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Developments in advanced practice nursing roles: UK perspective
Dr Kim Manley CBE
Learning & Development Manager: Resources for Learning & Improving, Learning & Development Institute, RCN
Visiting Professor Bournemouth University
Overview Overview
Nursing Political context Modernising Nursing Careers NHS & RCN Career framework What is advanced practice? Competences
Value-addedness of nursing
Nursing is about:
caring values; focusing on relationships with individuals, groups and
populations; managing/facilitating the context of care; enabling co-ordination and continuity of care; using knowledge of patients as people with concepts and
implications of health and illness to inform assessment, interventions, evaluation, patient education and health promotion (Manley 2000).
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A conceptual framework for nursing expertise in the UK (Manley et al 2005)
Professional artistry
Holistic practice
knowledge
Knowing the patient/client
Moral agency
Saliency
Skilled know-how
Enabling factors
Two key parameters to expertise in nursing
• Developing EXPERTISE in all OTHER FUNCTIONS necessary for continuing to provide quality services –developing person-centred systems
• Developing EXPERTISE in the practice of nursing for a particular client group
LEARNING & DEVELOPMENT
• Personal and people development (Core 2)
• Learning and development (G1)
PERSON-CENTRED, EFFECTIVE & SAFE NURSING PRACTICE
• Assessment and care planning to meet health and wellbeing needs (HWB2)
• Promotion of health and wellbeing & prevention of adverse effects on health & wellbeing (HWB1)
• Protection of health and wellbeing (HWB3)
• Enablement to address health and wellbeing needs (HWB4)
• Assessment and treatment planning (HWB6)
• Provision of care to meet health and wellbeing needs (HWB5)
• Interventions and treatments (HWB7)
• Communication (Core 1)
• Health, safety, security (Core 3)
• Equity, diversity and rights (Core 6)
KNOWLEDGE & INFORMATION
• Information processing (IK1)
• Information collection and analysis (IK2)
• Knowledge and information resources (IK3)
MANAGING CARE & SERVICES
• Procurement and commissioning (G3)
• Financial Management(G4)
• Services and project management (G5)
• People management (G6)
• Capacity and capability (G7)
• Public relations & marketing (G8)
QUALITY, IMPROVEMENT,
INNOVATION
• Development and innovation (G2)
• Service improvement (Core 4) • Quality (Core 5)
Competences for Nursing (Based on KSF dimensions)
Political Context Consultation on Non Medical Regulation – Foster
Review
“Trust, Assurance and Safety – The regulation of health professionals in the 21st century ” (DH, 2007)
“The Government believes that existing professionals should be subject to a system of regulation that is proportionate to the risks and benefits entailed” (p81)
Supports UK wide standards for higher levels of practice for advanced practice in nursing, AHP’s and healthcare scientists
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Trust, Assurance and Safety: The Regulation of Health Professionals
“patient, public and professional confidence in the health professionals' watchdogs,
improving patient safety and ensuring the fair treatment of health professionals’. The key changes include:
standardising the level of advanced practice across health professions
measures to ensure healthcare professionals are revalidated throughout their career and remain up to date with clinical best practice.
Extending Regulation Group Existing roles e.g. clinical psychologists, health care support
workers New roles e.g. surgical care practitioners Advanced practice
Changing context in UK: Service competence frameworks
Competency frameworks for the service are being developed that identifies all the competences expected to be delivered by health care team
Staff groups then identify which competences relevant to them
Areas of overlap and flexibility Gaps in competency provision
– Advanced practitioner – Assistant practitioner
A High Quality Workforce: NHS Next Stage Review
National standards for advanced and autonomous roles
Towards A Framework for Post Registration Nursing Careers (MNC)
Consultation November 2008 Content, structured career approach,
defined levels and competencies 5 domains proposed Widespread support for standardising
an advanced level of practice Match patient need to numbers of
nurses at different levels
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Modernising Nursing Careers: Coming from Going towards First post in hospital
Early specialisation
Often no link between job titles and level of competence
Confusion and role overlap between generalists and specialists
First post in community or a mix of both
Pathway careers, built on portfolio of Competencies
Nationally recognised standards for post-registration practice, and job titles that denote the level and seniority of the holder
Clarity about the division between generalist and specialist roles in the workforce and how they complement each other
Moving from and to….. Cont.
