A governance framework for advanced nursing
A health board drew up a governance framework to identify genuinely advanced nursing roles, and to assess and professionally develop practitioners in these roles
In this article…
- The need for governance frameworks for advanced practice
- How a health board introduced such a framework
- Early findings and recommendations
Thomas David Barton is head of the department of nursing, College of Human and Health Science, Swansea University; Lesley Bevan is assistant director of nursing, Abertawe Bro Morgannwg University Health Board; Gail Mooney is director of postgraduate studies, College of Human and Health Science, Swansea University.
Barton TD et al (2012) Advanced nursing 2: a governance framework for advanced nursing. Nursing Times; 108: 25, 22-24.
Keywords: Advanced nurse practitioners/Regulation/Governance
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page
5 key points
- Discussions in the UK on regulating advanced nursing practice have been long and complex
- Many such roles have evolved in an unregulated and unplanned way
- Concerns about advanced practitioners’ competence can be overcome by introducing structured local governance
- Advanced practice guidelines in Wales have been useful when setting up of local governance frameworks
- A governance framework can be used to help evaluate service redesign
This second in a three-part series outlines the introduction of a governance framework for advanced nursing practice. Part 1 explored the history of the evolution of advanced practice, while part 3, to be published next week, will discuss the future of advanced practice and how it may shape the career structure of nursing.
Deliberations in the UK on regulating advanced nursing practice have been long and complex, spanning over 20 years. Debates started in the late 1980s and early 1990s as service and strategic interest in advanced nurse roles grew (Kaufman, 1996; Fulbrook, 1995; Stilwell, 1988).
Despite a wealth of strategic intent and service change since then, professional regulation remains unresolved, and is now widely regarded as unachievable and unwarranted. For example, the Council for Healthcare Regulatory Excellence (2008) outlined the complexity of professional regulatory issues and made it clear that, in its view, the code of professional conduct (Nursing and Midwifery Council, 2008) encompasses advanced practitioner practice, negating any need for additional formal regulation. That view led indirectly to the development of the Advanced Practice Toolkit (Scottish Government, 2008) under the auspices of Modernising Nursing Careers (Department of Health, 2006). This provided some national conformity and guidance to employers, practitioners and educators.
More recently, two documents looked to governance as a mechanism of employer-led local regulation - the DH’s (2010) position statement on advanced practice and the Welsh framework for advanced practice (National Leadership and Innovation Agency for Health Care, 2010).
This article reviews how an integrated university health board has acted on the governance issues of advanced nursing practice. It describes how the board evaluated advanced nurse practitioners (ANPs), and how subsequently it is implementing a governance framework in accordance with the Welsh guidance (NLIAH, 2010).
The health board and ANPs
In 2009, the university health board nurse executive acknowledged it needed to evaluate its “off ward” specialist nurses. The executive suspected and later confirmed that many of these roles had evolved in an unregulated and unplanned way.
In many cases, the executive had only limited understanding of what these roles entailed, and of their measurable contribution to service delivery.
A detailed audit carried out across the health board’s acute hospital service (including mental health, learning disability and community services) resulted in the creation of a database of 385 known off ward nurses. Review and analysis of the data, using national competency frameworks as guidelines (Scottish Government, 2008; DH, 2004), pointed to a diversity of roles, ranging from those that would not meet the criteria for advanced practice as outlined in the Welsh guidance (NLIAH, 2010), through to those that were clearly very advanced. It was estimated that 40 of the off ward nurses met the criteria for an advanced practice role.
The nurse executive identified a need to establish a more robust governance framework that could be used to regulate these practitioners’ activity internally. The framework would be piloted with a small cohort of nurses (n=8) identified as having advanced practitioner roles.
A multiprofessional advanced practice steering group was established, with representation from clinical practitioners, nurse managers and university specialists. This group was tasked with developing the governance framework and assessment tools, and with establishing a resource for assessing practitioners and their portfolios.
Developing governance criteria
A key developmental feature of the governance framework for advanced practitioners was the need to agree criteria that all clinicians, managers and assessors would have to subscribe to. The advanced practice steering group initially developed these criteria; these refined after the Welsh guidance was published (NLIAH, 2010).
Within the health board, any practitioner working at an advanced level:
- Must have evidence of master’s level study appropriate to their role and job description;
- Must keep a portfolio of evidence structured in accordance with agreed health board templates. The templates include evidence of problem solving, critical thinking, reflection, clinical updating, leadership, research and relevant metrics;
- May be expected to make their portfolio available for independent review;
- Must identify competencies appropriate to their role and job description, and they (the practitioner and their competencies) must be assessed using appropriate tools. Evidence of this should be in the portfolio. Assessors could include peers, expert clinicians (multiprofessional), line managers, expert patients and academic specialists;
- Must have an annual performance review conducted by appropriate others - for example (potentially) by peers, expert clinicians (multiprofessional), line managers, expert patients and academic specialists.
Developing the portfolio
We needed to develop a portfolio template that was prescriptive enough to bring some conformity while being flexible enough to cater for the diversity of advanced practice roles.
That diversity cannot be overemphasised, with representation to the working groups from advanced nurse endoscopists to advanced practitioners working in rehabilitation and community settings.
The advanced practice group drew up guidelines that would form the basis of the portfolio content. These guidelines aimed to help practitioners develop a portfolio of evidence to demonstrate advanced practice as outlined in the Welsh guidance (NLIAH, 2010). The portfolio was intended to be used as evidence in annual appraisals.
In terms of evaluation, there would be two forms of assessment, outlined below.
