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Changing Practice

Developing an advanced practitioner critical care role to benefit the multidisciplinary team

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Exploring the policy drivers for creating an advanced nurse practitioner critical care role, and an educational programme developed to support it.

Authors

Authors Martin Carberry, ITU Dip, MSc, BSc, RGN, is nurse consultant in critical care, Hairmyres Hospital, NHS Lanarkshire; Beth Fleming, PhD, MN, RNT, DCT, DCCN, RGN, is senior lecturer, School of Health, Nursing and Midwifery, University of the West of Scotland, Hamilton.

Abstract

Carberry, M., Fleming, B. (2009) Developing an advanced practitioner critical care role to benefit the multidisciplinary team. Nursing Times; 105: 20, early online publication

This article explores the development of the advanced nurse practitioner critical care role and a master’s-level educational programme to support a multiprofessional advanced practice role. The experience gained could provide valuable information for similar projects. Further study is needed to evaluate the educational programme and the

Keywords: Critical care, Advanced practice, Nurse practitioner

  • This article has been double-blind peer-reviewed

Practice points

  • The experience gained during this project could provide valuable information for similar planned developments in education and advanced practice.
  • Continuing work is currently being planned to evaluate the role and to establish if the educational programme and clinical competencies are preparing experienced nurses for their advanced role.
  • A longitudinal research study has been planned to evaluate the ANPCC role and the impact on service provision and patient care. 

Background

  • The European Working Time Directive (Council Directive, 1993) introduced legislative changes in working practice across Europe. This resulted in a marked reduction in junior doctor working hours.
  • Modernising Medical Careers (DH, 2005), which focused on restructuring educational programmes for junior doctors, resulted in more time being devoted to training and postgraduate education.
  • These changes have the potential to reduce the number of hours junior doctors are available and, specifically, in the context of this article, to provide acute medical care.

Introduction

The European Working Time Directive (Council Directive, 2000; 1993) and Modernising Medical Careers (Department of Health, 2005) are likely to impact on the overall number of hours junior doctors are available to provide care (see Background Box). Policy has therefore provided the catalyst for this particular service redesign and, ultimately, the opportunity to explore the development of advanced practice roles in critical care.

This article outlines the key policy drivers underpinning the development of the advanced nurse practitioner critical care (ANPCC) role in three intensive care units in Scotland, recruitment and selection of practitioners and the planning and design of modules in a postgraduate certificate educational programme.

Literature review

In a recent review of the literature, Srivastava et al (2008) noted that policy initiatives and professional recommendations have significantly influenced the development of new nursing roles in ICU in the UK.

As a result of the EWTD (Council Directive, 2000) and the changes in education (DH, 2005), it is anticipated there will be an overall reduction in the available hours for junior medical staff to deliver care and moreover, a challenge for health boards to maintain the quality of existing service provision. So there is a need to evaluate the current provision of medical and nursing care in a critical care perspective, specifically in relation to the advanced practice work stream included in the Modernising Nursing Careers (MNC) initiative (DH, 2006a). 

The DH (2006a) built on the base set by Agenda for Change (DH, 2004) by establishing the use of competencies to influence role development and workforce planning.

Modern healthcare provision in Scotland encouraged nurses, midwives and allied health professionals to contribute to delivering an effective quality service (Scottish Government Health Department, 2007; Scottish Executive Health Department, 2005), including developing new ways of working. MNC’s advanced practice work stream (DH, 2006a) was addressed in Scotland by a working group that comprised service and educational staff (NHS Education for Scotland, 2008). This group’s main aim was to establish a comprehensive online toolkit that would provide a working definition of advanced practice, support service and education development and inform advanced practitioners alike.

The NMC’s (2005) definition of advanced nurse practitioners provided a context for the role and, as such, became a basis for discussions on developing the toolkit. The NMC (2005) described this role as: ‘Advanced nurse practitioners are highly experienced and educated members of the care team who are able to diagnose and treat your healthcare needs or refer you to an appropriate specialist if needed.’

The outcomes from the advanced practice working group and the toolkit were used to inform the development of the educational programme to support the ANPCC role. Moreover, the advanced critical care practitioner (ACCP) framework (DH, 2008; DH, 2006b) proved invaluable in determining the key competencies that nurses need when working at this advanced level.

