Advanced Nurse Practice

Background

What an Advanced Nursing Practitioner (ANP) is has not been well defined and there is concern that ANP means very different things in different parts of the NHS. To address this the Royal College of Nursing (RCN) set up a credentialing scheme to set a recognised standard for ANPs. This programme of work created a group (cohort) of ANPs, to discover their experiences of work, their well-being and their views of regulation and the credentialing scheme. 

Design

The approach to this work evolved over the period of the SRA programme as specific issues became apparent. The final design consisted of the following elements:

A UK wide longitudinal cohort was established in 2018. Surveys were carried out each year from 2019-22 with the same cohort of advanced practice nurses in the UK. The survey consisted of demographics, questions on contemporary issues in advanced practice, NHS staff survey questions, and validated questionnaires (SWEMWBS). A core set of questions were asked every year with some changes in response to the COVID-19 pandemic.

Sub-cohort qualitative studies were undertaken during 2018 (n=22) and 2021 (n=11).

Key findings

Variation of role, but with a continued commitment to the nursing identity

Attention to the four pillars remained constant during the length of the cohort, unsurprisingly clinical and leadership activities were most prevalent within ANP workloads. Whilst teaching also had a relatively high presence, research was consistently reported as being relatively absent in ANPs workload across the four years of the cohort, with just one-half reporting it as a regular part of their work.  The wide variation in grade, ranging from 6 to 8c, represents a wide disparity in pay and responsibility. The most common was band 8a (2019). There was support for some form of regulation or registration of ANPs and, of those who were RCN credentialed, two-thirds would recommend it, one-quarter felt it was value for money, and one-third felt it was necessary for their role. Importantly, of those who were credentialed, four-fifths felt that it allowed them to demonstrate formally to others that they were safe to conduct their role. ANPs continue to experience a wide range of roles, with almost two-thirds of the cohort working in primary care and many are clinically supervised by medical professionals. Consequently, our qualitative work highlighted challenges around professional identity, isolation and role confusion. Despite this, the essential characteristic of ANP working continued to thrive and the use of existing nursing knowledge, practice and  skills  are  central  to  the  work  as  it  is  being applied  albeit in a new  context.

ANPs remain dedicated and enthusiastic, although this and satisfaction of quality of care and the impact of their role is diminishing over time.

Work related stress was reported by around one-half of respondents across the four years, with the highest incidence occurring just after the most acute phases of the pandemic. Despite this, self-reported well-being remained favourable relative to the UK population throughout the length of the study period. ANPs also maintained a positive focus on their professional roles, with the majority indicating enthusiasm for their job throughout (range across the four years 80-90%), although this did diminish over time. The proportion of respondents who ‘look forward to going to work’ remained relatively high, although again this did diminish over time. Patterns of diminishing levels of satisfaction in relation to the impact on innovation, quality of care and clinical work were also observed over time. A similar trend is observed in relation to quality of care. Respondents reported less support across the four years for statements relating to initiative in the role, influence on improvement, and making improvements.

Covid: Safety concerns and poor communication from managers are the source of elevated levels of ANP intention to leave.

The cohort afforded the possibility to add questions relating to the Covid-19 pandemic, with a survey shared with respondents in early 2021. The responses highlight huge concerns within this segment of the nursing workforce. Around two-fifths reported that the risk of exposure to Covid-19 to themselves and others could have been reduced, and one-fifth felt that their safety was not prioritised. Over two-thirds of respondents reported shortages of PPE and half-reported staff shortages. Unpaid overtime was prevalent with around one-quarter of respondents indicating this. The risk of intention to leave was elevated during this period, with one-quarter indicating that they wanted to leave the profession. Intention to leave was significantly correlated with safety not being prioritised and with an absence of communication from NHS management about coronavirus planning. Our qualitative work highlighted safety concerns for ANPs and their families during this time, extending to psychological well-being and the distress of close clinical colleagues dying from contraction of the virus. These reports align to those findings of our qualitative synthesis on the experiences of nurses from around the world during prior pandemics.

Publications:

Wood, E., King, R., Robertson, S., Allmark, P., Senek, M., Tod, A., Ryan, T. (2020) Advanced Practice Nurses' experiences and well-being: baseline demographics from a cohort study. Journal of Nursing Management 28(4): 959-967 https://doi.org/10.1111/jonm.13030   

Wood, E., King, R., Senek, M., Robertson, S., Taylor, B., Tod, A., Ryan, T., (2021) UK advanced nurses’ experiences of the COVID-19 pandemic: A mixed methods cross sectional study. BMJ Open. 16;11(3):e044139 http://dx.doi.org/10.1136/bmjopen-2020-044139  

Wood, E., King, R., Robertson, S., Senek, M., Tod, A., Ryan, T (2021) Sources of satisfaction, dissatisfaction and well-being for UK Advanced Practice Nurses: A qualitative study Journal of Nursing Management 29(5), 1073-1080 https://doi.org/10.1111/jonm.13245

Wood, E., King, R., Taylor, B., Robertson, S., Senek, M., Tod, A., Ryan, T. (2022) Moral distress in UK advanced practice nurses during the COVID-19 pandemic: A cross-sectional survey study. Nursing Standard https://doi:10.7748/ns.2022.e11885 

Wood, E., King, R., Robertson, S., Tod, A., Senek, M., Taylor, B., Ryan, T. Advanced  Nurse Practitioner wellbeing: a four year cohort mixed methods study. Nursing Open. Accepted 5th June 2024