Memory services provide access for people with suspected dementia to timely expert assessment and diagnosis, enabling them to receive appropriate information, education, treatment, post-diagnostic support and intervention (Dodd et al, 2014; National Institute for Health and Care Excellence (NICE), 2018; Copland et al, 2018). Mental health nurses have been key members of memory service multiprofessional teams in the UK for more than two decades, including in nurse-led clinics utilising non-medical prescribing (Clibbens, 2011).
This article discusses how advanced nurse practitioner (ANP) roles were developed and implemented across four localities of a large NHS Trust, providing a number of locally based memory services. How this improved the diagnostic pathway for people referred to the service and their carers is outlined. ANP roles were developed in the presence of a clear agreed strategy, ensuring practitioner competence and effective governance for the introduction of these roles. It is also argued that using the model provided would allow mental health nurses within memory services to make a major contribution to the transformation of such services.
The process of recognition for the expansion of the ANP role and appropriate remuneration linked to national NHS employment role profiles (NHS Employers, 2019) is presented. The Government has identified that memory service nurses in particular have responsibility to:
‘Ensure that the person has a timely diagnosis delivered compassionately and taking into account their personal needs and circumstances.’ Nursing, Midwifery and Allied Health Professions Policy Unit (NMAHP Policy Unit), 2016
The implementation of the ANP role in the NHS memory services described here demonstrates one way in which this can be achieved.
Literature on advanced nurse practice roles
The ANP role is described by the International Council of Nurses (ICN) as follows:
‘A nurse practitioner/advanced practice nurse is 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.’ ICN, 2019
Sheer and Wong (2008) described advanced practice for nurses as an umbrella term signifying nurses practising at a higher level than traditional nurses. The ICN also identified the regulatory mechanisms of the advanced practice role, which allow the ANP to diagnose patients, prescribe treatments, and prescribe medication. It defined ‘nurse practitioner’ as an officially recognised title for nurses working in advanced practice roles (ICN, 2019).
Advanced practice roles have been described as occurring in a wide range of practice settings (Scottish Government, 2010; ICN, 2019; Parker and Hill, 2017). There is also a significant number of research findings, mainly from the USA, that cite barriers to nurses working as advanced practitioners, including issues around prescribing. In the main, these barriers centre on the lack of recognition of the role by employers, as well as medical colleagues, and a lack of appropriate remuneration for the role (Hain and Fleck, 2014). The ICN (2019) describes ‘prescriptive authority’ as literally meaning the authority to prescribe, recognising this as a key advanced practice activity and a main research focus.
There remains a lack of literature that details the overall contribution of the ANP in mental health toward health and social care outcomes. One study in Hong Kong did find ANPs can make a difference to mental health service users’ wellbeing (Fung et al, 2016). Additionally, Fung et al (2014) identified that ANPs in mental health do have multifaceted roles but need to demonstrate that they are providing cost-effective services, again in a Hong Kong context. This remains a challenge for any mental health nurse (MHN) who is practising as an ANP. One important aspect of the effective implementation of such roles is that ANPs need to have support in developing the role by nurse administrators (service managers), if this is to be done optimally (Fung et al, 2016).
An important subject raised by Elsom et al's (2007) work with mental health service consumers and carers is the question of whether practice is better described as ‘expanded’ to include traditionally medical roles, rather than being considered more ‘advanced’ than existing mental health nursing interventions (Elsom et al, 2007). It is clear that nurses in advanced (or extended) practice roles can make a positive difference to health and social care outcomes for service users and their carers. There remains, however, a need for roles and titles to be clarified, linked to demonstrable postgraduate qualifications and recognised within a clear career pathway.
