A lack of clarity about advanced nursing practice led a Welsh trust to develop a portfolio for advanced nurse practitioners to document the nature of their roles
In the absence of national regulation of advanced nursing practice roles, employers need to ensure adequate governance arrangements are in place. The development and production of a robust portfolio can demonstrate advanced nursing practice is essential, but is not easily compiled because of the nature and complexity of the individual advanced nurse practitioner’s role. This article discusses the advanced nurse practitioner role and the need for the portfolio. It highlights the challenges encountered by nurses in a Welsh health board when producing the portfolio, which will be introduced in Wales to demonstrate clinical governance and ensure patient safety.
Citation: Townsend A, Croft A (2015) Developing a portfolio for advanced practice. Nursing Times; 111: 23/24, 23-26.
Authors: Alison Townsend is advanced nurse practitioner for urology services; Andrea Croft is lead advanced nurse practitioner in anticoagulation, both at Princess of Wales Hospital, Abertawe Bro Morgannwg University Health Board.
- This article has been double-blind peer reviewed
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Advanced nurse practitioners (ANPs) are a senior clinical resource at the front line of care delivery, particularly in terms of addressing the challenges of workforce shortages in the NHS and managing long-term conditions and the ageing population (Townsend, 2014; Department of Health, 2007). The development of these roles presents significant opportunities for workforce/service development and innovation (National Leadership and Innovation Agency for Healthcare (NLIAH), 2013). Although advanced nursing practice is not a new concept, there is no single, universally agreed definition - it should be viewed as a level of practice rather than a specific role (DH, 2010; NLIAH, 2010; Scottish Government, 2008).
The basis of advanced nursing practice is a high degree of knowledge, skill and experience applied to achieve optimal outcomes through:
- Critical analysis;
- Problem solving;
- Evidence-based decision making (DH, 2010).
However, despite significant debate, advanced nursing roles are not subject to regulation, and the plethora of job titles makes it difficult for the general public to understand the level of care they can expect from ANPs.
The directorate of the chief nursing office for Scotland has developed an advanced practice toolkit (Scottish Government, 2008) that has been adopted as a platform to develop and support advanced practice in Wales. This requires that ANPs demonstrate their ability to work at advanced levels of competence encompassing all four pillars of practice (Fig 1) so they can use the title “advanced” (NLIAH, 2010; Scottish Government, 2008). More recently, local regulation and governance by employers that requires them to review their ANPs has been suggested to ensure practitioners are fit for purpose (DH, 2010; NLIAH, 2010).
Advanced nursing practice has existed for decades but, due to the complexities surrounding its development, the field has been led essentially by innovation in practice (Barton et al, 2012). In 2009 the nurse in charge of workforce planning in our hospital trust recognised the need to evaluate the “off-ward” nurses. Like other trusts, ours had limited data for managers and peers to understand the diverse nature of these roles, making their contribution difficult to define. The ANPs were therefore asked to complete a questionnaire so their roles and workload could be audited.
The audit showed that, although many roles evolved in an unregulated way, ANPs played an integral part in the successful management of the patient journey. The nursing executive subsequently used this data to create a database of ANPs, and quickly recognised a need to ensure robust governance arrangements were in place to protect the public, organisation, and the ANPs - particularly in light of how many of the roles had evolved.
Developing the profile
Following the audit the executive nurse for workforce planning invited some of the more experienced ANPs to join a task group to assist with the process of governance. The group comprised several specialist nurses and nurse practitioners with diverse roles in an attempt to ensure it was as inclusive as possible.
The group initially examined the available tools for demonstrating a level of practice - none appeared to cover all relevant aspects for each role and some were difficult to apply. Eventually the group agreed the Scottish toolkit and pillars of practice (Scottish Government, 2008) was the most appropriate and user friendly. This was subsequently used to develop an Abertawe Bro Morgannwg University Health Board governance framework (Barton et al, 2012). The group also identified the need for a live portfolio to establish a level of practice.
In October 2009, the portfolio guidelines were proposed to the health board’s nursing and midwifery professional forum and gained approval. The portfolio would use the four pillars of practice from the Scottish toolkit; this contains specific criteria for each pillar of practice and ANPs must provide evidence demonstrating that they fulfil the specified criteria and illustrating advanced practice (Box 1).
Box 1. Examples of criteria demonstrating advanced practice
- Identifying a need to change
- Managing change
- Leading innovation
- Negotiation and influencing
- Team development
- Principles of teaching and learning
- Development of knowledge and skills
- Teaching, mentorship and coaching
- Developing service user materials
- Supporting others to develop knowledge and skills
- Decision making /clinical judgement/problem solving
- Managing complexity
- Clinical governance
- Developing confidence
- Higher-level communication skills
- Critical appraisal/evaluation skills
- Involvement in research
- Ability to implement research findings into clinical practice
A portfolio used by one of the group was reviewed as a working example, as it contained evidence of achieved competencies and skills training. We agreed to use this as the initial template and adjust it as required by individual ANPs.
