Advanced nursing practice - transforming nursing roles: phase two

Transforming Nursing Roles Advanced Nursing Practice - Phase II

Introduction

The Transforming Roles paper on Advanced Nursing Practice (ANP)^[1] set out core competencies, education priorities and supervision requirements for ANP roles in Scotland. Following publication, the Advanced Practice Short Life Working Group (SLWG) agreed to a second phase to expand this work to include:

• Core Competencies for Acute, Primary Care, Mental Health and Paediatrics/Neonates
• Metrics for measuring outcomes
• Non-clinical time
• Supervision
• Advanced Practice Academies

This report is the key output from the second phase of the SLWG work programme. It is intended that the contents of this report be viewed as an addendum to the Advanced Practice Phase I document^[2]. The established core competencies for all Advanced Nurse Practitioners (ANPs) in Phase I remain overarching, including for example, competencies relating to assessment, diagnosis, treatment and discharge. This report sets out competencies for the broad families of ANPs identified above, and has been developed to complement and build on the core competencies set out in the Phase I report.

Area Specific Competencies

Agreed competencies for practice ensures safe, effective and person centred care, and remains embedded within the Nursing and Midwifery Council (NMC) code and in nursing governance structures.

Following the publication of the phase I report^[3], a number of key speciality areas were identified as requiring an expansion of core clinical competencies to give more specific support and direction to employers and ANPs. These are:

• Adult Acute Care
• Paediatric Acute Care
• Neonatal Acute Care
• Adult and Paediatric Mental Health
• Adult and Paediatric Community Care

ANPs are experienced and highly educated Registered Nurses who manage the complete care of a patient, not solely any specific condition. Four pillars of practice define the core role and function of the ANP:

• Clinical Practice
• Leadership
• Facilitation of Learning
• Evidence, Research and Development

The competencies set out in this document focus on clinical practice. Further detail on practice relating to the non-clinical aspects of the ANP role is presented in the NHS Education for Scotland (NES) Advanced Practice Toolkit.^[4]

Comprehensive History Taking

The ANP undertakes comprehensive person centred assessment of physical, mental, psychological and social needs. In addition, the ANP will consider strengths and assets - actively involving the person, their family and carers, and support available from service partners. This includes a full analysis and interpretation of an individual's history including identification of alternative/augmentative communication needs.

Clinical Assessment

The ANP carries out comprehensive clinical examination of the patient in their entirety, inclusive of physical examination of all systems, mental health assessment and remote assessment where appropriate and can:

• Rapidly assess a patient using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach and/or Mental State Examination to intervene clinically in a timeframe that reflects the risk, as well as assessing and managing the ongoing care needs of those presenting with chronic illness;
• Request and undertake diagnostic tests / investigations;
• Demonstrate effectiveness in prioritising, escalating, de-escalating, providing self-help or management advice and refer for treatment/assessment/decision support in a timely manner within the clinical context of their role;
• Deliver person centred care by supporting patients to make informed decisions relating to their treatment and provide consent;
• Prioritise and manage workload to meet the needs of patients;
• Analyse and synthesise findings from various assessments, clinical tests and investigations;
• Demonstrate an understanding of the principles and processes of child and adult protection legislation to ensure the safeguarding of children and vulnerable adults;
• Undertake assessments of related co-morbidities for individuals with a learning disability and develop with the patient a care plan that reflects the complexity of their health;
• Request and undertake multidisciplinary/agency health and social services assessments.

Differential Diagnosis

The ANP applies high level decision-making and assessment skills to formulate appropriate differential diagnoses based on synthesis of clinical findings. This requires clinical reasoning to manage risk while dealing with undifferentiated client groups across the age spectrum.

Investigations

The ANP has the autonomy and authority to apply judgement and clinical reasoning to request, where indicated, appropriate diagnostic tests/investigations based on differential diagnoses and act on previously requested results of tests/investigations working collaboratively with other healthcare professionals.Table 1: ANP led investigations by area of practice

Acute Care

The Acute Care ANP is able to request and interpret the following investigations:

• Chest X-rays
• 12-lead Electrocardiogram (ECGs)
• Arterial Blood Gases
• Routinely requested blood tests

Depending on specialist area, the Acute Care ANP may be able to request and act on other investigations such as Pulmonary Function Tests, Echocardiograms, Ultrasound scans, Exercise Tolerance Tests, Magnetic Resonance Imaging (MRI) and Computed Tomography (CT).

