Essay: Advanced practitioners are the cutting edge of nursing innovation

Introduction
The increase of advanced practice roles is aligned to challenges to health service delivery that have precipitated the implementation of new models of care to meet the changing needs of patients (Ham et al., 2012). Unprecedented demands on health care are increasing as the population grows and lives longer, with lifestyle factors that may impact negatively on health, treatments advancing with technology and an increase in public expectations. Additionally, there is a growing need to deliver person centred care (Francis, 2013). Thus, in times of economic austerity, it has become essential to provide service innovation for healthcare in the United Kingdom (UK) in order to meet the demands of the ever-changing National Health Service (NHS). There is a necessity to reshape the NHS workforce in order to meet not only the requirements of the population, but to achieve and deliver the vision of the Five Year Forward View (NHS England, 2014a).
In 2016, Better Births set out the Five Year Forward View for NHS maternity services in England (NHS England, 2016a). Scotland’s review of maternity and neonatal services The Best Start followed suit (Scottish Government, 2017). Both reports highlight that keeping mothers and newborns together should be the foundation of neonatal care. Evidence shows that the implementation of Neonatal Transitional Care (NTC) has the potential to avoid unnecessary separation (British Association of Perinatal Medicine [BAPM], 2017). This can be achieved by multi-professionals working and learning in partnership to deliver safe and personalised care for the newborn and their mothers (Scottish Government, 2017) (Fig. 1). The role of the Advanced Neonatal Nurse Practitioner (ANNP) is pivotal in successfully delivering the NTC vision. The impact of the advanced practice role within the multidisciplinary team in ensuring consistent delivery of high quality NTC, to the right patient and at the right time (NHS England, 2014a), will be further explored.
The Role of the Advanced Neonatal Nurse Practitioner
There have been a number of political and educational drivers since the turn of the century that have generated substantial structural changes to the NHS workforce. The reforms introduced by the NHS Plan (Department of Health [DoH], 2000) had implications for all health care professions. These plans allowed the development of new approaches to care and treatment and provided a basis for the evolution of advanced practice in nursing and, consequently, the allied health professions. The training and education of the medical workforce has been influenced by the stipulation of the European Working Time Directive (Council Directive 2003/88/EC), Modernising Medical Careers (House of Commons, 2008) and the Tooke Report (2008). The regulations, requirements and working patterns of the medical profession have presented challenges which led many Trusts in the UK to invest in the training and education of different types of health care professionals, such as advanced nurse practitioners (ANP), in an attempt to ensure appropriate standards of care and maintain staffing levels (McDonnell et al., 2014).
Policy documents shaping the health service have actively promoted advanced practice roles (National Assembly for Wales, 2000; DoH, 2000; Scottish Executive Health Department, 2005; Northern Ireland Practice and Education Council, 2005). The NHS Modernisation Agency also embraced the concept of advanced nursing practice as innovative ways of working within multidisciplinary teams (DoH, 2005). Neonatal nursing has been at the vanguard of this development with well established advanced nursing practice roles imbedded within the service delivery of neonatal units across the UK (Smith and Hall, 2011; Howard, 2010; DoH, 2009).
The role of the advanced neonatal nurse practitioner was first developed in the United States of America in 1970’s (Johnson et al., 1979). In the United Kingdom (UK) the role was introduced in 1992 through a pilot study in Southampton (Hall et al., 1992). The ANNP role has since evolved and its popularity increased by the neonatal services review (DoH, 2003) and subsequent development of the Toolkit for High Quality Neonatal Services (DoH, 2009). The toolkit was proposed to make lifelong differences to premature and sick newborns and their families. Recommendations included specialist care by ANNP’s, senior charge nurses, nurses qualified in specialty and junior staff nurses, alongside a designated medical team.
Although the ANNP has long been recognised as an integral part of the workforce, there is a lack of agreement regarding the service model in which they practice (BAPM, 2010). Furthermore, the absence of a statutory standard adds additional challenges when monitoring the full implementation of this role or to quantify the number of advanced practitioners working in clinical practice (McKeon-Carter, 2013; Smith and Hall, 2011). Two recent developments have contributed significantly to the regulation of the advanced practice roles and responsibilities in the UK; firstly, the Royal College of Nursing (RCN) credentialing (2017) set out to help professionals, employers and the public to provide formal recognition of the APN role (BOX 1); secondly, later within the same year, Health Education England (2017) in partnership with NHS Improvement and NHS England, released the multi-professional framework for advanced clinical practice.
