There are several key definitions of advanced practice within the context of nursing. The International Council of Nurses (ICN) defines the role specific to nursing as the advanced practice nurse (APN). An APN is ‘a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical 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, 2021). The Royal College of Nursing (RCN) (2021) defines advanced practice as a level of practice, rather than a role, type, or specialty of practice. Advanced practitioners are educated at master's level in advanced practice and are assessed as competent in practice, using expert knowledge and skills. They have the freedom and authority to act, making autonomous decisions in the assessment, diagnosis and treatment of patients. Health Education England (HEE) (2017) has a similar definition and identifies advanced clinical practice as provided by experienced, registered health and care practitioners. It is a level of practice characterised by a high degree of autonomy and complex decision-making. This is underpinned by a master's level award or equivalent that encompasses the four pillars of clinical practice—leadership, management, education and research—with demonstration of core capabilities and area-specific clinical competence. In addition, advanced clinical practice embodies the ability to manage clinical care in partnership with individuals, families, and carers.
Although key organisations suggest advanced clinical practitioners (ACPs) should be educated to master's level or equivalent, not all advanced level practitioners in England hold a master's; therefore, employing organisations must ensure that they have achieved this level of practice through experience and expertise. The need for master's level education is advised, but it is not mandated, nor is ‘ACP’ a qualification that can be registered with a professional body; it has yet to be made a legally protected title that requires professional registration.
The most contemporary framework for advanced clinical practice within the UK encompasses an inclusive interprofessional model of care to maximise effective and safe patient care. This was created by HEE in 2017, in partnership with NHS Improvement and NHS England, and includes a national definition and standards to underpin the multiprofessional advanced level of practice.
The NHS Long Term Plan
The NHS Long Term Plan (NHS England, 2019) highlights how advanced clinical practice is central to helping transform service delivery and better meet local health needs by providing enhanced capacity, capability, productivity and efficiency within multi-professional teams. Developing advanced clinical practice roles, as well as the level of practice just below and above ACP level, should be considered a key component of contemporary workforce planning, as described in the NHS Long Term Plan (NHS England, 2019).
Personalised care is one of the five major practical changes to the NHS that will take place over the next 5 years, as set out in the NHS Long Term Plan (NHS England, 2019). Personalised care means people have choice and control over the way their care is planned and delivered. In accordance with this change, the word ‘patient’ has not been used throughout the framework and has been replaced with person/people as appropriate. The ACP (primary care nurse) can create the opportunity for people to collaborate and be involved in their own health and care, if that is what is important to them at that moment (HEE et al, 2020).
The importance of advanced clinical practice in primary care
Primary care and general practice are continually evolving to meet the increasing and more complex needs of local communities and their populations. This requires new ways of working and the investment and development of multi-professional general practice and primary care teams. ACP (primary care nurse) roles, within general practice and primary care, have so far developed within the UK without a set standard, which has led to varying levels of attainment, resulting in much disparity. This has created confusion for employers, fellow healthcare staff and patients because of variation in titles, qualifications, and competency (HEE et al, 2020).
Recent research by Evans et al (2020) highlighted that primary care in the UK has traditionally been heavily dependent upon GPs, medical doctors who work on their own or in groups/hubs referred to as ‘practices’ or ‘general practices’. GPs operate as businesses and can either be partners in a practice or salaried employees. Primary care services are commissioned from a practice by geographically based clinical commissioning groups (CCGs) funded by the NHS (Evans et al, 2020). The structure and organisation of practices can be variable. At the minimum, most employ nursing staff (eg practice nurses, nurse practitioners or advanced nurse practitioners) and ancillary staff (eg phlebotomists or healthcare assistants), as well as receptionists and a practice manager (PM). GP practices link with a wide range of other primary care services (eg dental, pharmacy, physiotherapy, podiatry, audiology) to provide comprehensive services to their local populations. In some settings (especially cities), in addition to services delivered through GP practices, primary care is also available through a system of ‘walk-in’ centres, family planning/sexual health clinics or out-of-hours urgent care centres.
