Advanced level nursing in England: organisational challenges and opportunities

Authors


Abstract

Aim

To explore the background, activities and future development needs of advanced practice nurses within a large NHS Trust in England, allowing for a wider review of the current situation within the UK.

Background

There are currently no national requirements for advanced practice nursing within the UK, which has led to considerable variability in these roles. Recently, focus has been placed on local governance rather than regulation of advanced practice nursing. However, governance and coordinated workforce planning within the UK is in its infancy.

Methods

An electronic survey was sent to all nurses within one Trust identified as practising at an advanced level; a total of 136 responses were received.

Results

The survey identified considerable variation in titles, educational preparation and current activities even within similar roles. Some participants identified the need for more support in undertaking professional development activities.

Conclusions

The findings echo the wider picture within the UK, and point to the need to actively work on developing strategies for governance, education, and succession planning for advanced practice nursing.

Implications for nursing management

In the absence of national regulation, UK NHS Trusts should develop their own registers of advanced practice nurses in order to facilitate improved management, governance and workforce planning systems.

Introduction

In the past few decades, there has been increasing international interest in extending clinical nursing practice beyond the level of initial registration. The development of expanded roles for nurses has been spurred by many factors, including medical staff shortages, changing population needs and nurses’ desire to further advance their careers (Sheer & Wong 2008). Examples of such expanded roles include that of clinical nurse specialist (CNS) and nurse practitioner (NP). While often differing in their focus and activities, such roles are included within the umbrella term of advanced practice nursing (APN), denoting the higher level of nursing at which they practise. Globally, the picture of APN is one of diversity, where roles have evolved to fit the needs and environment of the country, with recognition, educational and regulatory requirements varying considerably (Ketefian et al. 2001, Schober & Affara 2006).

Although debate continues as to the nature of APN, the broad and flexible definition posed by the International Council of Nurses (ICN) is readily accepted worldwide. This definition acknowledges the importance of context while emphasising that all those in APN roles should be experts in clinical practice, with knowledge grounded in both theory and experience. It also emphasises the importance of Masters level study. The ICN define an advanced practice nurse as:

‘A registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for advanced practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed. A Masters degree is recommended for entry level’.

(ICN 2008)

The ICN definition acknowledges the importance of context in shaping the characteristics of advanced nursing. This paper will focus on a specific national context (England) in order to explore the challenges and opportunities health care organisations face in realising the potential of the APN contribution.

Background

A systematic review of 42 empirical studies (Jokiniemi et al. 2012) identified the following role domains as characteristic of APN: advanced clinical practice, practice development, education, research, consultation and administration. Although the focus of the role can vary among APNs, Jokiniemi et al. (2012) observed a consensus that advanced clinical practice is the central domain, with educational preparation at Masters level. However, despite the convergence in the international literature on the role domains and attributes of the APN, there remains much variation in role titles and recognition. For example, the inclusion of ‘nurse midwife’ as a recognised advanced practice role in the USA contrasts with the way in which midwifery is regulated and practised in many other countries (Dowling et al. 2013).

Despite an extensive international literature concerning the concept, definitions and nature of advanced nursing practice, there is relatively little information on what advanced practice nurses in the UK are actually doing in their day-to-day work activities. While many countries such as the USA, and more recently Australia, have formal recognition and regulation for a variety of discrete APN roles (Sheer & Wong 2008), UK requirements for APN have remained flexible and permissive. Despite considerable lobbying by the Nursing and Midwifery Council, an influential 2009 report on professional regulation in the UK concluded that advanced practice could be embraced within the scope of initial registration and additional regulation was not required (Council for Healthcare Regulatory Excellence 2009).

It has been argued that such a permissive approach bolsters innovation and encourages expanded roles responsive to local service needs (McGee 2009). However, with no national oversight or required standards guiding the development of APN, roles have emerged in an unplanned and ad hoc manner (Por 2008). Notably, one large descriptive survey of nurses in advanced practice roles across the UK (Ball 2005) identified considerable variation in activities undertaken and educational and training backgrounds, even within similar roles. For example, while Masters degrees are generally recognised to be a minimum standard for APN (International Council of Nurses 2008), there is no required level or type of advanced study for those in APN roles (Por 2008). Indeed Ball (2005) found that only 15% of respondents within the UK held a higher degree at that time (Masters or PhD).

