The Advanced Practice Toolkit
The following information is a selection from the Advanced Practice Toolkit – visit the site itself for a comprehensive review.
It has been suggested that ‘advanced practice’ is simply a broad term that refers to all practice roles at a level above that of initial practice, including under its umbrella both ‘specialist’ and ‘consultant’ roles.
We believe this interpretation is unhelpful in that it adds little in terms of clarity or consistency. It may also further confuse professionals and the public and, as a result, compromise governance in relation to expectations of practitioners and the service as a whole.
It is therefore important to have clarity about what ‘advanced practice’ means.
Specialist and advanced
Nomenclature issues around ‘specialist’ practice titles continue to create difficulties for the public, service leads and practitioners.
Nursing staff working with a ‘specialist’ title continue to contribute in important ways to health care provision in NHS Scotland. But there is no shared understanding amongst stakeholders of what the ‘specialist’ role actually entails. This may reduce the impact and effectiveness of such roles.
Considerable debate has focused on whether ‘specialist’ practice is at a lower level than ‘advanced’. In fact, it’s increasingly recognised that ‘specialist’ should be considered as one pole of the ‘specialist–generalist’ continuum, rather than on the developmental continuum from ‘novice’ to ‘expert’. This approach defines ‘specialist’ practice as that which is particular to a specific context, be it a client group, a skill set or an organisational context.
Advanced Level Practice
‘Advanced’ practice, it is argued, is a particular stage on a continuum between ‘novice’ and ‘expert’ practice.
The ‘advanced’ role profile is characterised by high levels of clinical skill, competence and autonomous decision-making and reflects a particular benchmark on the career development ladder, as exemplified in the Career Framework for Health (Skills for Health, 2006).
Junior-level specialist and/or the advanced generalist
While many ‘specialist’ nurses may function at an ‘advanced’ level, it’s possible to identify roles that might characterise the ‘junior-level specialist’ and/or the ‘advanced generalist’ role (Fig. 2.1).
Fig. 2.1 Relationship between specialist and advanced practice.
Importantly, Fig. 2.1 recognises that the developmental pathway towards advanced level practice in nursing may be different for individual practitioners, with some following a ‘specialist nursing’ route through focus on high-level skills and decision-making within a particular client group or clinical context, while others will develop a portfolio that reflects high-level assessment, decision making and autonomous practice across a greater breadth of practice.
‘Senior’ and ‘advanced’
We propose, therefore, to advocate the use of the terms ‘senior’ and ‘advanced’ when describing benchmarked developmental levels, and use ‘specialist’, if required, to define specific contextually focused role types.
This is not to devalue ‘specialist’ knowledge or skills, or the roles of existing Specialist Practitioners, but to recognise that these roles do not necessarily characterise an advanced level of practice.
For example, in the NES Professional Development Framework for Specialist and advanced Cancer Nurses (NES 2008), a ‘specialist nurse’ is regarded as someone with in-depth knowledge and skills in the speciality who would usually be functioning at Level 6 of the career framework (the level of ‘Senior Practitioner’).
Defining advanced practice
We recognise that a considerable amount of work has been undertaken by a number of different organisations over the last few years to define ‘advanced practice’.
International Council of Nurses definition
Advanced practice roles, such as the advanced clinical nurse specialist role, have been developing globally for the last two decades. The International Council of Nurses, through its International Nurse Practitioner/Advanced Practice Nursing Network, developed a definition of a Nurse Practitioner/Advanced Practice Nurse in 2001 (ICN, 2001). The aim was to facilitate a common understanding and guide further development of these important roles.
The ICN definition of advanced nursing practice identified the need for the following components:
“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. A Master's degree is recommended for entry level.”
Career Framework for Health definition
Skills for Health developed the Career Framework for Health in 2006. It provides steps on a structured career ladder that can be characterised as level ‘benchmarks’ to support consistency.
The framework places the ‘Advanced Practitioner’ at Level 7, defining advanced practitioners as:
“Experienced clinical professionals who have developed their skills and theoretical knowledge to a very high standard. They are empowered to make high-level clinical decisions and will often have their own caseload. Non-clinical staff at Level 7 will typically be managing a number of service areas.”
Skills for Health has also provided role-level descriptors for each of the levels of the Career Framework (Skills for Health, 2007). The elements described for ‘Advanced Practice’ (Level 7) are set out in this table.
Theoretically, all health care roles can be mapped to the Career Framework for Health. The Skills for Health definition for advanced-level practice therefore relates to a wide range of professional roles and can be seen as an over-arching definition of ‘advanced practice’ which crosses professional groups and practice contexts, such as education and management/leadership.
From a nursing perspective, the definition is clearly consistent with the ICN characteristics of an advanced-level nurse.
Nursing and Midwifery Council definition
The NMC definition of the advanced nurse practitioner (NMC, 2005) is shown in this table.
The NMC definition can be viewed as a contextualisation of the wider international definition of the clinical ‘advanced-level practice’ nurse. The Royal College of Nursing and Association of Advanced Nursing Practice Educators (2006) subsequently worked with the NMC to map the related competencies to the Knowledge & Skills Framework (KSF).
