The evolution of advanced nursing practice: past, present ...

1 Copyright EMAP Publishing 2019. This article is not for distribution except for journal club use Clinical Practice Keywords advanced nursing practice/. Regulation/ nursing roles Discussion advanced practice This article has been double-blind peer reviewed In this How advanced practice has developed in healthcare Persistent perception of advanced practice nursing as a replacement for doctors The continuing absence of a regulatory framework in the UK for advanced care roles The evolution of advanced nursing practice: past , present and future Key points Authors Alison Leary is professor of healthcare and workforce modelling, London The development South Bank University and University of South-Eastern Norway; Katrina MacLaine is of advanced associate professor of advanced practice and course director, London South Bank practice in the UK University, and chair, Association of advanced Practice Educators.

2 Was pioneered in the 1970s Abstract advanced nursing practice in the UK was pioneered in the 1970s. advanced nursing roles have grown but the UK lacks a regulatory framework to define In contrast with advanced practice and the education it requires; this has led to confusion as to what other countries, advanced nursing practice comprises, and has implications for patient safety. All four the UK lacks a UK countries are developing or have developed frameworks for advanced practice, regulatory which should help ensure patients, professionals and healthcare providers benefit framework for from the potential contribution of advanced nurse practitioners.

3 advanced practice roles Citation Leary A, MacLaine K (2019) The evolution of advanced nursing practice: past , present and future. nursing Times [online]; 115: 10, 18-19. Studies show, in M. terms of safety, quality and ahase (2019) described junior Despite subsequent international and efficiency, doctors' concerns about the UK definitions of advanced nursing prac- advanced -practice growth of medical associate tice, variation in the understanding of nurses are of great professionals (MAPs), for such roles remains, causing ongoing con- benefit to patients example physician associates.

4 Although fusion (Leary et al, 2017). In addition, over and services there was some confusion in the reported the past decade, the concept of advanced debate about MAPs and advanced practi- clinical practice has expanded beyond Without a regulatory tioners, recent developments have made nurses in all four countries of the UK to framework and a this confusion and occasional resentment, include allied health professionals. While protected title there unsurprising. Junior doctors debating the this does much to demonstrate the impor- is no protection for issue cited situations in which other work- tance of recognising advanced practice as a the public forces were competing with or replacing level of care with common core character- them, denying junior doctors training istics across professions, it has added to advanced practice opportunities or risking patient safety.

5 The complexity surrounding this subject. is often seen as a There is a long history of advanced solution to the Development of advanced nursing practice in other countries. In the shortage of doctors, nursing practice US, it has been in existence for several years neglecting the other Depending on how advanced ' is defined, but expanded under President Obama's valuable aspects of the roots of advanced nursing practice can Affordable Care Act ( practice be traced back over a century. For many, its CareAct). There was a perception that development in the UK was pioneered by advanced nursing practice was a medical Barbara Stilwell, who led the establishment role replacement (Coombes, 2008) but, of the first advanced nursing practice course generally, the role is now accepted.

6 In 1990 at the Royal College of nursing Insti- Recent legislative changes have seen the tute. Manley (1997) gave further formal defi- role thrive as it offers an affordable, well- nition of the role and level of practice. evaluated healthcare option. In the US, an nursing Times [online] October 2019 / Vol 115 Issue 10 18 Copyright EMAP Publishing 2019. This article is not for distribution except for journal club use Clinical Practice Discussion educational and regulatory framework is less value. As a result, activities associated The misuse of titles such as advanced administered by the American Association with medicine seem to have higher status.

7 Nurse practitioner' by employers who do of Nurse Practitioners; it aims to protect Thinking of advanced practice in this not require staff with that title to have any the public and the role, and gives it a way also reinforces the concept that there is underpinning education or assessment of clearer identity. Other countries, such as a simple hierarchy of skills with an associ- clinical competence has serious implica- Australia, have a similar set-up but the UK ated hierarchy of value. It leads to task tions for public protection.

8 This is unlikely lacks such a framework. There is now guid- shifting' from medicine to other professions to be addressed without regulation. The ance from Health Education England but does not articulate the added value nursing and Midwifery Council's recent ( ) but no regula- offered by these professions. Employers and decision to look at the post-qualification tory or legal framework for advanced prac- policy makers then start to believe they need landscape, including advanced practice, is tice beyond initial professional registra- to only upskill' other workforces in med- welcome.

9 The lack of regulation of these tion in any UK country. As such, there is ical-technical skills to meet demand; they do roles is not only a workforce issue but also little professional or regulatory accounta- not realise that those non-physician work- one of patient safety (Kelly et al, 2019;. bility, particularly for workers using job forces also bring an important, unique con- Leary, 2018); with hard-pressed employers titles such as associate advanced nurse tribution to care (Leary, 2019). trying to deliver services with more practitioner or clinical nurse specialist efficiency, few seem willing to tackle these (Jones-Berry, 2018; Leary et al, 2017).

10 Studies show, in terms of issues. The proposal for an Academy As HEE's framework was launched when safety, quality and efficiency, of Advancing Practice in England is wel- the Royal College of Emergency Medicine's advanced clinical practitioner curriculum advanced -practice nurses come and may help tackle these issues but needs a mandate to require employer com- ( ) and the Fac- are of great benefit mitment. ulty of Intensive Care Medicine's curriculum The opportunities for advanced -practice ( ) were already Workers who also see medicine, or an nurses to meet healthcare's growing in existence, two perceptions of advanced association with it, as desirable or of higher demand are considerable.