The executive nurse for workforce was also involved with the NLIAH group working on advanced practice for allied health professionals. As a result of this association with a national agency developing a framework for advanced practice, the work to develop a live portfolio was eventually rolled out across Wales.
A primary concern for all members of the group was what evidence to include in the portfolio. Some ANPs were able to obtain clinical data from the hospital information department as they had recordable clinical data, while others carried out procedures and were able to record these. However, collating recordable data alone did not demonstrate the level at which practitioners were performing, as most of this information only demonstrated the number of procedures or care episodes delivered. Those working in more supporting, rather than medically grounded, roles struggled to decide what evidence was appropriate.
The group found it difficult to decide on suitable evidence to show a level of practice. While the Scottish toolkit clearly sets out the “novice to expert” continuum, all the ANPs were very experienced and it was difficult to explain and demonstrate to others what made practice advanced. Having worked at this level for a long time, ANPs did not appreciate the level of know-ledge behind daily decision making that informed their practice. Most were “unconsciously competent” in their roles, and found it difficult to articulate what made their practice advanced. In addition, most nurses’ portfolios kept for the Nursing and Midwifery Council tended to contain certificates of formal training, study days and such like - most of us struggled to understand that these did not demonstrate a specific level of practice. Examining the marking grid for Master’s-level education helped with this process.
The group focused on obtaining evidence that demonstrated the actions taken regularly as a part of their roles. A key element was that the evidence would demonstrate safe practice, as governance was high on the health board agenda. Practice was therefore assessed using the health board’s risk matrix and the areas requiring formal competencies or protocols were identified.
Most of the work involved in collating portfolios involved the ANPs physically collating their evidence and organising it within the portfolio so others were able to easily read and digest it, resulting in their feeling reassured that the ANP was fit for practice at the advanced level. The evidence varied from signed-off protocols and assessments highlighting a level of clinical practice, to audits/contributions to strategic developments illustrating leadership and management elements of the role.
In June 2010 the group recognised that due to the diverse nature of ANP roles, we needed an academic to act as an external assessor to review the content so the portfolios could be recognised as universally valid. The aim was to ensure the portfolios contained Master’s-level actions and decision making in line with NLIAH recommendations that all ANPs be working at this level.
The health board co-opted a member of Swansea University’s faculty; throughout the summer the group met regularly and examined a range of documents and information including:
- The draft framework for Wales on advanced practice;
- The Scottish toolkit;
- 360-degree feedback;
- Clinical learning logs;
- Job planning;
During this period the academic member of the group suggested shifting towards more reflective evidence and excluding the robust competencies and protocols required to meet the governance element such as peer review of skills and risk assessment. However, the executive nursing team were concerned the revised portfolio did not meet the criteria for ensuring safe practice. We reverted to meeting as a nursing group without academic support with a view to focusing initially on the portfolio content required by the health board, and gaining academic validation at a later date. In hindsight this period highlighted the diverse opinions on what was required from a portfolio.
The health board portfolio guidance agreed by the group included a completed evidence matrix to help others decide what evidence was appropriate and relevant to demonstrate advanced practice. The evidence consisted of a number of documents; pieces of evidence could be used in more than one pillar. Commonly used documents included:
- Assessments of procedures (most of which were previously done by medical staff), signed off by a peer, including protocols (clinical pillar);
- Reflective accounts of particular incidents demonstrating the decision-making process, such as a critical incident and how the practitioner dealt with this, critical thinking skills, assessment and decision-making skills (clinical pillar);
- Anonymised clinic letters and referrals to other health professionals, and referrals such as GP letters from a clinic consultation recommending treatment/ alteration of treatment (clinical pillar);
- Anonymised copies of patient notes illustrating the care and decisions taken (clinical pillar);
- Formal competencies from specialist bodies and clinical assessments by a medical practitioner or other health professional (clinical pillar);
- Copies of national guidelines practitioners had been involved in (leadership pillar);
- Copies of audits/research that had been implemented and improved practice (research pillar);
- Annual reports indicating the purpose and effectiveness of the role and its value (leadership pillar);
- Copies of teaching programmes for staff/patients/others (education pillar);
- Case studies illustrating advanced knowledge and problem solving, as in Box 2 (clinical pillar).
Box 2 Case study
A 71-year-old woman presented in accident and emergency complaining of shortness of breath with chest pain over the past six weeks. Medical history included mechanical aortic valve replacement (taking warfarin), chronic obstructive pulmonary disease and hypertension. The patient was admitted for investigations.
On admission her international normalised ratio (INR) was 2.2, slightly below the desired therapeutic range of 2.5-3.5. The patient usually attended her surgery INR clinic and took 13mg of warfarin daily. The INR was generally stable.
No medication changes were made during the admission. On day four the patient’s INR was >10, warfarin was omitted and vitamin K given. The reason for the sudden rise in the INR was unknown. The anticoagulation advanced nurse practitioner was asked to speak to the patient to establish a cause for the high INR.
On extensive investigation no immediate cause was found, until the patient was asked if she ate the Welsh delicacy, laverbread (seaweed). Every Saturday evening since before her valve replacement, she ate 250g of laverbread for her tea. This Welsh treat, exceptionally high in vitamin K, had kept her INR steady for the past 10 years, until she came into hospital and did not have her usual Saturday tea.
