The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [17]
Advanced practice nursing and other role developments
The other group of nurses whose roles are changing in respect of creating a safer, more efficient health service are those in advanced practice roles. ‘Advanced practice’ is an umbrella term relating to the skills, knowledge, expertise and attitudes that are firmly grounded in clinical practice, and encompasses aspects of education, research, consultation and case management (Hawkins and Holcombe 1995, NMC 1999, Royal Marsden NHS Trust 2003).
Initially, the New Deal for junior doctors (NHSME 1991) began the debate about the areas of medical practice that could be carried out by nurses, with bold statements being made about the potential cost savings (Richardson and Maynard 1995). With the publication of The Scope of Professional Practice (UKCC 1992), procedures previously carried out by doctors became the responsibility of nurses and new advanced practice roles evolved. The new advanced practice senior clinical roles such as clinical nurse specialists, nurse consultants and nurse practitioners ensure that experienced and highly skilled nurses stay close to patient care (DH 2006a). The Chief Nursing Officer’s ‘ten key roles’ for nurses in England (DH 2000) provided the legitimacy and authority needed to assume new responsibilities, such as the freedom to admit and discharge patients or order diagnostic investigations. In practice, this means that nurses are undertaking numerous procedures that are more invasive and complex than 30 years ago when the first edition of this manual was published.
One of the challenges of advanced practice roles has been assessing competence at this higher level of practice (Lillyman 1998). Benner’s 1984 model of skill acquisition offers a framework to define the development from novice through to clinical expert. This and her subsequent work (Benner et al. 1996) have been used extensively to articulate the qualities that distinguish an expert nurse and to define expert nursing care. This framework has been used to develop role development profiles, tools that:
Support competence acquisition in relation to role developments, enabling individuals to take responsibility for planning, managing and evaluating learning and to provide the opportunity for the individual to maintain a record of their own developing competence.
(Royal Marsden Hospital 2004)
Those activities that have not previously fallen within the scope of nursing practice and for which the nurse has not received education and training may be considered to be role developments. Procedure guidelines are integral to role development and are part of the process of ensuring clinical effectiveness in ‘doing the right thing the right way’. Within the UK, there are constant challenges for employers to define and manage these roles because currently there is no national legislative statement of what constitutes an advanced practitioner. This also has implications for the general public as any nurse can call themselves an advanced practitioner.
The NMC initiated national consultation on this aspect of nursing practice in 2005, with the intention of establishing a specific part of the Register for nurses who were functioning as advanced practitioners. In February 2007, a White Paper was published, Trust, Assurance and Safety – the Regulation of Health Professionals in the Twenty-First Century (DH 2007a), stating that ‘where appropriate, common standards and systems should be developed across professional groups where this would benefit patient safety’. In response to this and the later review by the Council of Regulatory Excellence (2009), the Department of Health published Advanced Level Nursing : A position statement (DH 2010e) to assist employers in developing new advanced practice roles and posts and to provide a national benchmark