In the absence of national regulation of APN, the UK focus has shifted to an increased emphasis on local governance and personal accountability (Barton et al. 2012a,b). However, the health departments of Scotland, Wales and England have all released publications designed to guide the development and management of APN roles at the local level, albeit in the form of recommendations rather than requirements (Scottish Government 2008, Department of Health 2010, National Leadership an Innovation Agency for Healthcare 2010). The three publications offer broad and flexible definitions of APN, describing it as a higher level of nursing rather than any specific role or extended skills set, while also emphasising the need for a more coordinated approach to developing and managing roles.

Despite this national guidance there is, as yet, little published literature available on the topic of governance of APN in the UK. Barton et al. (2012a) describe how one National Health Service (NHS) Trust (an NHS Trust is a group of hospital and/or community services forming a corporate unit) in Wales implemented a robust governance framework to guide APN. This was important because the diversity of roles, unplanned development and varied levels of education and abilities within that Trust meant that governance at an employer level was essential – their concern was over practitioners who were not aware they lacked competence to practise. Another Trust in Manchester, England, UK, developed a workforce project in conjunction with higher education institutions, creating a strategic, planned approach to developing, supporting and training people for new APN roles. Their overarching goal was to make sure that there were enough of, and the right type of staff to address local development needs, though they focused more on the training and implementation process and evaluation of impact rather than governance of the roles (Acton Shapiro 2009, Neville & Swift 2012). However, data from other regions is lacking. Insight is needed into the challenges and opportunities facing health care organisations across the UK and it is to this need for empirical evidence that this paper is directed.

Methods

Study design

Because of the unregulated nature of APN in the UK, it is hard to know who the advanced level nurses actually are, what they do or what they need. One large NHS Trust within the East Midlands region of the UK recognised the need for more detailed information, and so convened a working group, made up of Trust and higher education institution (HEI) representatives, to evaluate the background and development needs of advanced level nurses working within the organisation.

As there was little information available on the current state of APN within the Trust, a cross-sectional, descriptive survey was identified as the most appropriate method for initial scoping. In the form of questionnaires, surveys can reach large numbers of nurses, allowing for a broad understanding of the issues at hand (Gillis & Jackson 2002). It was also concluded that an electronic survey would be the most appropriate way to reach respondents, as e-mail addresses of staff were readily accessible via the Trust intranet (Polit & Beck 2010).

A questionnaire was developed based on contemporary literature concerning ANP (Ketefian et al. 2001, Hinchliff & Rogers 2008) and drawing on a previous Royal College of Nursing survey (Ball 2005). The survey was first piloted with a small group of APNs within the Trust and revisions made accordingly, thus enhancing validity. The final version of the questionnaire encompassed three sections: the nurses’ educational and professional background (nine questions), the activities that they undertake within their roles (three questions) and two further open-ended questions related to their achievements and future development needs. Reliability of the instrument has not been tested, but a similar approach was used by Ball (2005).

Ethical considerations

Following discussion with the Trust's Research and Development Department, it was agreed that the survey represented an evaluation of current practice and that approval from the local NHS Ethics Committee was not required. However, the ethical principles of beneficence and non-maleficence were carefully considered, as advised by Polit and Beck (2010). It is always sensitive to ask people about the nature of their work during a period of recession, as there is natural concern over what the information will be used for in a climate of cost-cutting. The survey was therefore reviewed by trade union representatives, who requested the removal of a question asking respondents to name their role title; it was considered that this question would compromise anonymity. This change was made and the survey was sent out with a covering e-mail explaining the purposes were related to training and development, and that all responses would remain anonymous. The e-mail explained that, while the researchers were part of a Trust working group, they were not in a managerial role and had no direct influence on Trust policy.

Participant selection

The first challenge encountered was that there was no Trust-wide directory of advanced level nurses working within the Trust, and so there was no immediate way of accessing the them. The matrons of each directorate were therefore contacted and a presentation about the project was given at the matron's meeting. Matrons were asked to personally identify those nurses they considered to be working as either clinical nurse specialists or advanced practice nurses within their directorate. This resulted in a list of 323 nurses across the Trust for whom staff e-mail addresses were obtained. As there are around 3500 nurses employed at the Trust, the portion the matrons considered to be working at an advanced level represents 10% of the total nursing workforce.