Mental health nurse prescribing of medication and advanced nursing practice
The prescribing of medicines as one component of an advanced practice role has been developing as part of MHN roles generally (Hemingway and Ely, 2009; Hemingway, 2016) and often particularly in memory services, where this role has a clear established benefit (Mitchell, 2013). Historically, there has been some resistance to MHNs prescribing, with one key criticism that this leads the MHN to practise within a biologically reductionist approach and takes the role away from a true recovery focus (Dobel-Ober and Brimblecombe, 2016). However, despite such criticisms and a relatively slow start compared with adult nursing colleagues, non-medical prescribing for MHNs is now becoming well established in the UK and forms an identified element of NHS trust and other provider organisations’ business plans and commissioned pathways of care (Hemingway and Brimblecombe, 2018). Prescribing by MHNs has been shown to be as safe as that by psychiatrists (Fisher and Vaughan-Cole, 2003; Norman et al, 2010), and that safety and quality have been specifically shown within memory services (Page et al, 2008a). MHNs, alongside other UK non-medical prescribers, are providing competent and effective prescribing at a cost saving for the NHS (Health Education North West, 2015). Healy (2016) argued that prescribing mental health drugs is not done to benefit the service user; he asserted that the critical challenge for the MHN prescriber is to ensure that the person prescribed for is truly at the heart of decisions about the medicines they take, a point repeated by the Royal Pharmaceutical Society (2016). MHNs working as ANPs in memory services are well placed to promote choice and effective medication management, working in partnership with service users and carers.
One of the universally cited barriers to MHNs working as prescribers and adopting other advanced practice activities, such as dementia diagnosis, has been a lack of recognition both for the role in terms of status and through remuneration (Dobel-Ober and Brimblecombe, 2016). In considering the ANP role and its context in modern mental health care, it is therefore clear that certain conditions need to be in place for this role to be commissioned and integrated into service transformation and delivery. Hemingway and Ely (2009) provided a narrative description of the UK MHN prescribing context and set out certain conditions that would need to be in place for nurses to successfully adopt prescriptive authority (see Box 1). These conditions are also relevant for the adoption of the role of ANP.
The advanced nurse practitioner role in memory services
With an ageing population and a growing number of people reporting memory problems there is a need for early diagnosis and access to expert care to ensure an optimum outcome (Cabinet Office et al, 2015; NMAHP Policy Unit, 2016; NICE, 2018). Dementia is a global issue; in 2017 there were an estimated 50 million people globally with dementia (Alzheimer's Disease International, 2019). In the UK alone there are currently at least 850 000 people estimated to be living with dementia (Alzheimer's Society, 2019). The Department of Health and Social Care (DHSC) has identified the importance of timely dementia diagnosis and what someone should expect from health and social services (DHSC, 2018). In the UK, NHS memory services are the main initial point of assessment for people with suspected dementia and their families and carers (Wattis, 2011; Copland et al, 2018; NICE, 2018). Financial pressures on NHS services, increasing rates of referral for people with suspected dementia to services, and targets for increasing the proportion of people diagnosed (while speeding up the diagnostic pathway), all require creative solutions. Services must maximise the effective development of a skilled multiprofessional workforce to meet these demands (NHS England, 2018; 2019).
The NHS Trust described in this article therefore set out to meet this demand by speeding up access to ‘non-complex’ dementia diagnosis by ANPs, enabling psychiatrists to concentrate on more complex diagnoses. This was achieved by recognising and fully utilising the skills of experienced memory nurses more effectively. The new ANP role also enabled service users experiencing non-complex dementia, their families and carers to access assessment, diagnosis (and, when appropriate, treatment) of dementia from one health professional, rather than in multiple appointments with different professionals. Extended roles for MHNs have been shown to contribute to improved outcomes for service users and carers (Page et al, 2008b; Boyd, 2013; Mitchell et al, 2013). The Trust's memory services had non-medical prescribing well established and a model of nurse diagnosis was well established in the service through the nurse consultant role (Clibbens, 2011). However, there were concerns that other specialist memory nurses needed further training in assessment, diagnosis and treatment of dementia to meet increasing service demands. These concerns were also mirrored nationally. Page and Hope (2013) identified a clear need for specialist memory nurses to develop increased skills and competencies to meet future service needs.
Developing the ANP role
Developing the ANP role involved transforming the dementia assessment pathway in the Trust and ensuring there was a clear evidence-based pathway specifying the role and function of the ANP in the pathway and the referral and triage process. Importantly, the Trust's nursing strategy had been developed to include key sections related to modernising nursing roles and career paths (for example standardising job titles, role content and values-based job descriptions). The action plan for implementation of the Trust nursing strategy was developed to include the development of the ANP role in memory services across the Trust. Ultimately, the ANP role was anticipated to deliver cost-effective services, reducing reliance on agency medical staff, and, importantly, freeing up consultant psychiatrists for patients with more complex presentations.