Advanced nurse practitioners have been defined as:
“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. A Master’s degree is recommended for entry level” (International Council for Nurses, 2002).
ANNP’s are senior neonatal nurses that have already developed in depth neonatal skills, knowledge and understanding prior to the advanced practice training. Therefore, they have a strong understanding of nursing issues; offer professional continuity and are able to holistically manage the care of the infant and their families building on established working relationships with all members of the multidisciplinary team (Spinks, 2009).
As part of Modernising Nursing Careers (Scottish Executive, 2006), the Scottish Government (2008) first outlined the characteristics of the ANP with the Advanced Practice Toolkit. This framework incorporated four themes or pillars for advanced practice (Fig.2) and offered guidance to employers, practitioners and educators for each country within the UK; this was updated in 2012 (NHS Education for Scotland [NES], 2012). The main principles of the NES model (2007), outlined in BOX 2, underpinned the four pillars of advanced practice. Incorporating the principles set out on the Toolkit, NHS Wales (2010) developed the Framework for Advanced Nursing, Midwifery and Allied Health Professional Practice in Wales, and the Department of Health (2010) issued the Advanced Practice Position Statement to be used as a benchmarking for this level of practice providing more clarity around the concept of advanced level nursing.
Advanced practice should be viewed as a “level of practice” rather than a “specific role” (Scottish Government, 2008) and therefore all of the pillars are essential to advanced practice. However, some pillars or domains will be more evident depending on the specific area of practice (King et al., 2017; RCN, 2012). These domains will form the basis of the overview of the role of the ANNP in delivering high quality neonatal care, with a special focus on transitional care.
The concept of transitional care seeks to avoid unnecessary admissions to the neonatal unit as well as providing additional support for infants born too small and /or late preterm and their families (NHS Improvement, 2017b). Every newborn should be kept with their mother if at all possible. Evidence suggests there are improved health outcomes when keeping mother and infant together (Crenshaw, 2014), and separation increases the risk of failing to establish and continue breastfeeding leading to an increased risk of medical problems, in both mother and infant (Dumas et al., 2013; Bigelow et al., 2012). The weight of evidence would suggest healthcare professionals should question the need for a neonatal unit admission for the provision of a safe maternity and neonatal service.
The ANNP is key to successfully delivering high quality NTC as they are assessed as competent in practice using expert knowledge and skills underpinned by master’s level education (Scottish Government, 2017); this enables ANNPs to practise autonomously and holistically assess the neonate, mother and family with a variety of methods. These include newborn physical examination and ordering and interpreting diagnostic tests when necessary, as well comprehensively assessing the antenatal, perinatal and neonatal history in order to assess potential risk factors. This consolidated practice enables them to determine evidence-based therapeutic interventions such as the prescribing of medication (DoH, 2006). The efficacy and effectiveness of such interventions are monitored subsequently, and a management plan of each episode of care will follow suit. In addition, referral and discharge from NTC can also be undertaken by the ANNP.
Nurses were enabled to independently prescribe in 2006 allowing ANNPs to become more autonomous in what had historically been a medical role (DOH, 2006). The successful implementation of these roles is further supported by recent changes in UK legislation which allow non-medical prescribing of controlled drugs (Home Office, 2014).
The advanced practitioner works in partnership with other healthcare professionals, such as midwives, utilising high level communication skills in order to optimise the health outcomes of both the infant and the mother, delegating care and providing support when required (NHS Improvement, 2017a; Mayes, 2014). Where complex and unpredictable care arises, the ANNP uses their own professional judgement to manage the event and act appropriately within the boundaries of practice. The need for the ANP to be professionally accountable and make autonomous decisions is recognised by the RCN (2012). However, the Nursing and Midwifery Council (NMC) (2015) discusses the need to practice within the practitioner’s realm of competence and not to exceed the limits of their role, experience and training. ANP’s do not tend to rotate within the hospital and hence their professional credibility is enhanced by their constant presence within the service providing continuity of care (Imison et al., 2016; Kennedy et al., 2015; McDonnell et al., 2014; Hall and Smith, 1995).