Primary and Community Care

The Community and Primary Care ANP is able to request and act upon the reports of the following investigations:

• Chest X-rays
• 12-lead ECGs
• Echocardiograms
• Ultrasound scans
• Routine investigations that relate to men's health and women's health, and in particular sexual health

The Community and Primary Care ANP is able to request and interpret the following investigations:

• Pulmonary function tests

Depending on service requirements, there may be additional investigations that the ANP is able to request, interpret and act upon.

Mental Health

The Mental Health ANP is able to independently request and act upon:

• Further diagnostic tests/investigations including routine Bloods, ECG;
• Further physical diagnostic tests and investigations. Review of results within scope of practice at a competent level;
• The application of protective and safeguarding legislation
• Use of evidence based mental health assessment tools across all specialties.

Mental Health ANPs are able to assess and manage risk to inform decision-making for care, support and treatment planning.

Paediatric Acute and Community Care

The Advanced Paediatric Nurse Practitioner:

• Has the autonomy appropriate to their scope of practice and context of clinical area to request diagnostic tests based on differential diagnoses
• Is able to accurately interpret and act on laboratory/ diagnostic data.

Neonatal

The Advanced Neonatal Nurse Practitioner (ANNP) is able to request and act upon the following investigations:

• All routine blood tests relevant to the neonate;
• Neonatal X-rays;
• Neonatal Cranial ultrasound scan;
• Neonatal abdominal, chest and hip ultrasound;
• Arterial Blood Gases.

Depending on specialist area and level of competence, the ANNP may also be able to request and act on other investigations including:

• Neonatal ECG
• Neonatal Electroencephalography (EEG)
• Neonatal Cerebral Function Monitoring (CFM)
• Neonatal Echocardiogram

Treatment

The ANP formulates an action plan for the treatment of the patient, synthesising clinical information based on the patient's presentation, history, clinical assessment and findings from relevant investigations, using appropriate evidence based practice. The ANP is an independent prescriber and also implements non-pharmacological related interventions/ therapies, dependent on situation and technical requirements of care. The ANP must be able to initially and independently manage a broad range of presenting conditions. The following list of treatments is not exhaustive, but is intended to highlight the key conditions an ANP should be familiar with.

Table 2: ANP led treatments by area of practice

Adult Acute Care

Adult Acute Care ANPs are able to manage all aspect of patient care relating to the following:

• Medical Emergencies, including anaphylaxis, respiratory failure, cardiac arrest, sepsis, shock, and the unconscious patient
• Common presentations, including abdominal pain, acute pain, bleeding, breathlessness, chest pain and palpitations, collapse/black out/syncope (fainting) and pre-syncope, acute confusion/delirium, altered consciousness and disturbed behaviour, diarrhoea and vomiting, dizziness and vertigo, falls, fever, fits/seizures, headache, head injury, jaundice, limb pain, swelling and abnormalities, the oliguric patient, poisoning, rash, suicidal ideation, nausea and vomiting, weakness and paralysis, and wound assessment and management.

The Acute Care ANP will also have a good working knowledge of symptom management in palliative and end of life care.

Primary and Community Care

Primary and Community Care ANPs are able to manage all aspects of patient care relating to the following:

• Medical Emergencies: Anaphylaxis, respiratory failure, cardiac arrest, sepsis, shock, and the unconscious patient
• Common Presentations: Abdominal pain, acute pain, bleeding, breathlessness, chest pain and palpitations, collapse/ black out/syncope and pre-syncope, acute confusion/delirium, altered consciousness and disturbed behaviour, diarrhoea and vomiting, dizziness and vertigo, falls, fever, fits/seizures, headache, head injury, jaundice, limb pain, swelling and abnormalities, the oliguric patient, poisoning, rash, suicidal ideation, nausea and vomiting, weakness and paralysis, and wound assessment and management
• Palliative care (long term conditions and end of life care): Skills, knowledge and competence to manage treatment
• Paediatric: symptom management of common childhood presentations, acute and non-acute conditions e.g. viral illness, rashes, infectious diseases, croup, asthma
• Women's health: family planning and sexual health, coil insertion, sexual issues/screening
• Men's health

In the telehealth/telecare setting, as well as in direct consultation, the ANP should be able to quickly identify potential stroke, acute coronary symptoms, sepsis, urgent mental health conditions including acute confusional state, cognitive impairment and increased risk linked to suicidal thoughts and take appropriate management actions.