Advanced nursing in critical care

Advanced nursing roles in intensive care have been established in some critical care settings (Llewellyn and Day, 2008; Ball and Cox, 2004). However, it was the DH (2006b) which comprehensively described the role of the ACCP, its function in the multidisciplinary team and potential benefits to patient care. Essentially, the ACCP supports the critical care team by performing many traditional medical roles while maintaining a nursing focus (DH, 2006b). The ACCP will therefore carry out tasks such as physical assessment, diagnosis and contribute to developing and managing treatment planning. The role also involves practical skills such as advanced airway management, central venous catheter placement and non-medical prescribing.

A newly formed ANPCC project steering group adopted the main components of this model, and provided a broad overview of the competencies needed to support it. The DH – working with the Intensive Care Society, British Association of Critical Care Nurses, Intercollegiate Board for Training in Intensive Care Medicine and the RCN – published a competency framework to support ACCP role development and education (DH, 2008). These guidelines were invaluable in terms of informing the development of the ANPCC competency package. 

The ANPCC role contributes substantially to the advancement and recognition of nurses performing such roles. However, practitioners in these advanced roles take on responsibilities that were previously deemed to be doctors’ (Llewellyn and Day, 2008; McGee and Castledine, 2003). This may prompt criticism from both nursing and medical colleagues.

In a critical care setting, nurses and medical staff share many areas of expertise and competence and where appropriate, nurses make autonomous decisions about patient care (Furlong and Smith, 2005). However, the ANPCC will function as part of the critical care team and work collaboratively within a clearly defined scope of practice, shown by achieving competencies associated with the role, much of which will be under supervision pending experience.

In summary the EWTD, together with the workforce implications of MMC (DH, 2005) and professional recommendations of MNC (DH, 2006a) provided the main political and professional drivers for the ANPCC role.

Specific to critical care, the advanced practice role was influenced by pilot work in England and Wales (DH, 2006b). However, there is little information on providing educational support to carry out such a role.

There was therefore an opportunity to develop specific modules in an educational programme to support advanced practice in an acute and critical care setting.

Selection and recruitment process

The ANPCC selection strategy was carefully defined using a tripartite process, namely Objective Structured Clinical Examination (OSCE), psychometric testing and competency-based interview. The pre-selection criteria for the post were defined at first-degree level, a minimum of five years’ post-registration experience, with three years’ experience in a critical care environment.

Essentially, the OSCE is an objective measure of clinical competence using a scoring system in the form of a behavioural checklist which is carried out in a simulated clinical setting to assess clinical skills performance (Marks and Humphrey-Murto, 2005). Martin and Jolly (2002) showed that OSCEs are valid predictors of not only clinical competence but also of future performance in the clinical area.

Each shortlisted candidate was exposed to the same specific clinical scenario, namely septic shock. A consultant in intensive care medicine independently scored key components of the scenario using a pre-determined checklist and a consultant nurse validated them. The information and feedback gained from the OSCE experience provided the interview panel with detailed information about candidates’ abilities, in particular their clinical knowledge, ability to work under pressure and communicate effectively. This information was used to generate specific areas of candidate competence to be explored with them during the competency-based interview. The OSCE feedback was used along with a detailed briefing on each candidate from psychometric testing, carried out by an educational psychologist over one day.

Psychometric testing has been widely accepted as a benchmarking tool to assess a person’s ability or personality in a measured and structured way (Cheeseman, 2004). The three specific categories investigated to explore the ANPCC candidates included: the Watson-Glaser critical thinking test (Watson and Glaser, 2002); the Rust Advanced Numerical Reasoning Appraisal (RANRA) (Rust, 2002); and the 16 PF (personality factors) personality testing (Smith, 1994). These tests would provide an indication on whether candidates had the right attitude, attributes and personal qualities to perform an advanced nursing role.

Outcomes and scores from both the psychometric testing and OSCE were available to the multidisciplinary interview panel before interview. The interview was competency-based, with candidates having to provide examples of how and when they dealt with areas considered important for the role. These included specific clinical evidence of working and dealing with stressful situations, changing the outcome of situational conflict by using negotiation skills. All candidates received coaching on the interview process, specifically the questioning style of the competency-based interview and panel expectations, with examples in each field provided. 

This feedback from the tests was used to assess each candidate’s suitability for the post and to explore specific competency-based skills at interview such as clinical, personal and leadership qualities and shortfalls. The multidisciplinary interview panel found the tripartite process invaluable in supporting candidate selection. The rigorous processes used to select candidates for the ANPCC role resulted in five suitably qualified and clinically competent nurses being employed for the trainee post.

Programme development

The postgraduate certificate in advanced clinical practice is a master’s-level programme designed recently to support allied health professionals performing an advanced role.

The programme aims to encourage critical and analytical thinking, while promoting the use of evidence-based practice and application of these concepts to their advanced role.

