In my new role at the Nursing and Midwifery Council (NMC) I am excited to be leading the review to consider if we should regulate advanced nursing and midwifery practice, which is part of the NMC corporate plan 2023-25 (NMC, 2023).
Beech et al (2019) published findings from research undertaken at The Nuffield Trust, outlining several high-impact interventions. These, if put into action, could help improve the workforce crisis. One recommendation was that, in the interests of both patients and public, Health Education England and professional regulators should actively and co-operatively support the ability of non-medical staff to safely undertake advanced clinical roles and extend their scope of practice.
Citing the UK as an outlier, Beech et al (2019) made a key recommendation: ‘In the interests of patients and staff, we recommend that the Department of Health and Social Care and the professional regulators give consideration to more formal national regulation of advanced practice.’ They cited problems with the regulatory framework, including the absence of protected titles or a clear national competence framework, warning that this opens up clinical governance risks, and is likely to inhibit the portability and sustainability of roles.
In this context, the NMC recently commissioned research from The Nuffield Trust to both engage with key stakeholders and look at the existing literature from all four UK nations, and consider international approaches to the regulation of advanced practice.
Led by Palmer, the research was published this May (Palmer et al, 2023). It found great variation in how professionals enter and practise in advanced roles across the UK, resulting in a lack of consensus and no single definition of advanced practice, nor any consistent outcomes, or standards of education or proficiency.
The evidence did suggest, however, that there are latent risks in the current arrangements for the preparation and employment of professionals in advanced practice roles. Of note, are the risks associated with diagnosis, advanced decision-making, prescribing and delivering care interventions. Some participants in the research thought that, in certain settings outside the NHS, the risks to service users increased. However, the research also found wide variation in the understanding of, and support for, advanced practitioners across different NHS employers.
In the UK, the onus is placed on nurses and midwives working in advanced practice roles to themselves take responsibility for ensuring that they work within existing regulatory frameworks. Employers are responsible for assuring the suitability of an individual's qualifications and experience to undertake any advanced practice role. This differs from the position in many other nations where there is specific regulation of advanced practitioners.
A cross-country comparison identified 11 countries with significantly similar scopes of advanced practice, with only Finland and the UK not specifically regulating advanced nursing practice. Only one country currently regulates advanced midwife practitioners.
Furthermore, countries such as the USA, Canada, Australia and New Zealand also all have continuing education requirements for advanced practice. The Nuffield Trust report (Beech et al, 2019) found substantial variation in advanced practice master's programmes and, in some instances, only limited assurance on the standards of those completing them. Furthermore, the researchers noted the increase in the number of new providers delivering advanced practice programmes. Additional non-regulatory processes that were noted included the commissioning and accreditation of master's level advanced practice programmes, and credentialling of professionals' qualification/competency by some professional bodies.
One of the most consistently raised regulatory issues was around protection of title, although the scale of the problem appears to vary between nations. One of the greatest concerns was around the lack of protection of the title ‘nurse’ (unlike ‘midwife’). Others recognised that protection of an advanced practice title would not prevent other job titles being used for people in advanced roles.
Overall, stakeholders were in favour of specific regulation and were able to articulate a variety of regulatory approaches that could be used to provide greater assurance. They indicated that any recommended approach would have to take account of the complex and evolving regulatory landscape.
This phase of discovery provides us with an initial evidence base, enabling us to identify lines of enquiry for the NMC to explore further before crystallising options and making recommendations later in the year. In exploring whether additional regulation of advanced practitioners is needed, we will begin with our overarching objective – the protection of the public – and with the related objectives of maintaining public confidence in our professions and promoting professional standards. Please get involved with being part of this work.