Assessment of competence Practitioners would be required to identify a work-based assessor(s) who would assess them against specified competencies, skills and knowledge. This should be reviewed every year and any learning needs incorporated into personal development plans (PDP). The university would support this through developmental programmes of study for both practitioners and assessors.
Assessment of portfolio As part of the governance framework, the health board would develop and maintain a database of advanced practitioners using the electronic staff record system. Internal assessors prepared by the university would assess practitioners’ portfolios and decide whether there was sufficient evidence to allow them to work at an advanced level. Once a practitioner was placed on the advanced practice database, portfolios would be reviewed every year.
The advanced practice group developed a guideline for portfolio content. This guideline was flexible, to acknowledge the diversity of roles, while giving each practitioner some sense of the types of evidence that should/could be included. The portfolio guideline has three distinct sections.
Portfolio section 1
- Personal details (name, address, contact details/place of work);
- Qualifications (professional and academic). Practitioners may wish to include course documents;
- Curriculum vitae;
- Narrative context, that is, personal context and objective context;
- Current PDP and plans for role/service.
Portfolio section 2 In this section, practitioners keep an up-to-date copy of their job description, person specification and Knowledge and Skills Framework outline. This is important as the portfolio will be used as evidence in annual reviews.
Portfolio section 3 The NLIAH (2010) described the pillars (domains) of advanced practice (Table 1) and articulated the core principle that advanced practice is a level of practice rather than a role. Thus, advanced practice is not characterised by the “clinical” domain alone, but also encompasses features of research, education, and management and leadership. Section 3 therefore could/should contain mapped evidence of advanced practice from all these four domains. However, the portfolio guidelines explicitly acknowledged that domain evidence in portfolios would vary, reflecting the nature and diversity of advanced practice roles.
This template is intended to be a guideline for structuring the portfolio, not to restrict the creative presentation of evidence. Nevertheless, each domain has to start with a summary and critical structured reflection on the evidence (Rolfe et al, 2010; Jasper, 2006).
In addition, the health board required every practitioner to undertake a thorough risk assessment of their role before collecting data and evidence, and ensured that, where necessary, practice protocols were put in place. These would need to be clearly evidenced in the portfolio.
The advanced practice group also provided guidelines and examples on portfolio evidence to enable practitioners to structure portfolios meaningfully.
A group of eight ANPs were identified from a diverse range of areas to pilot the advanced practitioner portfolio of evidence, and attended a study session on gathering evidence for advanced practice using portfolios.
Members of the steering group attended a study session on assessing portfolios and assessed those of the pilot group. Feedback from this is being used to make minor adjustments to the portfolio template and the governance framework will be extended to known advanced practitioners in the health board.
Introducing a governance framework should be viewed as a positive measure that seeks to ensure advanced practitioners are fit to practise, and to ensure public protection in the absence of national professional regulation.
While many have said that ANPs pose no risk to the public above or beyond that of new registrants, so may be regulated through the code of conduct, there is nevertheless a concern about practitioners who are unaware that they may lack competence.
The ad hoc development of advanced nurse roles, the random use of titles that may imply levels of clinical expertise that cannot be verified and varied educational development of individual practitioners all point to the need to govern advanced nursing practice at employer level.
In this initiative, many practitioners were found not to meet advanced practice criteria. Although this auditing and governance may be perceived as threatening to practitioners and as yet more bureaucracy, in reality it enables employers and service providers to assure the public that they are deploying nurses to advanced roles in such a way that they can assure their fitness to practise.
In the longer run, employers will be able to plan service redesign and develop new advanced nursing roles in a more meaningful and targeted way than before. It assures a level of staff development that is planned and underpinned by education, which is also measurable and safe. Box 1 contains recommendations for trusts.
It is clear there is no desire or perceived need for a centrally regulated register of advanced practice nurses. Even if there were, there would still be a demand for frameworks of employer-led governance.
It is no longer enough to assume that the code of professional conduct is sufficient to guarantee public protection where advanced nursing roles are developing at such a pace to meet service demand.
The introduction of advanced practice guidelines in Wales has led the way in enabling frameworks of local NHS governance. Preliminary feedback from the initiative outlined here shows the governance criteria and portfolio approach are seen as a useful and structured approach.
This initiative is enabling a more robust understanding of these practitioners’ roles at a senior management level, and providing evidence that supports the effectiveness of such roles in terms of patient outcomes. It also enables evaluation of service redesign, as advanced practitioners are increasingly used in wider and more challenging arenas.
- Part 3 of this series, to be published next week, will explore the future development of advanced nursing
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Council for Healthcare Regulatory Excellence (2008) Advanced Practice: Report to the Four UK Health Departments.
Department of Health (2010) Advanced Level Nursing: a Position Statement.
Department of Health (2006)Modernising Nursing Careers: Setting the Direction.
Department of Health (2004) NHS Knowledge and Skills Framework (KSF). London: DH.
Fulbrook P (1995) What is advanced practice? Intensive and Critical Care Nursing; 11: 1, 53.
Jasper M (2006) Reflection, Decision-Making and Professional Development. Oxford: Blackwell Publishing.
Kaufman G (1996) Nurse practitioners in general practice: an expanding role. Nursing Standard; 11: 8, 44-47.
National Leadership and Innovation Agency for Health Care (2010) Framework for Advanced Nursing, Midwifery and Allied Health Professional Practice in Wales.
Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC.
Rolfe G et al (2010) Critical Reflection in Practice: Generating Knowledge for Care. Basingstoke, Hampshire: Palgrave McMillan.
Scottish Government (2008) Supporting the Development of Advanced Nursing Practice - a Toolkit Approach.
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