Mental Health

Across all mental health specialties including Forensics, Old Age Psychiatry, Children and Adolescent Mental Health Services (CAMHS), Perinatal, Addictions, Rehabilitation, Psychiatric Liaison, Acute Hospital and Community, the Mental Health ANP is able to:

• Differentiate, advise and educate on a range of mental health presentations
• Provide suicide and self-harm management and treatment
• Understand, and possess knowledge and competence, to manage a range of Mental Health and associated disorders
• Differentiate between treatments for depression, dementia and delirium and correct management across all settings
• Assess and advise on managing acute behavioural disturbance across all settings
• Manage physical healthcare issues within the limitation of the area of practice
• Manage acute substance misuse and detoxification across all settings.

Understand both pharmacological and non-pharmacological management of delirium and the management of stress and distress.

Paediatric Acute Care

In response to medical emergencies, the Paediatric Acute Care ANP is able to perform a full ABCDE assessment:

• Airway - Obstructed or partially obstructed airway (Croup, anaphylaxis, foreign body, Tracheitis and Epiglottitis)
• Breathing - Bronchiolitis, Asthma and Pneumonia
• Circulation - Sepsis, Hypovolemia (Diarrhoea and Vomiting, blood loss), Diabetic Ketoacidosis and Duct dependent heart defects
• Disability - Status Epilepticus, altered consciousness, head injury and Hypoglycaemia
• Exposure – Burns

Paediatric Acute Care ANPs have a sound understanding of child protection legislation, ensure that legislative requirements are being met with their setting and take a lead role in educating colleagues within MDTs and improving systems for compliance.

Neonatal

The Advanced Neonatal Nurse Practitioner is able to manage all aspects of care relating to the neonate including:

• Neonatal Resuscitation: Advanced Neonatal Resuscitation appropriate to gestational age and clinical presentation both at birth and in the hospital or community (neonatal transport) setting
• Birth Asphyxia: Hypoxic Ischaemic Encephalopathy (HIE), Therapeutic Hypothermia (Total Body Cooling)
• Management of the Preterm Baby: An in-depth knowledge of holistic management of the preterm neonate from birth to discharge appropriate to gestational age and clinical presentation.
• Neonatal Respiratory Disease: Respiratory Distress Syndrome, Bronchopulmonary Dysplasia, Transient Tachypnoea of the New-born, Persistent Pulmonary Hypertension of the New-born, Pneumothorax, Congenital Pneumonia, Congenital Diaphragmatic Hernia, Pleural Effusion, Immune and Non-immune Hydrops Fetalis
• Common Congenital Abnormalities/Birth Trauma
• Neonatal Sepsis: Aetiology, management and treatment of early and late onset sepsis.
• Neonatal Jaundice and Haemolytic Disease: Blood group incompatibility, maternal antibodies, maternal infection, investigations and management of neonatal jaundice.
• Neonatal Congenital Heart Disease: Aetiology, management and treatment of common neonatal congenital heart conditions.
• Neonatal Seizures
• Inborn Errors of Metabolism/ Metabolic Disease

Depending on the specialist area and level of experience, the ANP may also have in-depth knowledge of management of the surgical neonate.

Admission, Discharge and Referral

The ANP has autonomy and authority to admit to and discharge from identified clinical areas, dependent on patient need at time of review. This includes the autonomy and authority to refer to, and work in partnership with, all appropriate health and social care professional groups and agencies.

Generic Competencies Relating to the Non-Clinical Pillars of Practice

• Facilitation of Learning: ANPs are able to apply the principles of teaching and learning to support others to develop knowledge and skills, acting as a mentor to junior staff and taking responsibility for their own CPD.
• Evidence, Research & Development:ANPs are able to demonstrate an understanding of the research process and how research findings can be applied to practice. They are able to critique and synthesise research evidence to inform practice. In addition, ANPs have a working knowledge of Quality Improvement methodology and the ability able to apply it within their own area of practice.
• Leadership:ANPs demonstrate an ability to monitor and assure quality of care acting as change agents and role models. ANPs are competent in clearly stating their position or case, using supporting evidence where available, and are able to lead to ensure the best outcome for patients. They will advocate for improved safe, effective and person centred services across professional and service boundaries and can demonstrate effective leadership that uses critical and reflective thinking. ANPs promote evidence-based innovation.

The ANP will work within the scope of their professional practice, demonstrating an awareness of their own limitations in knowledge, understanding and clinical competence, and recognise when to seek expert advice in accordance with the Code^[5].

Metrics

A key requirement for the development of the ANP roles is the development of benchmarking indicators focused around outcomes that can be applied across all established and new roles.

