Lisa Eve, BSc, RN, RSCPHN-HV, is nurse prescribing in general practice and non-medical prescribing lead, South West London Strategic Health Authority, and seminar leader, department of general practice and primary care, Guy’s, King’s and St Thomas’ School of Medicine, London.
The Nurse Practitioner Project, commissioned by the South West London Workforce Development Confederation (2002) - now known as the South West London Strategic Health Authority Workforce Development Group - ran for 12 months, commencing May 2001. The aim of the project was to investigate the NP role locally within primary care.
The Nursing and Midwifery Council (NMC) has been reluctant to formally recognise the NP role or to set standards for educational programmes or competencies required to underpin the role. This may have contributed to a general lack of clarity in these issues (Tye and Ross, 2000; Ashburner et al, 1997) and there are indications that it may also have indirectly encouraged inappropriate use of the title, so adding to the overall confusion.
Proposals are now being made by the NMC to limit the use of specialist practitioner titles to those who have gained a recognised higher degree level qualification (Anon, 2004a).
Patients’ expectations of a nurse who uses the NP title may be that she or he will provide a more expert level of care (Anon, 2004b). However, some jobs are given specific titles in order to make them appear more attractive to prospective candidates. Some nurses will have been required to complete specialist training prior to undertaking a new role using the NP title, whereas others will not have been required to do so.
In order to understand how the NP role has evolved, it is important to review its historical development. The role was first seen in the US in the 1960s with its primary function being to meet demand arising from a population increase combined with a shortage of primary care physicians, initially in the paediatric field (Chambers, 1998). Paediatric and primary care nurse practitioners offered advanced nursing practice within their clinical setting and appear to have been the first holders of the NP title.
Development of the NP role in the UK was pioneered during the 1980s by Barbara Stilwell (1982) and Barbara Burke-Masters (1986).
Chambers (1998) identified that the reasons for patients consulting the NP fell into three distinct areas: preventative health care; the management of chronic ailments; and patients presenting with new problems.
Burke-Masters worked independently as an NP for a voluntary organisation with a patient population of single homeless men in east London. The autonomous nature of her role could be perceived as a central feature of the inception of the NP role.
Chambers (1998) argues that by prescribing, making direct referrals to hospital and providing health care, Burke-Masters’ role could be seen as that of a substitute doctor, filling gaps in care provision offered to vulnerable groups, an argument that has been supported by Fawcett-Hennesy (1991).
Improving the patient experience
Whether the NP role has developed to provide a surrogate form of medical care or as an expansion of the nurse role remains central to the argument surrounding its development (Horrocks et al, 2002; Offredy and Townsend, 2000; Holcomb, 2000).
Walsh et al (2001) point out that the function of the NP lies between nursing and medicine and that these roles do not have clear-cut demarcation lines. However, practising between these two boundaries means NPs can offer patients ‘added value’ as their role combines elements or interventions of both nursing and medicine.
The extent of such ‘added value’ can be illustrated by a number of studies that showed that the NP role achieves both patient satisfaction and/or effective clinical outcomes that are comparable with those achieved by doctors of a similar grade (Cumberlege, 1986; Salisbury and Tettersell, 1988; Bond et al, 1998; Horrocks et al, 2002).
Improving the patient experience is a cornerstone of government policy in this area, as demonstrated by a range of policy documents including The NHS Plan (DoH, 2000) and Liberating the Talents (DoH, 2002).
Wider policy context
It is widely acknowledged that the Scope of Professional Practice (UKCC, 1992), which has since been replaced by the Code of Professional Conduct (NMC, 2002), influenced nurses to develop new roles to meet patient need.
The NHS Plan (DoH, 2000) outlined a vision of more autonomous nursing roles to meet the needs of patients. The document cites the need to review the mix of skills and to break down existing boundaries between nursing and medical roles, thus encouraging ‘smarter’ working.
It could be argued therefore that NPs have never been better positioned - with their enhanced, educationally supported knowledge and skills - to work with GP and nursing colleagues, jointly planning and meeting the ever-expanding need for improved, modernised health care.
An increase in such collaborative working meets one of the government’s ‘10-year vision of improvement’ priorities.
Clarifying the NP role
In order to reflect the different perspectives surrounding interpretative and positivist research, the data collection for the project included a combination of qualitative and quantitative approaches.