Recruitment, data collection and data analysis

The electronic survey was distributed via an e-mail link using the Trust intranet to the 323 nurses in January, 2012. The survey was sent out by one of the authors (KK), with a supporting message from the director of nursing. Initially, there was a brisk response but as the response rate dwindled after the second week, a reminder was sent out and the link to the survey e-mailed again. The survey finally closed after 1 month with 136 responses (42%). Although less than 50%, this response rate is relatively high compared with other electronic surveys of health care professionals (Braithwaite et al. 2003). Informal feedback has suggested that reasons for non-response included – as anticipated – a fear that the survey represented a hidden agenda around work-force change or job re-evaluation; in addition, that a number of potential respondents were on sick or maternity leave. Responses to the survey questions were downloaded and analysed using Microsoft Excel, and are reported using descriptive statistics.

Results

Who are the advanced practice nurses?

During the initial sample selection, the lists obtained from the matrons indicated that the advanced practice nurses had a wide variety of titles and roles. However, because of the unique nature of these roles it was not possible to identify job titles within the survey, as that would have compromised anonymity of the respondents. Therefore, following Ball (2005), participants were asked to place themselves within a recognised APN role category: advanced nurse practitioner (ANP), clinical nurse specialist (CNS), nurse practitioner (NP), nurse consultant (NC), or to describe themselves as ‘other’. The results (Table 1) indicate that the largest proportion (68%) of respondents self-identified as a CNS (n = 93). This percentage was checked against the mailing list of 323 nurses and was found to be consistent with the proportion of CNS titles in the wider group.

Table 1. Background of respondents (n = 136)
  n %
  1. n/a, not applicable.

  2. a

    Responses add up to more than 136 as some respondents achieved more than one qualification (total number of responses = 156).

Role
Advanced nurse practitioner54
Clinical nurse specialist9368
Nurse consultant21
Nurse practitioner1713
Other1914
‘Agenda for Change’ pay band
Band 511
Band 65238
Band 77253
Band 8107
Missing response11
Years in current role
1–34332
3–52115
5 or more7253
Educational qualifications achieved since initial registration
Post-registration diploma42n/a
Bachelor degree72n/a
Postgraduate certificate19n/a
Masters degree23an/a
Nature of the team within which the respondent works
Multidisciplinary team9973
Nursing team2619
Medical team107
Missing response11

Owing to the anonymity of the survey it was not possible to identify the titles of those nurses who opted for the ‘other’ category. However, informal verbal feedback suggests that this category included advisors, matrons, outreach nurses and assessment nurses.

Table 1 also reports on the pay bands at which the respondents were working. The greatest number were working at the UK Agenda for Change pay band seven (53%, n = 72), with one at band five (initial registration level, around £24 000 per annum) and 10 at band eight (from £40 000–£80 000 per annum, depending on responsibility and experience). Advanced practice nursing roles within the UK are generally associated with pay bands six, seven and eight (i.e. advanced practice nurses can expect to earn anything from £26 000 to £80 000 per annum).

The nurses who responded were experienced, with only two respondents having been qualified as a nurse for less than 5 years, and with 99% having been qualified for 5 years or more (n = 133). When asked how long they had been working within their current APN role, it was clear that the majority of respondents were experienced in working at an advanced level (Table 1). It was found that 53% had worked within their current role for more than 5 years (n = 72). However, there was also evidence of APN roles developing across the Trust, with 32% of respondents (n = 43) having been in their APN post for less than 3 years.

While only 12% of respondents (n = 16) completed their pre-registration education at degree level, Table 1 shows that a further 53% had undertaken a bachelor's degree since qualifying (n = 72), 14% had a postgraduate certificate (n = 19) and 17% had a Masters degree (n = 23). As it cannot be guaranteed that all respondents understood the terms ‘post registration diploma’ and ‘postgraduate certificate’, it is probably safest to observe that 65% of respondents (n = 88) held a bachelor's degree and 17% a Masters, noting that these cannot be aggregated as most Masters graduates are likely to have ticked both boxes. A further 10 respondents (7%) reported that they were working towards a Masters, including five of the NPs.

