As service demand for nurses with advanced skills increases, regulation, career frameworks and governance will become major issues for practitioners and providers
In this article…
- Key issues in the future development of advanced nursing
- The importance of governance and regulation
- Recommendations for future development
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 3: what does the future hold for advanced nursing? Nursing Times; 108:
This third in a three-part series on advanced nursing explores the future demand for a flexible but regulated nursing career framework.
Part 1 explored the historical evolution of advanced nursing, while part 2 discussed the development of a governance framework.
- This article has been double-blind peer reviewed
- Download a print-friendly PDF file of this article here
5 key points
- The service demand for advanced nursing is growing
- The evidence suggests that advanced nurses can play a key role in resolving service issues
- Enabling the right organisational culture is pivotal in service provision, particularly to new ways of working
- A major restraint to advanced nursing in the UK has been failure to develop mechanisms of governance
- The concept and evidence base for advanced nursing is maturing
The articles in this three-part series have challenged the notion that there is a unified formula that embraces and explains all that is meant by advanced nursing (Barton et al, 2012a; 2012b). We have also argued that title protection, definitive definitions and rigid competency sets are becoming increasingly redundant. In this article, we explore the future demand for a flexible yet regulated nursing career framework.
Advanced nursing is and must be rooted in practice. The previous articles in this series observed that its historical development, as far back as the late 19th century, has always been led primarily by practice, with education, management and evidence as related core components of its wider identity.
There is a compelling parallel between the historical struggles of Mrs Bedford Fenwick and her contemporaries for nurses’ formal registration and today’s effort to establish a career framework that acknowledges advanced nursing.
Current advanced nursing
The future of advanced nursing in the UK is driven by two main issues:
- The demand for some form of national regulation and governance;
- The changing organisation of health service delivery in the UK.
First, the prospect of formal statutory regulation of advanced nursing should be considered, and the associated complex recent history and contrasting lobby (Council for Healthcare Regulatory Excellence, 2010; Department of Health, 2010). There is no doubt that many would like to have seen a new part of the register for advanced nurses. However, the current strategic view is that these practitioners represent no greater risk to the public than new nurse registrants, and that the code of conduct (Nursing and Midwifery Council, 2008) provides all the professional and public protection needed.
That this view causes unease and related concerns over practitioners who may be either “conscious” or “unconscious” incompetents (Longley et al, 2004) is contrasted by the lack of evidence that advanced nurses are failing in their duty of care. Indeed, the contrary appears to be the case; systematic reviews point to these practitioners producing very positive patient outcomes (Newhouse et al, 2011).
However, we contend that the NMC code alone is not sufficient to manage a nursing career framework that encompasses advanced nursing. We suggest that well-structured and transferable mechanisms of employer-led governance and mandatory education should now prevail, and that this should form part of a national strategy sanctioned at regulator and government level (DH, 2010; National Leadership and Innovation Agency for Healthcare, 2010; Scottish Government, 2008).
This brings us onto the second issue of changes to health service organisation. The Centre for Workforce Intelligence assessed the current and prospective workforce risks and opportunities for nursing and midwifery (Dunkley and Haider, 2011). These authors noted that the NHS was experiencing widespread organisational instability and change, coupled with the prospect of continuing financial constraint. A consequent loss of experienced staff and reduction in recruitment will affect the whole health workforce.
Despite this apparent threat to the health professions, such change can paradoxically bring new opportunities, and enable new roles and service models to emerge. That potential is a demand for active and creative workforce planning and redesign, and health managers must engage with this challenge right now.
It is simply not acceptable for resource restrictions and consequent service redesign to be reactive. Indeed, anticipated changes to skill mix and skill deployment may improve efficiencies and care, and planning for that encompasses the growing resource and potential of nurses with advanced roles and responsibilities (Dunkley and Haider, 2011).
The quest for advanced nursing
An international review by Pulcini et al (2010) collected data on advanced nursing from 32 countries.
The authors noted 13 advanced nursing titles, with 22 countries providing advanced nursing education, and 11 of those identifying a master’s degree as the most appropriate credential. Twenty-three countries had formal recognition of the nurse practitioner-advanced nurse practitioner (ANP) role. Half of those required ANPs to maintain or renew licences, with most requiring continuing education or clinical practice. Significant support for advanced nursing came from domestic nursing organisations (92%), individual nurses (70%) and governments (68%). Opposition to introducing advanced nursing roles came primarily from doctors and doctor organisations (83% and 67%).
This evidence shows there is a precedent for regulatory frameworks, which the UK should follow. Although such a framework may not have statutory status, it should have central government and regulator endorsement, provide clear national guidance and bring consistency to advanced practitioner governance. The service demand for advanced nursing is growing, driven by reductions in junior doctors’ working hours, recruitment and retention problems in clinical specialties, and substantial health service restructuring with workforce redesign demands (Carnwell and Daly, 2003).