The introduction and development of ANNP’s has provided a stable workforce able to provide high standards of neonatal care that are consistent, safe and reliable without the presence of paediatric medical staff on site. There are currently two independently nurse led neonatal units in the country (Pearce, 2017; Hall and Wilkinson, 2005; Ward Platt and Brown, 2004) where advanced practitioners have assumed all the responsibilities carried out by junior doctors in other units within the same region. The successful outcomes of ANNP’s on improving practice and delivering high standards of care have also been reported in studies relating to attendance at deliveries (Aubrey and Yaxall, 2001), routine newborn examinations (Lee et al., 2001) and the use of ANNPs in acute neonatal transfers (Leslie and Stephenson, 2003).
The insightful review by The King’s Fund (2012) summarized that the aim of leadership is to “improve population health and patient care”. After the Francis (2103), Keogh (2013) and Berwick (2013) reports addressed the need for strong nurse leadership, NHS England (2014b) focused on delivering leadership through compassion to transform healthcare provision. Compassion is one of the 6C’s – Communication, Care, Commitment, Courage, Competence (DoH, 2012). However, to deliver compassion in leadership one required emotional intelligence (Feather, 2009). These leadership qualities are essential attributes of the ANNP.
The link between leadership and positive culture leading to better outcomes is well recognised in the literature (West et al., 2015). In the framework leading Change, Adding Value (NHS England, 2016b), compassionate leadership is the cornerstone for ensuring the best quality of experiences and outcomes for the population by using resources wisely (FIG. 2). Advanced practitioners are perfectly positioned to have an impact on improving health through the delivery of compassionate leadership and the responsibilities of nurses for health and wellbeing are set out in the professional regulatory Code (NMC, 2015). Furthermore, standards have developed to ensure nurses can provide best care and support from the outset with the new standards of proficiency for registered nurses’ stating that nurses have to be good leaders to ensure the care delivered is safe with appropriate communication throughout (NMC, 2018).
ANNPs have enhanced skills to provide senior level leadership, guiding and directing their patients care (Scottish Government, 2017). It has been suggested (Hyde, 2017; Thompson and Watson, 2003) that service innovation for healthcare in the UK is imperative in order to meet demand and sustainability. The work by Gerrish et al. (2011) and Walsgrove and Griffith (2015) contributed to show how advanced practitioners adopted innovative ways of addressing deficits in care, leading developments and maintaining standards of practice. The neonatal rapid access clinic is an example of leading innovation within neonatal care (Skene et al., 2012); a clinic set up and led by a team of ANNPs in order to reduce neonatal readmissions to hospital as well as facilitate the early discharge from the postnatal ward. These interventions further support avoiding separating infants form mothers (NHS Improvement, 2017b), and it would be suggested that this project could soon be implemented by many Trust in the UK.
The ANNP role is multifaceted and involves collaborative working across professional, organisational and system boundaries. ANNP engagement with maternity and community services is fundamental to building professional working relationships and influences the improvement of health outcomes and healthcare delivery systems (NHS Improvement, 2017a; Scottish Government, 2017; NHS England, 2016a).
The ANNP has an active role in education, learning and training. The advanced practitioner is actively involved in developing themselves and others, acting as a role model for advanced practice, ensuring standards of care delivery are maintained through clinical practice and improving quality through developing robust governance systems. It was proposed two decades ago by Scally and Donaldson (1998) that clinical governance in the NHS improves quality, accountability and safeguards standards of care and, as Harris (2000) suggests, the ANNP has the skills and knowledge to assess risk within the neonatal service and is well placed to work across boundaries breaking down multi-professional barriers to deliver high quality care to the infants and their mothers (NHS Improvement, 2017a; NHS England 2016a).
The educational role of the advanced practitioner can take a variety of forms. The collective case study by McDonnell et al (2014) highlighted the impact ANP’s have on developing junior doctor’s clinical competences; both nurses and doctors valued ANP’s clinical experience and expertise and sought their professional advice and support on a regular basis. This is further supported by the qualitative study undertaken by Kennedy et al (2015) which suggested that ANP’s take advantage of every opportunity to promote and encourage learning, entwining the clinical and educational aspects of the role on a regular daily basis, not only with healthcare professionals but also delivering quality health education and promotion in patient consultations as suggested by Walsgrove and Griffith (2015). A cross-sectional descriptive survey developed by a large NHS Trust in England (East et al., 2015) revealed that advanced practitioners were involved in producing and running educational teaching programmes, publishing literature in the form of articles and books and presenting at international conferences as well as developing clinical guidelines.