Finally, respondents were asked to identify the nature of the team within which they work: 73% (n = 99) stated that they worked within multidisciplinary teams, 19% (n = 26) within a nursing team and 7% (n = 10) within a medical team (Table 1).

What do the advanced practice nurses do?

According to the literature on advanced practice nursing, UK APN roles often include elements of expert practice, education, research and consultancy (Manley 1997, Ball 2005). Following the pilot study, these categories were expanded to incorporate a broader range of activities. Participants were asked to estimate the overall percentage of time over the past month that they had spent working on these various activities, aggregated to 100% total (Table 2). ‘Education’ refers to teaching students and colleagues, while continuing professional development (CPD) activities are included within ‘scholarship’. While there was variation between the roles, it is clear that clinical practice was the most important category of activity at 67%, with NPs reporting spending the greatest amount of time in direct practice (75%) and NCs the least (45%). Overall, only 3% of the nurses’ time was spent on research activities, with only NCs spending any appreciable amount of time in that area (13%).

Table 2. Estimated time spent on work activities each month
ActivityEstimated time (%)
Clinical practice (working with patients)67
Management and administration (e.g. completing documentation, attending meetings)15
Education (teaching students and colleagues)7
Service development (e.g. working on Trust initiatives and change projects)4
Scholarship (your own formal or informal study, e.g. time spent on-line identifying evidence for practice, study days)4
Research (designing a study, collecting/analysing data, writing up, disseminating – either on your own or as part of a team)3

The survey then asked respondents to tick a box indicating the range of clinical activities they undertake in a typical month. Again, the options reflect activities identified within the literature as characteristic of APN roles (Ball 2005). The results are presented in descending order, with the most commonly undertaken clinical activities at the top of the list (Table 3). Nearly all respondents (99%, n = 135) reported undertaking the assessment of clients’ health care needs. However, less than one-quarter of the respondents regularly undertook independent prescribing. The three areas of clinical activity where the greatest differences were reported between ANPs/NPs and CNSs were: undertaking a comprehensive examination, ordering investigations and making a diagnosis (i.e. areas that traditionally fall within the remit of medical practitioners).

Table 3. Range of clinical activities undertaken
Clinical activity (respondents asked to tick all that apply) n %
Assess health care needs of patients/clients13599
Provide education/training to staff12290
Refer patients/clients to other health care providers12290
Develop plans of care in collaboration with patients/clients11988
See patients referred to you by another health care professional11685
Undertake health promotion/provide health education to patients/clients11484
Take a comprehensive history11081
Support people to enable them to manage/live with illness11081
Provide counselling to patients/clients10275
Admit/discharge patients from your caseload9973
Undertake specialist, ‘extended role’ procedures or interventions9771
Order clinical investigations9469
Coordinate and manage care programmes for individual patients/clients9167
Run a nurse-led clinic7656
Screen patients for disease risk factor or signs of illness7253
Undertake a comprehensive physical examination6548
Make diagnoses5540
Undertake independent prescribing3324
Undertake supplementary prescribing129

Survey respondents were then presented with an open-ended question asking them to describe any further activities they considered relevant to their role as an advanced practice nurse. Fifty three responses were received, illustrating that these nurses are making a considerable contribution to advancing practice at the local, regional and national levels. Such activities included: participating in national and regional clinical specialist groups (n = 15); producing educational resources and running teaching programmes (n = 10); publishing papers and book chapters; participating in Department of Health reviews; presenting at international conferences; providing consultancy to other Trusts and patient organisations; and developing clinical guidelines. Three respondents reported that they had received national awards in recognition of their work.

Training and development needs

Respondents were asked to elaborate on any further education or training needed to support them in their current role and future development. Eighty participants responded, with 77 identifying one or more training and development needs (Table 4). However, three participants stated that they had no particular needs (one was about to retire, one felt that medical colleagues kept her up to date and one suggested that her role was so specialist that no relevant study opportunities were available).