We formed a core educational group comprising an academic (Beth Fleming), a nurse consultant (Martin Carberry) and consultants in intensive care medicine, to develop specific modules in the programme. In addition, the group ensured that adhering to working within and across professional boundaries was fully acknowledged and made explicit in the programme. On deciding the course’s academic level, the group reviewed developments in advanced practice from a regulatory perspective, which calls for the professional development of those in such a role to be commensurate with master’s-level thinking (NMC, 2005).

Framework and content

Atkins and Ersser (2000) suggested that when developing an educational programme for advanced practice, it is essential to identify the role’s nature and function. In relation to defining the advanced nurse practitioner’s role, the NMC (2005) carried out substantial work in this area and then formulated a comprehensive definition to contextualise the role. The group felt the NMC’s (2005) definition encompassed the essential qualities the ANPCC needed, and was the benchmark from which the specific module content could be developed.

The group mapped the ANPCC role and that of the advanced practitioner against the NHS Knowledge and Skills Framework (DH, 2004a; 2004b). The KSF contains core and specific dimensions which identify broad functions that the NHS needs to enable it to provide a good-quality service and simultaneously to develop its workforce. In relation to programme development, the NHS KSF makes explicit the level of knowledge and skills needed to function effectively in a particular post. The group therefore mapped each of the modules against the KSF’s core and specific dimensions, providing tangible evidence of achievement from both an academic and professional perspective. The specific theoretical and clinical components of the modules were designed to underpin the core competencies of advanced nursing practice namely, module 1 advanced assessment, module 2 diagnosis and module 3 advanced interventions. The three level 11 (eleven) (Scottish Credit Qualifications Framework, 2003) 20-point modules (see Table 1) in the programme were designed to enable students to show achievement of knowledge, skills and competence at master’s level. 

The three modules are done on a part-time basis over three trimesters with a maximum of two years to complete the programme. Each module consists of 200 hours of notional student effort, the equivalent of eight taught weeks. The teaching strategies included simulated learning, problem-based learning and workshops supported by practitioners with specific expertise. Specific to critical care, the ANPCCs will take part in supplementary workshops relating the theory to practice in an intensive care setting. Table 1 outlines the modules, academic notional student effort hours to achieve the modular learning outcomes and the clinical practice hours required.

Table 1.  Modules, academic and practice hours

Postgraduate Certificate Advanced Clinical Practice  
Module title Academic points Year 1 trimester Academic notional student effort Clinical practice hours  
Advanced Patient Assessment 20 One 200 hours  350 hours  
Diagnostic Decision Making 20 Two 200 hours  350 hours  
 
Advanced Patient Interventions 20 Three 200 hours  350 hours  
Advanced Non-medical Prescribing 20 Year 2 trimester      
One 200 hours 350 hours  

 

Corcoran and Nicholson (2004) and Harris et al (2001) advocated the use of a portfolio to support independent learning, synthesise learning to practice and enable role development. All students doing the module must complete a work-based learning portfolio of competencies. The competency portfolio combines the strategies of reflecting on prior knowledge and experience, with actively identifying practice and learning needs and, more importantly, how these needs will be met and evidenced in practice.

NES (2008) and the NMC (2007) recommended that educational programmes addressing advanced practice should make explicit the core and specific competencies associated with the role. In addition, the ANPCCs must complete a specific critical care portfolio that synthesises advanced knowledge with the skills and attitudes necessary for their role. The portfolio of competence was informed by national competencies (RCN, 2007; NMC, 2007; DH, 2006a), with specific relevance to those formulated for the critical care practitioner role as part of the National Critical Care Practitioner Programme (DH, 2008). 

In relation to critical care, the ANPCC students were allocated a clinical supervisor. The clinical supervisor’s role will be to apply their knowledge, skills and expertise to determine achievement of competencies and therefore the ANPCC’s competence to perform this advanced role. Academic and consultant nurse support was also made available for the supervisors and ANPCC students. A series of informative days were organised to engage both students and clinical supervisors in the principles of portfolio development and of teaching and learning in the clinical setting. These sessions proved invaluable in creating a supportive learning environment and also provided ANPCCs and clinical supervisors with an in-depth understanding of the learning process from an educational and clinical perspective.

Conclusion

The tripartite selection process provided a robust and informative model to support the interview panel’s decision about selection and recruitment into the ANPCC role. Although early in the process, we can conclude that strong initial feedback from independent OSCE concurred with outcomes from psychometric testing and initial observations of the trainee ANPCCs in post, in particular relating to work-based values, performance under pressure and decision-making skills. 

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