The evolution of advanced nursing practice: past, present and future

Introduction

Mahase (2019) described junior doctors’ concerns about the growth of medical associate professionals (MAPs), for example physician associates. Although there was some confusion in the reported debate about MAPs and advanced practitioners, recent developments have made this confusion and occasional resentment, unsurprising. Junior doctors debating the issue cited situations in which other workforces were competing with or replacing them, denying junior doctors training opportunities or risking patient safety.

Development of advanced nursing practice

Depending on how ‘advanced’ is defined, the roots of advanced nursing practice can be traced back over a century. For many, its development in the UK was pioneered by Barbara Stilwell, who led the establishment of the first advanced nursing practice course in 1990 at the Royal College of Nursing Institute. Manley (1997) gave further formal definition of the role and level of practice.

Despite subsequent international and UK definitions of advanced nursing practice, variation in the understanding of such roles remains, causing ongoing confusion (Leary et al, 2017). In addition, over the past decade, the concept of advanced clinical practice has expanded beyond nurses in all four countries of the UK to include allied health professionals. While this does much to demonstrate the importance of recognising advanced practice as a level of care with common core characteristics across professions, it has added to the complexity surrounding this subject.

There is a long history of advanced nursing practice in other countries. In the US, it has been in existence for several years but expanded under President Obama’s Affordable Care Act. There was a perception that advanced nursing practice was a medical role replacement (Coombes, 2008) but, generally, the role is now accepted.

Recent legislative changes have seen the role thrive as it offers an affordable, well-evaluated healthcare option. In the US, an educational and regulatory framework is administered by the American Association of Nurse Practitioners; it aims to protect the public and the role, and gives it a clearer identity. Other countries, such as Australia, have a similar set-up but the UK lacks such a framework. There is now guidance from Health Education England but no regulatory or legal framework for advanced practice beyond initial professional registration in any UK country. As such, there is little professional or regulatory accountability, particularly for workers using job titles such as associate advanced nurse practitioner or clinical nurse specialist (Jones-Berry, 2018; Leary et al, 2017).

As HEE’s framework was launched when the Royal College of Emergency Medicine’s advanced clinical practitioner curriculum and the Faculty of Intensive Care Medicine’s curriculum were already in existence, two perceptions of advanced clinical practice have been created:

• As an advancement of professional practice by a professional group;
• As a generic medical substitute role, particularly in areas such as emergency departments and acute medicine.

There is no doubt that gaps in the medical workforce were one catalyst for rethinking traditional roles and responsibilities. However, in many countries including the UK, advanced practice has evolved to better meet the needs of different populations rather than being part of a strategic workforce plan. As the critical mass has grown, its benefits have been recognised experientially; numerous studies show that, in terms of safety, quality and efficiency, advanced-practice nurses are of great benefit.

Exceptional examples exist – such as Cuckoo Lane, a nurse practitioner-led general practice in London, and specialist nurses advancing practice for patients’ benefit – but these still seem to be unseen by workforce policy makers. This is puzzling as healthcare demand is growing (The King’s Fund, 2016) and advanced-practice nurses and other professionals are in a key position to meet this increasing demand.

So why is advanced practice not seen as a solution to anything other than a shortage of doctors? This is partly because of the traditional way the healthcare workforce is viewed. Technical skills associated with medicine that generate clinical activity are valued, whereas areas of practice including complex case management, safety and the psychosocial aspects of care appear to carry less value. As a result, activities associated with medicine seem to have higher status.

Thinking of advanced practice in this way also reinforces the concept that there is a simple hierarchy of skills with an associated hierarchy of value. It leads to ‘task shifting’ from medicine to other professions but does not articulate the added value offered by these professions. Employers and policy makers then start to believe they need to only ‘upskill’ other workforces in medical-technical skills to meet demand; they do not realise that those non-physician workforces also bring an important, unique contribution to care (Leary, 2019).

Workers who also see medicine, or an association with it, as desirable or of higher status are more willing to take on a role that is closely aligned with medicine, and not value advancement from within their own profession. First described by Anderson et al (1974), this seeking of higher status condemns their primary profession to a lower status. The collective term ‘non-medical professional’ reinforces this division.

Becoming a substitute workforce, or otherwise entering the jurisdiction of another group, can be risky (Maxwell et al, 2013) as it can lead to issues around power. Studies have shown how certain occupations have controlled the passing of their knowledge to those they consider to be outside the group (Abbott, 1988). The Department of Health’s (2017) proposal to continue including advanced critical care practitioners in the regulation of medical associate professions is the first step towards advanced practice being located under this banner.

Thinking about the future

Although the UK’s four countries have developed or are developing frameworks for advanced practice, there is still a lack of clarity in some key areas. The apparent dichotomy of what advanced practice has become, particularly in England, has contributed to this. We need to recognise that professions tend to grow, die, change, adapt and compete (Abbott, 1988). Is advanced care provision within autonomous nursing practice? Or, as the Royal College of Physicians (2018) asks in its workforce document, is the advanced practitioner simply a tier 1 medical worker dependent on a senior physician to practise?

The misuse of titles such as ‘advanced nurse practitioner’ by employers who do not require staff with that title to have any underpinning education or assessment of clinical competence has serious implications for public protection. This is unlikely to be addressed without regulation. The Nursing and Midwifery Council’s recent decision to look at the post-qualification landscape, including advanced practice, is welcome. The lack of regulation of these roles is not only a workforce issue but also one of patient safety (Kelly et al, 2019; Leary, 2018); with hard-pressed employers trying to deliver services with more efficiency, few seem willing to tackle these issues. The proposal for an Academy of Advancing Practice in England is welcome and may help tackle these issues but needs a mandate to require employer commitment.

The opportunities for advanced-practice nurses to meet healthcare’s growing demand are considerable. With some thought, the profession’s future could be bright and lead to better care for patients and families.