The evidence suggests that advanced nurses can play a central role in resolving the service issues highlighted above and, if deployed appropriately, will improve patient care (Dunkley and Haider, 2011).
It is perhaps only fair and balanced to allude to the critical questions of motivation. Are advanced practitioners pioneers, facilitating new roles and better patient outcomes, or are they simply a cost-effective response to service cuts, or even a convenience in meeting shortages and changes in the medical profession (McKenna et al, 2003)? These speculative questions warrant further consideration elsewhere.
A more material point is whether the answers to these questions matter. As professional boundaries are constantly moving (Barton, 2006), we would argue that all health professionals draw selectively from a common toolkit of theoretical knowledge and clinical skills. Therefore it is the practical application and outcome of that knowledge and these skills in the context of patient care and need, and the governance of that practice, that are relevant and most critical.
Definitions, roles and competencies
It is not our intention to reiterate the literature and research that has provided structure to advanced nursing definitions (Furlong and Smith, 2005). Equally, a plethora of work has considered the scope, diversity and conformities of advanced nursing role descriptors and competency frameworks (Mantzoukas and Watkinson, 2007).
It is now possible to visualise a hierarchy of skill and expertise to identify the novice advanced practitioner and the expert advanced practitioner (Maylor, 2005). We have a better understanding of the nature of generalist and specialist practice and how intimately related the two concepts are. With this developing body of evidence and emerging career framework, we can now tackle the constraints that limit the full and best use of this emerging new resource.
Constraints and management responsibility
Innovative practice development and improved patient care are potentially constrained by outmoded organisational structures and cultures, characterised by rigid professional hierarchies, dated working traditions and inefficient working practices (Ball and Cox, 2004; Ewens, 2003).
Ewens (2003) also suggested that this type of outdated, inflexible organisational culture pervades healthcare providers in the UK. The evidence certainly points to organisational models of contemporary health service delivery that impede the effective use of advanced nurses (Barton and Mashlan, 2011; Ball and Cox, 2004). This predictably has the effect of demoralising nurses and other health professionals.
It follows that enabling the right organisational culture is pivotal in health service provision, particularly regarding new ways of working (Woods, 1999). Ewens (2003) argued that the responsibility for resolving problems with organisational culture lies mainly with nurse managers and executives. We would add that this responsibility extends to the managers of all health-related professions, including that of medicine.
Norris and Melby (2006) specifically noted that recent blurring of professional boundaries between nursing and medical roles – arising directly from the emergence of advanced nurses – would inevitably affect professional traditions. Those traditions would be resistant to change, and that constraint would need to be pre-empted and resolved if new service models were to be implemented effectively. Therefore, regardless of any perceived patient benefit that may arise from introducing advanced nurses, such innovative development will not occur unless senior organisational management facilitates a culture that enables practice development (Jones, 2005).
Enabling the successful introduction of advanced nursing services will require clear understanding of the depth and breadth of the concept, the diversity of roles, professional boundaries and the education required. In addition, there will be the demand for a proactive and structured process of organisational governance (Griffin and Melby, 2006).
Governance and regulation
The basis of our polemic on advanced nursing is the opportunity it offers to a health service facing severe threats, in terms of both resource restriction and dramatic changes in health demography.
Underpinning that opportunity is the long, complex and sometimes hesitant development of the concept of advanced nursing in the UK, and the failure of health organisations and managers to realise the potential radical service redesign and new professional models.
One of the major restraints has been the failure to develop mechanisms of governance in the UK. We have been blinkered by the notion that the only form of safe regulation was that of the statutory introduction of a new part of the nursing register.
The CHRE (2010) made the following observations on the wider scope of regulatory options:
- Registered health professionals should only practise in areas in which they are competent to do so; they are responsible for the care they provide;
- Employers should have appropriate support and performance-management systems in place if they employ health professionals in extended roles;
- Regulators should ensure their codes of conduct adequately reflect the requirement for health professionals to stay up to date (education) and to operate safely within their areas of competence;
- Regulators should only pursue the option of creating a specialist list or annotation on the register when all other approaches have been exhausted;
- The secretary of state for health and ministers in the devolved administrations should assess any application to change legislation in relation to specialist lists or annotations on a register solely against the risks posed to patient safety and public protection;
- All parties should demonstrate an active commitment to cooperating and sharing information to manage risks to patient safety and public protection.
Regulatory issues fall on all parties –practitioners, managers, employers, educators, regulators and government; they are not confined to any one individual or group (Marsden et al, 2003).