A number of factors have led to the current focus on outcomes in health care, including:

• Increased emphasis on providing quality care and promoting patient safety;
• Regulatory requirements for health care organisations to demonstrate care effectiveness;
• Increased health system accountability and changes in the organisation, delivery and financing of health care.

It is recognised that ANPs play an important role in determining patient and system outcomes. In particular, there is growing evidence of the positive impact that ANP care has on patient outcomes in terms of promoting access to care, reducing complications and reducing costs of care through improving patient knowledge, self-care management and patient satisfaction. ANPs are recognised as being integral to developing and sustaining the capacity and capability of the health and care workforce now and in the future.

It is important therefore that ANPs are able to measure and articulate the impact of their care on patient outcomes, including both their professional impact as well as being able to demonstrate their contribution to health and care delivery. This is particularly important in relation to the Scottish Government's Vision for Health and Social Care Integration^[6] and the need to ensure public value.

Principles

Metrics should relate to both quality of care and patient outcomes. It is common within the academic literature for nursing roles to be assessed using a range of measures based around traditional medical/systems outcomes such as length of stay, admission rates and mortality. Further research is required to develop measures that have a focus on the role and contribution of nursing, which would specifically be able to demonstrate the ANPs unique contribution.

There are a number of underpinning principles that should be applied when developing ANP metrics for patient outcomes. These are outlined below:

Principle 1: Metrics should be both qualitative and quantitative and triangulated to demonstrate effectiveness.

Principle 2: Metrics that measure effectiveness of practice must be based on key result areas/ outcomes and align with service needs.

Principle 3: Where possible, metrics should be based upon existing data sources and systems to support a Once for Scotland approach and minimise additional work required for data collection.

Principle 4: There must be clear methods for displaying outcomes of ANP practice through time (scorecards/dashboards etc.). These should be aligned to the national nursing assurance framework, Excellence in Care.

ANP Metrics

In addition to the above principles, the following points also contribute towards good practice:

• Metrics should be SMART:

S: Specific (clear, precise and directly attributable to ANP practice)

M: Measurable (amenable to evaluation)

A: Appropriate (consistent with overall goal and identified priorities)

R: Reasonable (realistic and feasible to achieve)

T: Time-limited (outline a specific timeline for achievement)

• Appropriate metrics will vary according to the ANP's area of practice and service requirements. As such, they will to some extent be context dependent and require flexibility in their application.

The examples provided here are intended to illustrate only. Metrics may change over time to reflect changes to services and priorities.

Metrics for clinical practice should not be viewed in isolation from the other three pillars of advanced practice that are also fundamental to the role. Metrics that demonstrate the impact of the non-clinical pillars should also be identified according to the specific Advanced Practitioner role.

Data should be collected through time and must also demonstrate the effective ANP decision-making elements of the role. ANP teams (of any size) should measure their impact on patients and service by using a basket of meaningful metrics appropriate to the area of practice. The number of metrics should be kept limited but should demonstrate safe, effective and person centred care. It is recommended that at least one measure be chosen for each of these.

Non-Clinical Time

The environment in which ANPs function remains complex and demanding. To meet these needs, the ANP must work within the four pillars of advanced practice:

• Clinical practice
• Facilitation of Learning
• Leadership
• Evidence, Research & Development

ANPs require specific non-clinical time to allow working across the four pillars. It is recommended that as a minimum, 3.75 hours per calendar week, pro rata, be allocated as non-clinical time on an ongoing basis. This should be built into workforce planning and made clear during job planning processes, both for individuals and at an organisational level. As part of this, job planning should be an explicit aspect of managing individuals and teams.

Clinical Supervision

Supervision for ANPs and the supervisory role required was discussed extensively during the preparation of the Phase I paper. All ANPs should be prepared to make constructive use of supervision, have a named Clinical Supervisor and be offered at least four Clinical Supervision sessions per year.

Further information on Clinical Supervision can be found on the NES website at the following link: https://learn.nes.nhs.scot/3580/clinical-supervision

Continuing Professional Development (CPD)

Developing staff to work as an ANP is a significant investment for the employer and commitment for the individual. To ensure that organisations benefit from such an investment and that ANPs continue to deliver robust up-to-date evidence based care, it is imperative that ANPs have opportunity and access to high quality CPD. Each ANP retains a professional responsibility to reflect on and develop their practice in line with the NMC Code and Revalidation requirements. It is essential that CPD activity is planned within work programmes and sufficient time is allocated

Supporting Professional Activities (SPA)

Specific SPAs should be negotiated with the ANPs line manager and resource must be made available to enable the undertaking of these activities.