The proliferation of the NP title and surrounding lack of clarity was clearly highlighted in the project’s six-month review, from May to November 2001, of the recruitment section in a popular nursing journal. It revealed that the NP title was being used to advertise more than 40 different nursing roles ranging from E to H grade. A larger study undertaken by Tye et al (1998) revealed similar findings. When contacted by phone to enquire why the title NP was being used, the advertisers gave the following reasons:
- ‘It was used by the previous post holder and will continue to be used by the new post holder’;
- ‘The post holder will be working autonomously’;
- ‘The post holder will be an F-grade junior sister. We do not wish the successful applicant to be pulled into ward work, hence the use of the title’;
- ‘We are having great difficulty recruiting to this post and feel that using this trendy title may help.’
The advertisers were also asked whether the nurses recruited would need to have undertaken a specific degree programme. Over 85 per cent of answers revealed that this was not required.
The review indicated a consistent lack of standardisation for the parameters of the NP title that creates a potential patient, nurse and employer protection issue, especially where specific programmes of education have not been undertaken (Box 1).
The Medical Defence Union’s comments (2001) were subsequently used to compile the following recommendation: that a nurse within South West London Strategic Health Authority should not use the title nurse practitioner unless she or he holds a relevant first or higher degree and meets all the project’s defining characteristics (Box 2, p32).
Continuous reviews of nursing journals were undertaken to identify existing NP-defining characteristics and competency frameworks.
Many of the NP definitions appeared to contain elements of, or had been adopted from the RCN’s (1997) definition.
Midway through the project it emerged that the RCN was in the process of publishing a revised NP definition. This was based on that of the National Organization of Nurse Practitioner Faculties (NONPF) in the US, revised to make them more applicable to NPs working within the UK.
These competencies can be adapted and used by employers to set minimum standards for new and existing NPs.
Following discussion with other UK workforce development groups, the project unanimously adopted and recommended the adapted NONPF (2000) competencies.
Developing the project’s recommendation of the adoption of an NP definition, the project steering group, following significant discussion, finally concluded that the revised NP definition from the RCN (2002) succinctly describes the characteristics of the NP. The definition (Box 2), it was noted, contained many similar nationally and internationally identified characteristics reviewed throughout the project.
One omission from this definition appears to be the lack of recognition of the prescribing role. In consultation with the project steering group, a specific prescribing characteristic was therefore developed and added as follows:
- Having necessary registration to allow prescribing of appropriate treatment.
The 12 characteristics can be applied to NPs working in primary or secondary care. If a nurse working as an NP is unable to fulfil these characteristics, then she or he should not be regarded as working within the role.
The project team realised that to adopt both NP defining characteristics and competencies from a specific organisation, such as the RCN, could be viewed as inappropriately narrow. However, the RCN has studied international development and current literature in developing both characteristics and competencies and, as well as being a trade union and professional nursing organisation, it is also a recognised educational institute.
The RCN is the only organisation in the UK to have imported a tried, tested and successful NP programme of education from the US, adapting the programme to enable NPs in the UK to perform successfully within their enhanced nursing role.
It was therefore in recognition of the RCN’s expertise and the need for consensus, as highlighted by other workforce development groups, that the decision was made to recommend the use of the adapted NONPF (2000) competencies and the defining NP characteristics, and to include the project’s 12th prescribing characteristic.
Regulation of both the use of such titles and, more importantly, the education and competencies required to meet specific nursing roles, is needed in order to guarantee public protection and enable confidence in the standards of care expected.
Two conclusions were drawn:
- A perceived overuse and confusion surrounding the role and use of the NP title;
- A perceived consensus in the development of both an NP definition and NP competencies.
The project made a number of recommendations, including:
- Organisations within South West London Strategic Health Authority area should be encouraged to use the NP title appropriately, based on the project’s identified defining characteristics;
- Employers should officially recognise the project’s identified NP competencies.
The project’s recommendations regarding use of the defining characteristics have since been adopted by local primary care and acute trusts in order to identify and employ nurses to provide points of first contact for patients.
Overuse of the NP title within primary care has been curbed and, from discussions with both medical and nursing colleagues, there appears to be a better understanding of the role.
Similar investigation being undertaken within other UK projects into a specific NP nursing role would indicate that the recently published consultation proposals (NMC, 2004), following publication of recently commissioned research (Longley et al, 2004) are well overdue.
This article has been double-blind peer-reviewed.
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