Table 4. Training and development
Self-identified training and development needsNumber of responses
Undertake an accredited educational programme: PhD (n = 1), Masters (n = 13), Bachelor (n = 3)17
Attend specialist modules and training courses [for example, advanced colonic polypectomy, psoriasis, genetics, liver virology, human immunodeficiency virus (HIV) course, reading chest X-rays, taking blood cultures]16
Secure study time and financial resources to attend study days, conferences and networking forums, and to maintain and develop clinical competence10
Complete a non-medical prescribing course9
Undergo training in history taking, clinical assessment and physical examination9
Undertake further development related to leadership and management (including learning about commissioning)6
Undertake training in counselling/advanced communication skills4
Obtain help to develop a career pathway (with clearer expectations of what is expected of different roles/grades)3
Receive support to present at conferences and publish3
Receive support to participate in research and audit2
Training in teaching and presentation skills1
Total80

The majority of respondents conveyed a desire for further formal or informal training related to their specialist clinical field or to generic advanced practice skills and competencies (for example, history taking and physical assessment; non-medical prescribing). Ten respondents reported needing more time and financial support, with two noting that it is difficult for them to undertake continuing professional development activities as their roles are unique and there is no-one to cover their absence. In addition to clinical education, respondents requested training in clinical leadership and management, counselling and communication skills. Several respondents expressed development needs in relation to research and publishing, reflecting a broad understanding of the nature of APN.

Discussion

In this survey of an English NHS Trust, the list of 323 nurses considered to be working at an advanced level by their matrons revealed a wide variety of job titles, activities in practice, educational backgrounds and job grades. This is similar to the findings of Ball (2005), and echoes the picture across England as a whole, reflecting the Department of Health (2010) observation that ‘there has been inconsistency in the how the term ‘advanced level practice’ has been applied to different nursing roles’. It can be argued that this ad hoc role development has made it difficult to develop clear governance or educational strategies after the fact, but in an absence of registration this is an important goal. The lack of a register of advanced nurses working in this Trust illustrates how difficult it is to even begin to introduce governance frameworks without a clear reference point as to who is, and who is not, an advanced level nurse.

While there were many similarities, our survey found variations within the clinical activities undertaken by respondents even when working under the same role title. For example, making a differential diagnosis is seen as a key element of the NP role in many of the national and international competency frameworks (International Council of Nurses 2008, Hinchcliff & Rogers 2008). Eleven of the 17 NP respondents replied that they make diagnoses, compared with all five of the (self-identified) ANPs. It is unclear from the survey whether this is because the NPs had not had the training, because they are not being given the opportunity to develop diagnostic skills or whether this is actually the point of distinction between NP and ANP roles (with implications for grade and pay). There were multiple replies from NPs in the free-text section expressing a desire to undertake advanced clinical skills training and prescribing certification, possibly signifying an area where increased access and support for training is needed. However, Acton Shapiro (2009) found that some NPs were unable to always work at an advanced level because of staffing problems, financial constraints, lack of defined purpose and organisational and managerial support. This meant that these nurses were not being used to their full extent and thus were unable to have as powerful an impact on practice as might be anticipated.

Although the majority of nurses had been in their (reportedly) APN roles for more than 5 years, the fact that 32% of respondents reported that they had been occupying their role for less than 3 years suggests that either opportunity for APN roles is expanding across the Trust or that nurses are progressing into these positions as they are vacated. As suggested by Currie (2010), succession planning should include mechanisms to identify and support junior nurses with the potential to progress into APN roles, within a transparent clinical career pathway.

Despite the importance afforded to research as an element of the APN role (Jokiniemi et al. 2012), the findings presented in Table 3 indicate that only 3% of respondents’ time was, on average, spent on research activities. This is consistent with Ball's (2005) survey, where research was the least frequent activity undertaken by those in APN roles. However, in the open-ended questions some respondents identified their desire to undertake more research as a part of their role, indicating a potential development need. Participants in Doerksen's (2010) survey also cited the research domain as the area where they needed the most development, expressing the need for formal and informal mentorship (especially in partnership with University staff), increased managerial support as well as protected time to both learn and undertake research.