The CHRE (2010) suggested six main regulatory principles: proportionality; consistency; targeting; transparency; accountability; and checking for unintended consequences. Properly applied, these should enable advanced nursing practice innovations to be introduced with due consideration from all parties mentioned above. Only then can we truly assure the public that proper and due process is in place to ensure that patients receive the best possible care (Livesley et al, 2009). Box 1 contains recommendations for future development.
We believe that the concept and evidence base for advanced nursing is maturing, and now attaining a wider acceptance.
Responsibility for the next steps falls on all of us involved in moving advanced nursing forward to benefit patient care and service delivery. It is a responsibility that falls on practitioners themselves, employers and managers, educators and, finally, on the nursing regulator and the government.
The historical struggle for the formal registration of nurses is today being taken forward as we strive to build a flexible career framework and national strategy that accommodates the diversity and totality of advanced nursing.
Keep up to date
Do you want to be kept informed of new articles like this or on a wide range of specialist subjects? If you register with nursingtimes.net you can sign up for regular newsletters on the subjects that interest you, so you don’t miss the news and practice information that’s relevant to you. It’s quick and easy - just click here.
Ball C, Cox CL (2004) Part two: the core components of legitimate influence and the conditions that constrain or facilitate advanced nursing practice in adult critical care. International Journal of Nursing Practice; 10: 10-20.
Barton TD (2006) Nurse practitioners – or advanced clinical nurses? British Journal of Nursing; 15: 7, 370-376.
Barton TD et al (2012a) Advanced nursing 1: the development of advanced nursing roles. Nursing Times; 108: 24, 18-20.
Barton TD et al (2012b) Advanced nursing 2: a governance framework for advanced nursing practice. Nursing Times; 108: 25, 22-24.
Barton TD, Mashlan W (2011) An advanced practitioner-led service – consequences of service redesign for managers and organisational infrastructure. Journal of Nursing Management; 19: 7, 943-949.
Carnwell R, Daly W (2003) Advanced nursing practitioners in primary care settings: an exploration of the developing roles. Journal of Clinical Nursing; 12: 5, 630-642.
Council for Healthcare Regulatory Excellence (2010) Right-touch Regulation. London: CHRE.
Department of Health (2010) Advanced Level Nursing: a Position Statement.
Dunkley L, Haider S (2011) Nursing and Midwifery: Workforce Risks and Opportunities. London: Centre for Workforce Intelligence.
Ewens A (2003) Changes in nursing identities: supporting a successful transition. Journal of Nursing Management; 11:4, 224-228.
Furlong E, Smith R (2005) Advanced nursing practice: policy, education and role development. Journal of Clinical Nursing; 14: 9, 1059-1066.
Griffin M, Melby V (2006) Developing an advanced nurse practitioner service in emergency care: attitudes of nurses and doctors. Journal of Advanced Nursing; 56: 3, 292-301.
Jones ML (2005) Role development and effective practice in specialist and advanced practice roles in acute hospital settings: systematic review and meta-synthesis. Journal of Advanced Nursing; 49: 2, 191-209.
Livesley J et al (2009) The management of advanced practitioner preparation: a work based challenge. Journal of Nursing Management; 17: 584–593.
Longley M et al (2004) Innovation and Protection: a Framework for Post-Registration Nursing. Report for the Nursing and Midwifery Council Task and Finish Group. London: NMC.
Mantzoukas S, Watkinson S (2007) Review of advanced nursing practice: the international literature and developing the generic features. Journal of Clinical Nursing; 16: 1, 28-37.
Marsden J et al (2003) Nurse practitioner practice and deployment: electronic mail Delphi study. Journal of Advanced Nursing; 43: 6, 595-605.
Maylor M (2005) Professional development. Differentiating between a consultant nurse and a clinical nurse specialist. British Journal of Nursing; 14: 8, 463-468.
McKenna H et al (2003) Generic and specialist nursing roles in the community: an investigation of professional and lay views. Health & Social Care in the Community; 11: 6, 537-545.
National Leadership and Innovation Agency for Healthcare (2010) Framework for Advanced Nursing, Midwifery and Allied Health Professional Practice in Wales.
Newhouse RP et al (2011) Advanced practice nurse outcomes 1990-2008: a systematic review. Nursing Economics; 29: 5, 1-21.
Norris T, Melby V (2006) The acute care nurse practitioner: challenging existing boundaries of emergency nurses in the United Kingdom. Journal of Clinical Nursing; 15: 253-263.
Nursing and Midwifery Council (2008)The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC.
Pulcini J et al (2010) An international survey on advanced practice nursing education, practice, and regulation. Journal of Nursing Scholarship; 42: 1, 31-39.
Scottish Government (2008) Supporting the Development of Advanced Nursing Practice – a Toolkit Approach.
Woods LP (1999) The contingent nature of advanced nursing practice. Journal of Advanced Nursing; 30: 1, 121-128.