Regardless of the service mode, for patients, primary care is free at the point of delivery. The increasing demand on health services and continued financial constraints mean that it has never been more important to have educated and competent staff delivering the best care possible. Therefore, it has been recognised that the changing landscapes of both the NHS and the private sector require an advancing level of practice extending beyond initial registration (RCN, 2018).
The advanced practice nurse within community care
An APN will demonstrate courageous and critical thinking and must be a caring, compassionate and committed experienced nurse who, acting within their professional boundaries, will provide care for the presenting patient from initial history-taking through to clinical assessment, diagnosis, treatment, and evaluation of care. They will demonstrate safe, competent clinical decision-making and expert care, including assessment and diagnostic skills, for patients within the general practice. An APN will commit to demonstrating critical thinking in the safe clinical decision-making process. They will communicate and work collaboratively with the general practice team to meet the needs of patients, supporting the delivery of policy and procedures, and providing nurse leadership. The APN role is an advanced and autonomous role; therefore, HEE recommends that this role is considered equivalent to Band 8A on the Agenda for Change scale, with a salary range for 2021 being between £47 126 and £53 219.
The key responsibilities of primary care APNs include clinical practice, research, education and leadership. They must have an autonomous level of clinical practice, advanced communication skills, the ability to deliver a quality service, be a team player, and manage risk. Some of the key clinical responsibilities are listed below:
- Assess, diagnose, plan, implement and evaluate treatment/interventions and care for patients presenting with an undifferentiated diagnosis
- Clinically examine and assess patient needs from a physiological and psychological perspective, and plan clinical care accordingly
- Assess, diagnosis, plan, implement and evaluate interventions/treatments for patients with complex needs
- Proactively identify, diagnose and manage treatment plans for patients at risk of developing a long-term condition (as appropriate)
- Diagnose and manage both acute and chronic conditions, integrating both drug- and non-drug-based treatment methods into a management plan
- Prescribe and review medication for therapeutic effectiveness, appropriate to patient needs and in accordance with evidence-based practice and national and practice protocols, and within scope of practice
- Work with patients to support compliance with and adherence to prescribed treatments
- Provide information and advice on prescribed or over-the-counter medication on medication regimens, side effects and interactions
- Prioritise health problems and intervene appropriately to assist the patient in complex, urgent or emergency situations, including initiation of effective emergency care
- Support patients to adopt health promotion strategies that promote healthy lifestyles, and apply principles of self-care.
Opportunities for advanced practice nurses in community care
There are multiple role opportunities for APNs working within primary care, particularly with the emerging national developments currently taking place via HEE. Multiple credentialing pathways are under development that potentially open the doors to APNs as first-contact practitioners. This work builds upon the existing scope of practice of APNs, which includes:
- Clinical assessment of patients presenting with undifferentiated and undiagnosed conditions
- Prescribing medications for any condition within their scope of practice (on completion of an NMC-approved non-medical prescribing course)
- Referral of patients to secondary care (varies depending on local arrangements)
- Undertaking home visits
- Facilitating and leading specialist clinics.
Advanced nursing practitioners and the care of pregnant women in the community setting
The NMC states that only a registered medical practitioner or a practising midwife can provide assessments and pregnancy related care for a pregnant woman. ANPs in general practice settings may find themselves being asked to provide care for non-pregnancy-related conditions that may have an impact on the pregnancy or be called on to provide care in an emergency. Clear referral pathways must be in place for such scenarios. Should the ANP also be a registered practicing midwife, they will be able to care for pregnant women if they continue to meet the NMC requirements. These include notifying their intention to practice and maintaining the NMC revalidation requirements for midwifery (Care Quality Commission (CQC), 2021).