Restricted career options
Preparation for higher levels of practice away from the workplace, in academic institutions
Career in NHS within traditional hierarchical structures
Opportunities to major in one pathway or sector, while attaining basic competencies across the spectrum
Modular programmes, underpinned by experiential learning
Careers spanning sectors, with opportunities for entrepreneurialism and self-employment
Towards A Framework For Post Registration Careers
The starting point
Develop clear career pathways for nurses from first registration through to advanced practice
Align nursing career pathways with the patient care pathway, health care needs for nursing expertise, and how health care services will be managed and delivered in the future
Modernising Nursing Careers: Post-registration pathways
Children, family and public health First contact, access and urgent care Supporting long term care Acute and critical care Mental Health and psychosocial care
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National Career Framework/RCN
RCN BENCHMARKS
Health care Assistants
Competent nurse
Experienced proficient nurse
Senior practitioner/Expert nurse
Consultant nurse
NATIONAL CAREER FRAMEWORK
Health Care Assistants (Level 4)
Practitioner (Level 5)
Senior practitioner/ Specialist practitioners (Level 6)
Advanced practitioners (Level 7)
Consultant practitioners (Level 8)
• General Practice settings, alongside GPs and Branch surgeries • PMS (Personal Medical Services) sites [GP-led or Nurse-led] • GMS contract • Practitioner with Special Interests • Partnership • Out of hours services • NHS Walk-in Centres • Homeless/refugees/asylum seekers & rural health care • Nurse-led initiatives eg Intermediate Care Facilities • “NP Limited” !
Building on NP developments : Primary Care
Examples : NPs in A&E/MIU’s, Night NPs, Out-reach critical care, Children’s NPs, NPs in cancer care, acute medicine, respiratory, urology, opthalmology etc etc
Stimulated by : • European Working Time Directive • Hospital at Night, Hospital at Day • Lack of continuity of patient care • Need for acute assessment units • Greater awareness of contribution of nursing ???
Building on NP developments : Secondary & Tertiary Care Clarity on advanced practice
A defined level of practice, not a role or job title A national and 4 country agreed standard A level of competence which can be measured in relation to
both: – direct patient/client care – systems of care
A transferable skills base Consistent with National, European & International literature A widely supported integrated toolkit (Scottish MNC) Terminology which is understood across health professions
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1. Assessment and Management of Patient health/illness status
2. The nurse-patient relationship
3. The education function
4. Professional role
5. Managing and negotiating health care delivery system
6. Monitoring and ensuring the quality of advanced health care practice
7. Cultural competence
Domains of Advanced Nurse Practitioner practice (NMC, 2005; RCN, 2008) RCN competences (2008)
Mapped to the KSF Linked to the NHS career framework Recognised by the NMC Linked to ICN Potential for use in other disciplines
“Advanced nurse practitioners are highly experienced, knowledgeable and educated members of the care
team who are able to diagnose and treat your health care needs or refer you to an appropriate specialist if
needed”
Further “ANP’s are highly skilled nurses who can :
• take a comprehensive patient history
• carry out physical/mental examinations
• use their expert knowledge and clinical judgement to identify the potential diagnosis
Definition of an Advanced Nurse Practitioner
“The Scope of Practice, Standards and Competencies of the Advanced Practice Nurse” (ICN, June 2008)
“The APN is a registered nurse who has acquired the expert knowledge base, complex decision-making skills and competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice” (ICN, 2002)
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Expert Practice
Specialist Practice
Generalist Practice
Novice Practice
Professional Accreditation
Advanced practice programmes in 10 Higher education institutes against 15 standards focussed specifically on assuring quality of provision and standards of practice for graduates of advanced practice programmes
Revalidation - ?RCNs role for future Establishing quality and standards unit
Resources and experience in individual accreditation against standards and competences
Use of e-portfolio to collect multiple sources of evidence against standards and competences with compatibility to e-KSF to enable professional and academic accreditation
Key messages Advanced practice is a level of practice not a role
Advanced practice needs to be linked to the quality agenda – Person-centred care – Effective and Safe care – Context of care to sustain these
Advanced practice is about developing expertise in a number of competences primarily around nursing practice with greater responsibility and autonomy in decision- making
Advanced practice is about developing expertise in the systems required to sustain quality systems
Consultant nurses are expected to have expertise in both advanced practice as well as in the systems to sustain quality
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Professional artistry as a kaleidoscope
RCN definition, competences and guidance (2002, updated 2008) www.rcn.org.uk
RCN accreditation of ANP programmes