Process for developing the ANP post
The initial proposal for these new posts was discussed and agreed with members of the Trust board, including the nursing and governance lead, and the medical director. Support from lead clinicians in each locality was obtained. An implementation group was established to produce a detailed clinical governance document for the roles, new job descriptions and to identify an appropriate postgraduate course to deliver the required competencies. The whole process involved Trust business managers, practice governance coaches, clinical and managerial leads, professional leads and human resources staff (Miller and Clibbens, 2017). As part of planned service transformation and modernisation, each locality business unit within the Trust formally approved development of the roles following engagement and agreement with local clinical commissioning group (CCG) commissioning leads (Figure 1).
Box 2 contains key elements that enable the successful funding and implementation of the ANP roles in the Trust.
Process for the ANP candidate
Once the governance document, referral pathway and criteria were agreed and implemented, job descriptions were devised and approved, including an agreed person specification for interested applicants. This required significant experience as a band 6 or 7 memory nurse and independent prescriber, with previous successful degree-level study. The banding on successful completion was agreed as Agenda for Change band 7 (NHS Employers, 2019). There were clear preceptorship and supervisory processes implemented following successful completion of the course (Miller and Clibbens, 2017).
In order to develop this new role in the memory services an appropriate course to prepare the candidate for the ANP role was required. A distance learning Postgraduate Certificate for Health Care Professionals with a Special Interest in Dementia, at a local university was accessed. The course set out a number of competencies that could all be linked to the ANP role. The course content contained two modules: ‘The assessment and diagnosis of dementia’ and ‘Pharmacological and psychosocial support for people with dementia’. The assessment of clinical competencies was completed by an in-house clinical mentor through observed and discussed case examples each week in practice. ANP students found the course challenging, but its flexibility allowed for the development of the ANP role in the memory service through ongoing service provision by the student ANP combined with part-time study (Hemingway, 2017). This reduced any negative impact on the service through reduced resources while the course was completed over a 12-month period. Following completion of the course, non-medical radiology referral has also been developed to enable the ANPs to directly request CT and MRI brain scans within the diagnostic pathway. Education is seen as a key step for the development of ANPs generally (Sheer and Wong, 2008) and for the specialist memory service role in particular (Page and Hope, 2013).
Broader context for the Trust
The ANP role in memory services has enabled the effective utilisation of service transformation and opportunities to modernise nursing roles and careers to achieve improved quality and cost-effectiveness in service delivery. This is evidenced by an increased capacity within each memory service to diagnose dementia and the achievement by each service of national accreditation with the Memory Service National Accreditation Programme (MSNAP) (Copland et al, 2018), based on anonymised service user, carer and referrer feedback. For the Trust, this successful role development has been seen as providing a model that can be incorporated within other contexts of mental health care and incorporated into service and workforce transformation. Since the initial implementation of these roles, six further staff from across a range of mental health services have been supported to commence ANP postgraduate courses as part of further planned workforce development.
There is now an opportunity for MHNs as ANPs to contribute to the effective transformation and modernisation of services. Increasing demand for health care, provided within clear timescales and to a high quality, requires skilled health professionals such as MHNs to fully utilise and build on their skills and knowledge to meet this demand. The model described here within one NHS trust may have implications for services in the UK and internationally, and shows the importance of a coordinated strategic approach to commissioning and delivering services, within which ANPs can perform core and cost-effective elements of an evidence-based pathway.
At a time of increasing difficulty in recruiting MHNs, trusts that offer clear pathways for nurses to clinically and academically develop may achieve improved recruitment and retention in a competitive market for employers. Importantly, preparing the MHN appropriately for the role of ANP from the outset of their career is the key to developing MHNs who are competent and have the skills and knowledge to develop into the ANP role over time. Trusts need to continue to enable MHNs to develop competencies in non-medical prescribing and advanced physical assessment skills alongside essential psychosocial interventions, so these practitioners have the breadth of experience and skills to progress into much needed ANP roles and consultant nurse roles in the future.