Medical indemnity for advanced nursing practitioners in the community setting
All nurses must have adequate medical indemnity as part of the need to re-register with the NMC. The NHS operate the Clinical Negligence Scheme for General Practice (CNSGP) (CQC, 2021). This is a state indemnity scheme for general practice in England. It covers clinical negligence liabilities in general practice relating to incidents on or after 1 April 2019. All providers of NHS primary medical services are covered under the CNSGP. The scheme extends to all GPs and others working for general practice who carry out activities delivering primary medical services.
Frameworks for advanced practice nurses working in primary care
Scotland was the first country in the UK to produce a structured toolkit, giving APNs an identity through a defined role (Scottish Government, 2008), and was followed by Wales, which produced its own framework (National Leadership and Innovation Agency for Healthcare, 2012). In November 2010, the DH released a position statement on advanced level nursing that provided a benchmark for enhancing patient safety and delivering high-quality care by supporting local governance, assisting in good employment practices, and encouraging consistency in the development of roles (Department of Health and Social Care (DHSC), (2010). Another important proposal for additional roles and responsibilities was published by the Council for Healthcare Regulatory Excellence (CHRE) (2009). However, it seemed that government strategies to support APNs had not been publicised or applied throughout the NHS. According to the RCN (2012), Scotland and Wales had implemented the role successfully, giving Scottish and Welsh APNs a recognised professional identity much earlier on, but implementation in England had been less effective.
In 2020, NHS England, the GPN Ten Point Plan Team and HEE commissioned the development of the Advanced Clinical Practice (Nurses) Working in General Practice/Primary Care in England framework (HEE et al, 2020). The framework enables commissioners of services to specify minimum standards for ACP (primary care nurse) employment. It sets out clear expectations about what the ACP (primary care nurse) can do, recognising that the ACP (primary care nurse) has the knowledge and skills to be flexible in their approach and work autonomously to provide evidence-based care for people. This framework will facilitate the inclusion of the advanced care professional (ACP) (primary care nurse) into workforce plans, such as those formulated by CCGs, Strategic Workforce Improvement Groups (SWiG), Sustainability and Transformation Plans (STP), Integrated Care Systems (ICS) and Primary Care Networks (PCNs). Other organisations involved in the care of people will understand the ACP (primary care nurse) level of practice, which will facilitate allowing direct referrals, requesting further investigations (such as imaging, etc). The capabilities support the development and planning of the workforce to meet local population need and support a common understanding and expectation of the ACP (primary care nurse) operating at this level of practice, to facilitate the development and mobility of this workforce. It will allow service commissioners to understand the value of the ACP (primary care nurse) in leading/working within and across multiprofessional teams to deliver the best outcomes for people. Within the framework, four key domains (Figure 1) and 13 capabilities (Box 1) are listed. Within the first appendix of the framework, there are core clinical skills, core indicative knowledge, key clinical presentations, investigations, and referrals that are contextualised in a holistic and patient-centred way. An exemplar of one of the core system-based competencies can be seen in Table 1.
Box 1.Domains and capabilitiesDomain A. Person-centred collaborative workingCapability 1. Communication and consultation skillsCapability 2. Practising holistically to personalise care and promote public and person healthCapability 3. Working with colleagues and in teamsCapability 4. Maintaining an ethical approach and fitness to practiceDomain B. Assessment, investigations, and diagnosisCapability 5. Information gathering and interpretationCapability 6. Clinical examination and procedural skillsCapability 7. Making a diagnosisDomain C. Condition management, treatment, and preventionCapability 8. Clinical managementCapability 9. Managing medical and clinical complexityCapability 10. Independent prescribing and pharmacotherapyDomain D. Leadership and management, education, and researchCapability 11. Leadership, management, and organisationCapability 12. Education and developmentCapability 13. Research and evidence-based practice
Table 1. Example of the respiratory core clinical skill
Respiratory system:
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| Core clinical skills | Indicative presentations | Key clinical investigations/referrals (may include but not be limited to) |
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Opportunities and benefits of advanced practice nurses in community care
A Cochrane review by Laurant et al (2018) explored nurses as a ‘substitute’ for doctors within primary care. However, caution is advised when rationalising the introduction and development of advanced practice roles to resemble that of medical substitution. Advanced practice roles complement existing medical models and are not designed to replace them. Although Laurant et al's (2019) review commented that the nursing level was often unclear or varied between studies, several important themes emerged:
- Similar or better health outcomes for a broad range of patient conditions were achieved in nurse-led settings
- Nurse-led primary care may lead to slightly fewer deaths among certain groups of patients
- Certain disease outcomes are slightly improved in nurse-led settings
- Patient satisfaction is higher
- Nurse-led primary care achieves equal or better health outcomes for patients.