Many clinical areas of practice are comfortable with this definition for a clinical advanced nurse practitioner role, although there are concerns (particularly from mental health and learning disability practitioners) that the statement ‘carry out physical examinations’ is too restricted to acute physical health. They feel it may be more accurate to state ‘carry out in-depth clinical assessments’.
Beyond the clinical domain
The Nursing and Mifwifery Council (NMC) definition and key characteristics have formed the basis for most advanced practice models across the UK. Competencies have already been closely linked in Scotland to outlines for roles in Hospital at Night, Primary Care Out-of-Hours and emergency care services and to the outcomes of a number of academic ‘advanced practice’ programmes.
We’re keen to ensure that any consensus definition is applicable across all clinical contexts. The associated competencies should apply as much to advanced practitioners in, for example, mental health as they would to those in paediatric intensive care or the care of older adults in community settings.
We recognise that there are many nurses who function at an ‘advanced’ level but who may not be working in a specifically ‘clinical’ role. Recognising ‘advanced practice’ as a level of practice rather than a specific role, acknowledging that it is not exclusively characterised by the clinical domain but also includes those working in research, education or managerial/leadership roles, is consequently a core element of this work.
Importantly, staff working at ‘advanced’ levels in ‘non-clinical’ situations should have developed their skills and theoretical knowledge to similar high standards and should be empowered to make high-level decisions of similar complexity and responsibility to those in ‘clinical’ settings. But we have to emphasise that few nursing posts are solely restricted to one or other of these spheres − most are composites (in the figure below).
The relationship between different spheres of practice
Advanced practice as a ‘level’ of practice
Until recently, ‘advanced practitioner’ posts have tended to be characterised principally by high-level clinical and technical competence. Central to the toolkit’s ‘benchmarking’ approach is the idea that advanced practice is a ‘level’ of practice rather than a particular role.
We believe that separating these ideas allows the contribution of ‘advanced practice’ to be better articulated across different contexts. NHS Education for Scotland (NES) has built upon the literature to identify four overarching themes that articulate ‘advanced’ practice and reflect the different spheres of advanced practice (NES, 2007).
These themes are further supported in the NES model (NES 2007) by ‘underpinning principles’ such as:
- autonomous practice
- critical thinking
- high levels of decision-making and problem-solving
- values-based care
- improving practice (NES 2007)
The Advanced Practice Toolkit aims to use the emerging consensus around advanced practice to pull together educational, operational and organisational streams to support clarity and consistency. We want to establish a developmental pathway through which existing and new practitioners can work with their managers and service leads to:
- benchmark their competence
- identify developmental needs
- demonstrate the accepted and recognised attributes of advanced practitioners.
Parallels of definitions
We see clear parallels between the NES principles and themes and the NMC/RCN/AANPE competencies. We believe they describe the same ‘level’ of practitioner. NES has been using these to structure their capability frameworks (see 'Resources' in this section), providing a strong link to support practitioner development.
We see the Skills for Health definition, from the Career Framework for Health, as providing clear articulation of high levels of decision-making, skills and knowledge. It recognises the cross-professional nature of advanced practice and acknowledges the non-clinical advanced practitioner role.
The International Council of Nurses (ICN) definition of the advanced nursing role has application beyond the purely clinical domain and places nursing role development within an international context. It recognises the contextual nature of the skills that might be exhibited by an advanced practitioner, although the level of practice would be consistent in relation to autonomous practice, critical thinking, decision-making and problem-solving and the other underpinning principles.
The Nursing and Midwifery Council (NMC) definition articulates the clinical ‘advanced nurse practitioner’ role within the UK context. We recommend the adoption of a minor change to the NMC definition, to amend the phrase ‘carry out physical examinations’ to read ‘carry out in-depth clinical assessments’. We believe that this better reflects the role across different clinical contexts.
Advanced practice themes and definitions
This links to the NES advanced practice themes, which describe advanced practice across the four domains. More detailed definitions can then be created for each of the other domains to demonstrate the advanced practice level within that domain.
Relationship between advanced practice themes and definitions
For example, the review of the senior charge nurse/midwife role in Scotland, Leading Better Care (Scottish Government, 2008), has provided a structured role framework for the clinical leadership/ management role that will map against this model. Emerging work around clinical education careers (practice education) and clinical academic careers (research) provide the appropriate background for the development of the other articulations.
This allows each clinical context to develop the applied characteristics of advanced practice skills and knowledge without diluting the core benchmarked elements of the level. It also provides greater opportunities for either movement across this level – between a clinical practice role and a clinical education or clinical management role – or recognition of the ‘equal status’ of such roles across contexts.
We (the Advanced Practice Toolkit) therefore propose the following:
- advanced practice is a ‘level of practice’ rather than a role or title
- the Career Framework for Health articulates ‘Advanced Practitioners’ across professional boundaries
- advanced practice in nursing can be broadly defined by the International Council of Nurses’ definition
- the NMC definition articulates the clinical ‘advanced nurse practitioner’ role within the UK context
- advanced practice is shown across four key themes:
- advanced clinical/professional practice
- facilitating learning
- these themes are underpinned by autonomous practice, critical thinking, high levels of decision-making and problem-solving, values-based care and improving practice
- the skills and knowledge base for advanced practice are influenced by the context in which individuals practice.