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Moving on up: a higher level of practice

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VOL: 97, ISSUE: 47, PAGE NO: 38

Linda Walker, BSc, MA, RGN, RNT, CertEd, is lecturer practitioner, Cardiff and Vale NHS Trust and School of Nursing Studies, University of Wales College of Medicine, Cardiff

When the UKCC introduced the concept of advanced nursing practice in 1994, the lack of a definition caused confusion in the profession. The council revisited the issue, publishing a pilot standard (UKCC, 1999a) that listed the areas of practice (descriptors) defining what is now known as higher-level nursing practice. It then ran a pilot study to test the standard and the assessment process.

When the UKCC introduced the concept of advanced nursing practice in 1994, the lack of a definition caused confusion in the profession. The council revisited the issue, publishing a pilot standard (UKCC, 1999a) that listed the areas of practice (descriptors) defining what is now known as higher-level nursing practice. It then ran a pilot study to test the standard and the assessment process.

This article describes the roles and experiences of myself, as a candidate, and other key members involved in the assessment pilot study.

What is higher-level practice?
The pilot standard included descriptors that set out the characteristics of higher-level practice, each with a number of related standards. These standards identify specific outcomes against which nurses wishing to become higher-level practitioners will be assessed. There are seven descriptors:

- Providing effective health care;

- Improving quality and health outcomes;

- Evaluation and research;

- Leading and developing practice;

- Innovation and changing practice;

- Developing self and others;

- Working across professional and organisational boundaries.

A total of 36 standards need to be achieved across the seven descriptors before a nurse is recognised as practising at a higher level. Box 1 gives an example of the standards attached to one of the descriptors - 'Innovation and changing practice'.

While the UKCC states that there is currently no formal academic programme to prepare nurses for higher-level practice, it believes that the standard of achievement would be at master's degree level.

Nurses from any specialty are eligible to demonstrate competence at this level, whether they are in full or part-time posts and employed in the independent, voluntary or public sector.

The standards were then piloted to ensure that they could be achieved by any nurse. They had to be:

- Sufficiently generic to apply to all areas of practice;

- Sufficiently precise that valid and reliable judgements of practice could be based on them;

- Sufficiently flexible to adapt to change in practice and roles;

- Sufficiently specific to distinguish a higher level of practice from other levels of practice;

- Credible with consumers, practitioners and employers.

If the pilot study is successful and higher-level practice goes ahead, it will be added to the list of qualifications on the UKCC register. This is seen as one way to protect the public, as higher-level practitioners will need to show continual professional updating to reregister the qualification every three years. As with other registered qualifications, it can be revoked if the nurse does not maintain the appropriate standard of practice as well as the PREP requirements.

Overview of the assessment process
The UKCC linked the pilot study to a robust process that assesses the competence of nurses seeking to be recognised as higher-level practitioners. The process involves:

- The compilation of a portfolio providing evidence that within their role they meet all parts of the higher level of practice standards;

- A visit by a member of the assessment panel to the practitioner's workplace to verify the contents of the portfolio and identify any relevant contextual factors;

- Practitioners attending an assessment panel for interview and to allow the panel members to assess the portfolio against the standards.

The candidate's experience
After taking part in the UKCC's consultation exercise on specialist practice in 1998, I saw the pilot project as an opportunity to become involved in an important professional development and decided to apply to register as a higher-level practitioner candidate.

I received surprisingly little literature when I was accepted. It consisted of the standard against which I needed to 'prove' my competence (UKCC, 1999a) and a 17-page document explaining the steps I should take (UKCC, 2000a).

The first stage of the process was to match any evidence I had against the standards, and I was surprised at the volume of work I had generated over the years and forgotten about.

Matching the evidence to the standards on an evidence summary sheet was a time-consuming activity as each piece of evidence could be applied to several standards. I also had to consider that the panel would have to agree with my assessment of this evidence. Box 2 shows how previous work can be matched to particular standards on the evidence summary sheet.

I had to give a personal reflective account of why and how this evidence (articles and correspondence) was important. I also had to discuss the key issues I had faced, how I tackled them, what the outcomes were and what my organisation and I had learned.

The collated evidence, matched specifically to the standards, was added to my portfolio with my professional development plan and CV. During this time I was in frequent contact with my candidate support adviser (CSA), whose advice and support were critical to my progress. When I was nearing the completion of my portfolio, my workplace assessment and assessment panel dates were set.

A visiting panel member (VPM), defined as a practitioner who holds a similar post to the candidate but works in another part of the country, carried out the workplace assessment. During the day-long visit the VPM checked the claims I had made in my portfolio. For example, if I said I had written a particular policy, she checked that it existed by talking to my colleagues and managers. Initially, I found this level of scrutiny unsettling, but as the day passed I became more comfortable with the process and the VPM, who helped to put me at ease.

I was sent a report of the visit, which was extremely positive overall. The VPM indicated any gaps in my evidence, which was a useful preparation for the assessment panel.

The assessment panel was the most stressful part of the process. Although the panel members tried to put me at ease, the proceedings were particularly formal. Each panel member asked me a series of questions that aimed to check each of my claims against the standards. The assessment was extremely thorough, making for an intense three-quarters of an hour.