A more recent systematic review by Htay and Whitehead (2021) identified 13 international randomised-controlled trials concerning the effectiveness of the role of advanced nurse practitioners, compared to physician-led, within primary care and hospital settings involving both paediatric and adult patients. Five of said papers were included in Laurant et al's (2019) review. Several of the papers papers (n=6) featured within Htay and Whitehead's (2021) review focused upon primary and community-based care settings in which ANPs were practising. Of those six papers identified, the majority (n=4) were deemed to be of high to moderate quality as per the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria. Themes identified within the papers that concerned primary and community-based care included:
- Advanced nurse practitioners demonstrated greater adherence to recommended targets and practical guidelines
- Advanced nurse practitioners led to positive effects on patient care and service outcomes, including symptom severity
- Improved physical function
- Improved patient satisfaction
- Improved patient satisfaction.
Conclusion
Defining advanced level practice is not easy, but it is now evident that professional bodies are more composed in their definitions than ever before. There is a great deal of literature on the evolving APN role, the changing context of UK healthcare systems and advanced level nursing's contribution to effective and autonomous healthcare delivery. Advanced practice nurses within the community setting now have established job summaries and a recommend Band 8a salary, mapped to the independent and advanced skills sets of autonomous practitioners. Many opportunities now exist within the community setting to evolve patient care and ensure patients have the right support from the right professional at the right time.
Nevertheless, there remains a lack of consistency in titles, role definitions, and scope of practice, particularly in England. The identity and scope of the nursing role has evolved over the years, from following doctors' orders and delivering task-oriented care to acting as degree-educated, autonomous and evidence-based clinical practitioners. The evolution of the APN is supported by the RCN's credentialing programme, new and emerging frameworks and existing collaborative frameworks such as advanced level practice MDT frameworks by HEE, as well as the promotion of APN roles in government strategies and policies. Advanced practice frameworks now have clinical competencies that are linked within CPD educational programmes at master's level, making clarity and uniformity much more established moving forward. With these strategies and support in place, the APN identity will consolidate, and the role will become central to the delivery of holistic, patient-focused and high-quality care in the primary care setting, and to the achievement of healthcare-related organisational targets, such as reducing hospital admissions, length of stay and, most importantly, safe patient care.
Key points
- Nurses working at an advanced level can be employed in roles such as the advanced nursing practitioner. If working in the community care setting, they must show capability against the Core Capabilities Framework for Advanced Clinical Practice (Nurses) Working in General Practice/Primary Care in England
- Health and care professionals working at an advanced clinical practice level will be able to evidence the underpinning competencies, skills, and behaviours applicable to the specialty or health and care setting and job role they are working within
- Advanced level practitioners can demonstrate expertise and professional judgement to achieve set capabilities in areas that include diagnostics and therapeutics, enhanced skills in consultation, critical thinking and clinical decision-making, and the leadership they demonstrate within their teams.
CPD reflective questions
- Are you working within an advanced practice nursing role in the community setting? If so, how do you define your role?
- If you are employed by the NHS as an advanced level practitioner in the community setting, what actions have you and your employing organisation taken to recognise and action the NHS Long Term Plan?
- As an advanced level practitioner in the community setting, are you aware of the named domains, capabilities, and core clinical skills as identified in this article? Take some time out to look at the competency document and identify a SWOT analysis and action plan to develop clinical compentcies (if appropriate).