It is interesting to note that, while debate is taking place in the USA as to whether a Doctorate in nursing practice should become the preferred level of preparation for advanced practice nursing (Dowling et al. 2013), this survey indicated that only 65% of respondents had a Bachelor's degree and 17% a Master's degree. This is consistent with the findings of Ball (2005), suggesting that this low percentage of Masters-prepared advanced practice nurses is likely to be reflected across England. Given that a Masters-level qualification is consistently agreed to be a minimum level for APN (International Council of Nurses 2008, Department of Health 2010), there is a need for consideration of strategic priorities in this area, in terms of both providing opportunity and support for nurses to undertake higher level of study as well as developing and modifying educational programmes to fit the needs of the context, which is important to ensure the future of these roles (Currie 2010). Barton et al. (2012b), Livesley et al. (2009) and Neville and Swift (2012) all emphasise the importance of collaborative partnerships between universities and employers, through the use of broad frameworks that allow for tailored learning programmes and work-based learning. A number of respondents in our study made a plea for protected time to update their knowledge and skills and to complete their degrees.

Conclusion

The survey adds to relatively small body of knowledge available on advanced level nursing in England, echoing Livesley et al. (2009) that there is a ‘degree of confusion at policy, practice and professional levels’. Unlike much of the UK literature on APN that describes innovative approaches (Livesley et al. 2009, Barton et al. 2012b, Neville & Swift 2012), this study was carried out before any coordinated or strategic action at Trust (or regional) level, and highlights the challenges the Trust will face in bringing order to this aspect of its governance. This survey has confirmed again that there is still considerable variability in activities in practice, titles and educational backgrounds of advanced practice nurses even within one NHS organisation, which is likely to be consistent with the wider picture in England. Further research is needed to identify whether the Department of Health's (2010) position statement on advanced level nursing is sufficiently robust to guide and support English NHS Trusts.

Implications for nursing management

The response rate of 42% suggests that the findings of this survey should be interpreted with caution, as the characteristics of those participants who responded to the survey may differ from those who did not respond (Polit & Beck 2010). An initial difficulty was that Trust matrons had to personally identify nurses they considered to be working at an advanced level, implying there might have been advanced level nurses who were missed or some who were improperly included. However, as there are no local, regional or national registers of advanced practice nurses, or even any agreed definition of what constitutes APN, identification of a sample was difficult and this method was deemed the most appropriate.

In order to take a more strategic approach to maximise the contribution of advanced level nurses, and in the absence of national regulation, all English NHS Trusts should consider drawing up their own registers of advanced practice nurses. Such a register would help to establish a clear sense of the scope, activities, educational requirements and titles underpinning local APN roles. In turn, this would positively influence Trust governance and workforce planning. The local register should map to the Department of Health (2010) position statement on advanced level nursing and other relevant national and international frameworks, supporting the transferability of advanced level nurses’ experience and qualifications.

With respect to the findings of this survey, such an approach may well lead to the narrowing of the entry gate for what is considered to be advanced level practice. The enforcing of criteria such as being Masters-prepared and/or undertaking clinical activities such as caseload management or independent prescribing might lead to a considerable reduction in those considered to be practising at an advanced level within the Trust. This approach would have implications for both education and human resource management, but would bring this English Trust closer to what is happening in Wales and Scotland, where examples of coherent, strategic frameworks for advanced practice are beginning to emerge (for example, NHS Lanarkshire 2012). However, such an exercise is potentially challenging to health care organisations, as it will mean a review of job descriptions and pay bands with implications for human resource management.

Dowling et al. (2013) note that ‘of all the advanced practice roles in nursing and midwifery, the role of the CNS is most unclear’. Given the increasing linkage of the advanced level of practice to the extended and expanded roles undertaken by NPs, the 68% of respondents self-identifying as CNSs in this survey may also find themselves the most vulnerable to losing recognition as advanced practice nurses within the organisation, as might the 38.5% of respondents currently working at Agenda for Change Band 6 (Band 7 is generally recognised at the minimum grade for advanced practitioners).

Acknowledgements

The authors thank all members of the Advanced Practice Steering Group of the participating NHS Trust.

Source of funding

This study was internally funded by the participating NHS Trust.

Ethical approval

This study was reviewed and approved by the NHS Trust's Research and Development Department.

Ancillary