Job Title

This paper is focused on the roles and responsibilities of the Advanced Nurse Practitioner. As Advanced Practitioner roles develop across professions, where these relate to nursing, nurse should be included in the title (e.g. Advanced Nurse Practitioner) and clearly stated on identification badges and local workforce data capture.

Transition

It is recognised that there are highly trained, highly competent ANPs, whose roles have been established prior to the Scottish Government's Transforming Roles programme. Current developments will not in any way, disadvantage established ANPs.

It is recommended that competence review processes should be used to assess established ANPs against national definitions to match against the appropriate role and level of practice. Further professional development should be based on training needs analysis. For those who meet all the requirements, there will be no need to undertake further training or education. This decision should be made in partnership with the ANP and their employer, with senior nursing teams providing appropriate oversight.

Advanced Practice Academies

Over recent years, there has been a significant increase in the number of ANP roles within the workforce in Scotland. Newly developed processes for supervision and support have led to discussion about regional planning and the professional development of ANPs. Three ANP academies have been established – in the West, North and East of Scotland.

Purpose

The "Academy" approach is intended to unite a number of Health Boards to support the professional development of Advanced Practice across the Nursing Midwifery and Allied Health Professions (NMaHP) structures. The key function of the Academy is to develop a cohesive, consistent approach to the development of Advanced Practice across health and care services in Scotland, focusing on the development and maintenance of competence and capability, as well as leading on the development of new advanced roles. Academies support Advanced Practice programmes at partner Higher Education Institutions (HEIs) by providing expertise and facilitating support and supervision.

Strategic partners to the Academies include Higher Education Institutions and employers of ANPs within the independent sector, such as General Practitioners.

Each Academy has a two-tier structure. At the primary level of the academy, there is a network of support, learning and professional development for Advanced Practitioners across Health Boards, focusing on the clinical and professional requirements of these demanding roles, and providing opportunities for competence and capability development. This tier also includes a mentoring and supervision sub group, bringing together the mentors and supervisors of Advanced Practice.

The second tier comprises a group of senior leaders from Health Boards and HEIs, to provide an overarching view of Advanced Practice. This leadership/oversight group is intended to supplement any local Advanced Practice groups within each Board.

The Shared Learning Network/CPD Events

One of the ongoing challenges for Advanced Practice support and development is capacity and capability within Health Boards. Some Health Boards in Scotland may lack a critical mass of practitioners within a given clinical area, particularly in areas such as Primary Care, Paediatrics and Mental Health. Working as a diverse group of Boards enables a network of shared learning approaches, such as critical companion groups and action learning sets. Sharing resources and faculty, including in areas as simulation and clinical skills, is key for shared learning. The shared learning approach will also allow Advanced Practitioners to work across Health Boards to facilitate learning.

As part of the academy requirements Health Boards in Scotland are committed to delivering one full day of Continuous Professional Development every 12 - 18 months, aiming for 3 - 4 per calendar year across all Health Boards. Some boards may wish to work together on these events due to scale, i.e., smaller Boards may not individually have the resources to regularly generate such events.

Mentoring and Supervision Group

The Academy seeks to optimise the mentoring and supervision approaches within Health Board. Each Academy has a Mentoring and Supervision Group to bring established and new mentors together to share best practice, implement agreed approaches to supervision and allow peer review and support. As these approaches strengthen, there will be opportunity for mentors and supervisors to work across Health Boards, to support quality assurance on the implementation of training and education, including assessment of competence.

The Leadership Group

The membership of the Leadership Group consists of two to three identified individuals with responsibility for the professional development of Advanced Practice within Health Boards. This should be multi professional, to allow appropriate NMAHP representation.

The specific role and function of the Leadership Group is to:

• Lead on Advanced Practice development;
• Develop links with key stakeholders in each Health Boards;
• Give guidance and support in the implementation of Transforming Roles (Advanced Practice)
• Develop a shared network for learning and development for Advanced Practitioners across Health Boards. This will include the development of shared CPD opportunities;
• Develop a shared approach to supervision and support;
• Adopt professional oversight of the development of competence structures and assessment processes;
• Develop shared governance approaches to Advanced Practice. An example of this approach can be found in Annex B.

It is envisaged that the next phase of development within the Academy structure would be a research and Quality Improvement subgroup, generated in partnership with HEI colleagues.