The patient was asked to stop eating the laverbread until her INR was stabilised. She is now home on 6mg of warfarin daily with a stable INR - but, sadly, no more laverbread for tea.
Table 1 (attached) outlines what could be included in a portfolio for an ANP in endoscopy.
After the publication of the All Wales Framework (NLIAH, 2010) the executive nurse invited university staff to join the group to help with verification. Group members producing a portfolio also identified a workplace assessor to evaluate their evidence and validate their level of clinical practice. Due to the difficulties the original group had encountered when preparing their portfolios it was decided that all future ANPs would have an allocated “buddy” to help them to do this. Buddies would be ANPs who had already successfully completed the process.
In early 2012 five group members’ portfolios were successfully signed off and the health board decided that to be able to use the title “advanced practitioner” all ANPs must complete a portfolio, which must be verified by the group and the university. As a result of completing these portfolios the initial members have been able to use them to demonstrate to managers how their roles can support service change by:
- Reducing pressures in consultant outpatient clinics - using ANPs to review patients in clinic or using telephone consultations/letters;
- Taking on traditional medical procedures, making diagnoses and initiating treatment (the portfolio enables the health board to provide vicarious liability insurance);
- Initiating new service models as a result of audits/research - portfolios have raised the profile of the ANPs, who are now seen as a valuable resource;
- Using some portfolio work to demonstrate cross-boundary and cross-health board work at an external level;
- Replacing some medical staff with consultant nurses or ANPs to deliver work such as endoscopy and care of older people inpatient services.
In spring 2012 this process was rolled out across the health board and is now being used, evaluated and managed by the multidisciplinary workforce group. So far, 49 health professionals have gone through the process and been accredited as advanced level. A database identifies all recognised ANPs within the health board.
The workforce group continues to support the portfolio development and revalidation processes on an annual basis for practitioners on the advanced database, thereby continuing to comply with governance requirements. The work is being shared with all relevant interested parties across Wales as well as other areas of the UK.
The group is now examining the potential to roll out the portfolio structure to all registered nurses in the health board, which will hopefully enable practitioners from new registrants onwards to focus their education, skills and learning toward their chosen career pathway, and improve and enable succession planning.
Interestingly, the review of the use of the NLIAH (2013) framework for advanced practice illustrated that the exact number of ANPs working in Wales was still unknown and there was a huge variation between the findings across individual health boards; this is disappointing.
This process has been extremely challenging for all involved but particularly the original nurses because the “goal posts” shifted significantly throughout the process as alternative evidence and structures were repeatedly proposed.
The main difficulties for all practitioners concerned what evidence to include and what constituted advanced practice. Nurses are not generally encouraged to keep copies of complex cases indicating decision-making and judgement skills, and do not routinely participate in recorded case-based discussions unless working at specific levels and completing these alongside medical colleagues.
It was interesting to note how creative the group became in finding evidence relevant to the pillars: those who did not routinely use protocols or pathways often used reflective evidence based on an intervention or annotations from patient notes. All practitioners gained a sense of their own roles and the complexity of them; they also felt more comfortable that the health board was aware of their roles and able to fully support them from a governance perspective once the portfolio was accredited.
ANPs have seen a number of benefits to producing a portfolio, including a clear articulation of roles to non-clinical staff, regulation and protection of the public through clinical governance, ensuring vicarious liability and a demonstration of competence to reassure medical colleagues and other health professionals. It has also led to successful rebanding to a higher band of roles in some instances and protection of these jobs for future nurses.
We would recommend all ANPs consider producing a portfolio to support their roles in this way; they can also be used to support revalidation.
- Although advanced nursing practice has existed for decades there is no universally agreed definition
- Wide variations in roles and job titles make it difficult for patients to understand what they can expect from ANPs
- Effective clinical governance requires evidence from ANPs to demonstrate the advanced nature of their practice
- A portfolio tailored to ANPs’ needs can help them to define and collate this evidence
- Evidence clarifying the nature of advanced practice can increase understanding among both patients and other health professionals
Barton TD et al (2012) A governance framework for advanced practice. Nursing Times; 108: 25, 22-24.
Department of Health (2010) Advanced Level Nursing: A Position Statement. London: The Stationery Office.
Department of Health (2007) Trust, Assurance and Safety: The Regulation of Health Professionals in the 21st Century. London: Stationery Office.
National Leadership and Innovation Agency for Healthcare (2013) Review of the Utilisation of the NHS Wales Advanced Practice Framework. Cardiff: NLIAH.
National Leadership and Innovation Agency for Healthcare (2010) Framework for Advanced Nursing, Midwifery and Allied Health Professional Practice in Wales. Cardiff: NLIAH.
Scottish Government (2008) Supporting the Development of Advanced Nursing Practice: A Toolkit Approach. Edinburgh: Scottish Government.
Townsend A (2014) Patients’ views on a nurse-led prostate cancer clinic. Nursing Times; 110: 9, 22-23.