within the existing Master of Health Sciences program at McMaster University was developed. To date, 15 clinical nurse specialists/neonatal practitioners (CNS/NPs) are employed in five neonatal intensive care units in Ontario and other related institutions. A randomized trial to evaluate these individuals is in progress.
The concept‘expert’ has become common in the nursing literature since Benner's (1984) work more than a decade ago Whilst the term has a common meaning, it is apparent that when used in nursing it refers to a multitude of attributes and lacks clear definition This paper uses the strategy for concept analysis developed by Walker & Avant (1988) to seek an operational definition for the concept of ‘expert’, and suggests the denning attributes of possession of a specialized body of knowledge and skill, extensive experience in a field of practice, highly developed levels of pattern recognition, and acknowledgement by others These are discussed in relation to nursing practice and the circumstances under which the concept is used Development of cases is carried out to exemplify the concept, and the antecedents and consequences of the attributes are discussed, suggesting that the concept lacks clarity, both in conceptualization, and in use A first definition of the concept is posed to open debate concerning the relevance of the term for the future The conclusions reached suggest that whilst an operational definition is unlikely to be found, because of the problems of definition and measurement, it is possible, through various strategies, to recognize expert practice and use it to further develop nursing Furthermore, it is likely to become increasingly important to recognize and reward expert practitioners, given the political and economic constraints in health care today
The work of a specially trained nurse practitioner, to whom patients had open access, was studied in an inner city general practice over a period of six months in 1983. A total of 858 patients of all ages and ethnic origins sought consultations for 979 problems. Morbidity from every diagnostic group was presented but the majority of the problems (60.4%) fell into the 'Supplementary' group: preventive medicine; health instruction and education; social, marital and family problems; administrative procedures. The consultation room setting and the long appointment times available (20 minutes) may partly account for this. Additional problems, mostly concerning health education, were raised in 46.0% of consultations. Most patients chose a consultation with the nurse practitioner appropriately and in more than one-third of all consultations the nurse managed the presenting problem without further referral for investigation, prescription or other medical advice. It is concluded that nurses have a much larger and more autonomous part to play in the care of patients than hitherto.
The UKCC is currently consulting on its proposals to recognize and regulate a higher level of practice (UKCC, 1998a). These proposals follow the work undertaken by the UKCC from 1996-1998 on advanced and specialist practice and seek to build on the current postregistration education and practice (PREP) framework (UKCC, 1994). This article outlines the background to the consultation and puts the proposals into context. It is hoped that it will encourage practitioners to respond to the consultation, as the UKCC is very keen to hear the views of specialist nurses, midwives and health visitors. Copies of the UKCC's consultation document are available from Katrina Neal, Professional Officer (0171 333 6542) and are also available on our web site (http:/(/) Responses should reach Sarah Waller, Director of Standards Promotion at the UKCC, by 20 October 1998.