ANNPs are deeply involved in developing service user materials establishing clinical guidelines to support others to develop knowledge and skills as well as empowering parents and families with the provision of leaflets. By providing clinical guidelines, ANNPS, help to support staff in managing common neonatal problems to avoid unnecessary admission to the neonatal unit as well as training the relevant staff to equip them with the necessary skills and knowledge to deliver best practice based on current available evidence. A comprehensive handbook produced by an advanced practitioner within a neonatal unit (Local Trust Guideline, 2017) to aid and support junior doctors as well as newly qualified ANNPs can also provide reference and guidance for the midwifery team and the NTC team. As neonatal life support instructors, many ANNP’s are actively involved in teaching the nationally recognized life support course; some advanced practitioners teach on local neonatal specialist courses as well as committing to undertake the required teaching in order to educate future ANNP’s at different universities within the UK (Mayes, 2014).
As an advocate for the development of a culture that supports continuous learning and development, ANNP’s actively seek and participate in peer review of their own and the neonatal team’s practice and ensure preparation for professional revalidation (NMC, 2017) promoting good practice. E-Learning for Healthcare (2018) is a valuable and accessible online reference point which provides an extensive catalogue of programmes for the training and education of the health and social care workforce. It offers many opportunities to improve NTC delivery with the ‘avoiding term admission to the neonatal unit’ and ‘newborn physical examination’ programmes.
Reflecting on the changes in the way health care is being delivered, the NMC (2018) has launched a new framework for the education and training of nurses and midwives and a new standard of proficiency that nurses will be required to meet before they can apply for registration. Thus, it is envisaged advanced practitioners will work in collaboration with others in order to meet the learning and development needs of future professionals as well as continuing to utilise their high-level communication skills, publicising and disseminating their work.
The ANP strives constantly to improve practice and health outcomes; through decision making, problem solving and role modelling facilitating change and education (Walsgrove and Griffith 2015; Gerrish et al., 2011), the advanced practitioner has the ability to synthesize knowledge incorporating research into practice to ensure that the care delivered is evidence-based (Dobbins et al., 2009). In addition, the advanced practitioner translates this into practice development, audits and clinical governance. Dedicated to quality neonatal care, ANNPs actively participate in network groups and meetings which help drive the uptake of innovation across the sector and they are often involved in research trials (Mayes, 2014).
Although research forms an important element of the APN role (Scottish Government, 2008) recent studies indicate that research activities are the least frequently undertaken pursuit by those in advanced practice roles (East et al., 2015; Jokiniemi et al., 2012). It has been suggested by Doerksen (2010) and Mayes (2014), that increasing managerial support as well as the provision of protected time to both learn and undertake research may result in the ANP being able to improve their public profile and continue to share best practice both nationally and internationally. Although advanced practitioners received appropriate education for the role, it can be challenging for the novice ANP to address all of the clinical domains from the outset (Kennedy et al., 2015), hence the importance of providing support and mentorship to help maximise the impact of the advanced practitioner role.
Conclusion
There is strong evidence to demonstrate that advanced practitioners are the cutting edge of nursing innovation (Neville and Swift, 2012; Delamaire and Lafortune, 2010). In the changing landscape of UK health service at a time of severe austerity measures, advanced practice offers a significant opportunity to improve the quality of the patient experience, providing clinical continuity, mentoring and training for less experienced staff as well as filling gaps in the medical workforce.
The delivery of neonatal care has long been provided by a multidisciplinary team and therefore it can be argued the role of the ANNP has been developed as an opportunity for nursing career advancement and not only to accommodate medical shortage or political agenda. The ANNP can lead, shape and implement NTC with the aim to create better health outcomes for the infant, mother and families, putting them at the centre of developing and delivering all aspects of care.
Sound regulatory processes are required in order to enhance the sustainability and transferability of the ANP role. It could be argued that in order to increase public protection and adequate preparation for practice, the RCN (2017) system of credentialing will soon become a requirement from employers.
Provided that advanced practitioners are equipped with appropriate skills and knowledge underpinned by master’s level, the ANNP can influence the provision of high quality, safe and innovative patient centred care delivery, to the ultimate benefit of newborns and their families (BOX 3).