I was given the opportunity to demonstrate what I do in my work and to clarify any aspects of my portfolio. Three weeks later I received a formal letter confirming that I had achieved the required level for all the standards.

The entire process took five months from start to finish and I would highly recommend it. Not only was it challenging and stimulating, but the sense of achievement was immense.

The visiting panel member
'Before the pilot project began, the UKCC called for volunteers to take part either as candidates, support advisers or assessors. I was initially interested in applying as a candidate, but after some thought I decided it would be beneficial to view the process as a VPM,' says Annette Bartley, a lecturer practitioner/theatre sister training coordinator at Conwy and Denbighshire NHS Trust in Bodelwyddan, Wales.

'After initial contact with the project team I was mailed a forest of information to sift through. It was user-friendly and comprehensive, explaining the background to the project, the assessment process, the different roles and subsequent responsibilities.

'There were a number of eligibility criteria for VPMs. They should:

- Be a nurse, midwife or health visitor and hold current registration with the UKCC;

- Have close links with practice - spending most of their working time in practice (with the exception of the lay member);

- Have sufficient experience and qualifications to be able to make judgements in the area of practice against the pilot standard.

'After initial contact with the candidate to arrange a mutually convenient time for the visit, I received a shortened contextual narrative statement. This gave a brief overview of the candidate's workplace, roles and responsibilities, and key people with whom she worked. It was supported by a CV and a brief account of how the candidate felt she had met each of the standards.

'The narrative statement gave me an opportunity to gain an insight into the candidate's work and acted as a guide to who and how many people in her workplace needed to be interviewed. It also helped me to decide which documents, policies and protocols offered as evidence needed to be located. The purpose of the visit was to corroborate that the evidence was valid, authentic and reliable.

'At the end of the visit I took away the candidate's complete portfolio of evidence. Over the following week I spent a great deal of time examining the portfolio, seeking out the evidence and matching it to the standards.'

The assessment panel
The assessment panel consisted of four members: the chair (a fellow nurse), a lay member, the VPM and another member from a different profession but from the same specialty as the candidate. A member of the UKCC and a representative from a quality assessment team were also present to ensure the process was fair and unbiased (UKCC, 1999a).

Before meeting the candidate the members of the panel, who had never met before, were introduced to each other and had some time to view the candidate's portfolio and discuss the workplace visit. After the assessment process the panel discussed the evidence presented and decided whether the standards had been met.

'The process was robust,' says Ms Bartley, 'and I felt privileged to have been involved. I will be first in the queue to become a candidate myself if the project goes live, content in the knowledge that should I meet the standards, the process will have been rigorous and I would be worthy of the title of higher-level practitioner.'

The candidate support adviser
The UKCC appointed nine CSAs to provide support for all candidates across the UK. All were experienced nurses, midwives or health visitors with a sound knowledge of competence-based systems of assessment. The role of the CSA is to:

- Act as a mentor, supporting each individual to present valid and reliable evidence of competence against the standards in an easily 'trackable' form;

- Assist in gathering data to inform the evaluation process by keeping monthly logs of progress and interventions, and highlighting any barriers to progression;

- Facilitate the smooth transition towards assessment by maintaining regular contact with the candidate and project manager.

The first candidates were allocated to CSAs in February last year, followed by a further three waves in March and April.

'I found the role of CSA challenging and informative,' says Lynne Grundy, deputy NVQ centre coordinator at Conwy and Denbighshire NHS Trust. 'I had the opportunity to meet many skilled practitioners from all areas of nursing, midwifery and health visiting, and to support them in the assessment process. The candidates decided how much support they wanted, either by personal meetings, telephone or e-mail.

'Many of the candidates initially felt overwhelmed by the requirements of the standards and were concerned about how they would prove them by collecting evidence. My role was to offer support and to reassure them about the process. As a facilitator I directed them to areas of their practice that could be related to specifics within the standard and suggested how they could gather evidence. The candidates then had to compile a portfolio of evidence, clearly demonstrating to the assessment panel that they met all the criteria.

'I learnt a great deal throughout the whole process. I was in the privileged position of visiting many of the candidates in their workplace and saw some of the diverse and innovative practices that are taking place in all spheres of nursing, midwifery and health visiting.

'Some candidates decided not to proceed with the pilot for a variety of reasons and these will be evaluated. The first assessment panel took place in June 2000 and panels took place in all parts of the UK up to the end of November 2000.

'All candidates are informed of the decision within 21 days of the panel assessment and are given feedback on whether they have been judged to meet all or some of the standards.

'For the pilot there was no opportunity to resubmit because of time pressures, although there was an appeals procedure. However, if and when the project goes live, it is envisaged that the candidates will be able to resubmit the areas in which they did not meet the criteria.'

The future
Health care practice is developing rapidly, necessitating the regulation of new practice for the protection of the public (UKCC, 1999b). After the completion of the assessment panels, a report will be presented to the UKCC so that it can decide whether the pilot should go live in its current form. Having been through the process, we can report that it is rigorous, fair and achievable within the many and diverse areas of practice.

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