Support for regulation of advanced practice nurses

The research, carried out by the Nuffield Trust on behalf of the Nursing and Midwifery Council (NMC), found variation in the clinical content of advanced practice courses, the experience required for advanced practice roles, and employers and public understanding of the roles.

“Advanced practice currently means many things... this variation causes confusion"

Alison Leary

According to the report, nurses and midwives are increasingly taking on “more complex, autonomous and expert roles”, commonly referred to as advanced practice.

The report described a “fast-moving landscape” where advancer practitioner roles have been developing over time for a range of clinician, operational and professional reasons.

However, it explained that, as there is no clear definition about what advanced practice is, it was “impossible to be precise” about how many professionals are practising at advanced levels.

The NMC does not currently specifically regulate advanced practice in nursing and midwifery, the report explained, meaning that professionals working in advanced practice are responsible for ensuring they work within already existing regulatory frameworks.

In recent years the issue of whether advanced practice should have additional regulation, and what this may look like, has been subject to debate.

The research noted that the NMC had, twice before, discussed the possibility of beginning work on regulation of advanced practice but “did not proceed to make any changes”.

Now, as part of the regulator’s 2020-23 strategy, the NMC is looking at whether to introduce specific regulation for advanced nursing and midwifery practice across the UK.

In its report, which consulted stakeholders from higher education institutions, health unions and government bodies, the Nuffield Trust said: “The consensus from the interviews and focus groups was that some form specific regulation was needed for advanced practice in nursing and midwifery and that the status quo was not satisfactory.”

The research found great variation in how professionals enter and practice in these roles across the UK, meaning there is no single definition of advanced practice, nor any dedicated standards of education or proficiency.

The “most common route to advanced practice” in nursing and midwifery is through higher education such as a masters’ degree, it said.

However, it found that there was “substantial variation in master’s courses”, including difference in clinical content, entry requirements and the amount of experience needed before enrolling.

In addition, the report explained that nurses and midwives working in advanced practice were responsible for “recognising the parameters of their scope of practice, which it warned “was not always clear”.

Meanwhile it said that there was “wide variation in understanding of, and support for, advanced practitioners” across different NHS employers.

The report also found that most other nations across the world with nurses working at a similar advanced practice level as nurses in the UK had specific advanced practice regulation.

While it remained appropriate to have flexibility and some differences in the approaches to advanced practice, “there is risk if they became too divergent", said the report.

This is particularly the case to ensure “international consistency”, as the report highlighted that half of recent joiners to the NMC register trained overseas.

To implement regulation for advanced practice could be costly, researchers explained.

The report said: “There is a possibility of additional cost to employers, including increasing burden on services, if there is a significant expansion of clinical supervision and assessment requirements.

“We’re asking the NMC Council to discuss these initial findings and how they’ll help inform our next steps"

Andrea Sutcliffe

“The experience of other regulators suggests that the introduction of additional regulation would likely be expensive, resource-hungry and time-consuming for the NMC itself.”

The Nuffield Trust put forward some of the primary options available for the NMC to consider.

These options included: keeping the existing statutory regulatory framework as it is, developing annotation of the existing NMC register for advanced practice qualifications or evidence of equivalence, or developing a second tier of regulation for advanced nursing and midwifery practice.

The study also revealed that many stakeholders accepted that there might be routes to strengthening advanced nursing and midwifery practice other than through reform of statutory regulation.

It noted that, instead, the NMC could also influence employers to develop consistency in roles and safeguards, as well as engaging with educators “to promote consistency and quality in education delivery across advanced practice programmes”.

Should the NMC wish to develop advanced practice regulation, the Nuffield Trust outlined some key considerations for the regulator to take forward.

The report called on the regulator to investigate “the level of risk” that advanced nursing and midwifery practice poses to people.

It argued that any regulatory interventions should be “matched to the possible level of harm”, but should prioritise “light touch rather than heavy handed” regulation if possible.

In addition, researchers recommended that the NMC explored the implications of shifting some of the responsibility of advanced practitioners from employers to the regulator.

The regulator would also need to consider how standards for education would be met across a variety of programmes from a variety of providers, the report added.

Lastly, it warned that the costs and complexity of the introduction of any new form of regulation were “not to be underestimated”.

Alison Leary

Professor Alison Leary, chair of healthcare and workforce modelling at London Southbank University, and who has published research on variation in advanced practice job roles, welcomed the report.

She said: “The expansion of advanced practice in nursing, which is largely unregulated, is too dependent on employers for definition and scope.

“This includes workers with no clinical qualifications using titles such as advanced nurse practitioner – this presents a risk to the public.

“Advanced practice currently means many things, from the global definition of the International Council of Nurses to the employers promoting a medical substitute model –  this variation causes confusion.”

Meanwhile, Andrea Sutcliffe, NMC chief executive and registrar, said: “The independent research is clear that experienced nurses and midwives working in complex, autonomous advanced practice roles can have huge benefits for the care they provide for people.

“Yet people who use services may be unsure what it means when a professional describes themselves as an advanced practitioner.

“And where somebody works with multiple advanced practitioners, they might assume those professionals achieved their roles through shared knowledge and skills, which isn’t always the case.”

Andrea Sutcliffe

The NMC will discuss the early findings of the Nuffield Trust research at its next meeting of its governing council on 17 May.

The regulator said this research would then “inform further lines of enquiry” as it continues its review of the advanced practice landscape before presenting council with options to consider later in the year.

Ms Sutcliffe added: “We’re asking the NMC Council to discuss these initial findings and how they’ll help inform our next steps.

“This will include further lines of enquiry before we come to any conclusions on options for the future.

"It’s vital that we work closely with our partners, professionals and the public to co-produce any changes we may make.”

This review into advanced practice is the latest part of a wider NMC overhaul of post-registration standards, which the regulator has been working on since 2018.

Last year the NMC approved new post-registration standards for community and public health nurses, following a three-year review.