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The work of advanced nurse practitioners is misunderstood – even resented – by some medical colleagues, yet their role only enhances patient care and can boost the capacity of the NHS
Tensions have been simmering among clinicians about the role of physician associates (PAs), with the British Medical Association (BMA) warning that patients are being put at risk by the way non-medically qualified staff are being deployed in place of doctors. There are signs advanced nurse practitioner (ANP) role is getting dragged into the debate.
Nursing Standard. 39, 6, 19-22. doi: 10.7748/ns.39.6.19.s8
Published: 05 June 2024
Here, we look at how the role has attracted some negative comments recently and what life is like for these highly qualified nurses in an ever-changing health service.
What is an advanced nurse practitioner?
ANPs are expected to work autonomously, undertaking complex reviews of patients and diagnosing and treating them.
They must be educated to master’s degree level, and they often undertake education over the course of three years, alongside working.
ANPs were introduced more than 30 years ago and are now in a variety of settings, from general practice to emergency departments, orthopaedics and mental health. They may specialise in areas such as paediatrics, cardiac care and cancer. Typically ANP roles start at Agenda for Change pay band 8a, or band 7 for trainees.
Their roles can vary greatly, from treating acutely ill patients and conducting check ups, to prescribing medicines and advising on preventative care.
» Establish experience Some institutions require applicants to have five years’ post-registration clinical experience, as well as demonstrable experience in their specialty area
» Make a portfolio Include projects you have been involved with and what you have learned
» Become an independent prescriber, as this is part of the advanced nurse practitioner role too
» Gain a master’s-level degree This is normally undertaken part-time alongside practice
» Gather evidence of your practice across the four pillars set out in Health Education England’s framework:
» Work autonomously Use advanced clinical expertise and sound judgement and decision-making skills
Source: Advanced Level Nursing Practice (RCN)
‘Some doctors still question whether nurses should be working at this level’
Clifford Kilgore, consultant practitioner and advisory group member at the British Geriatrics Society
Why is advanced nursing practice facing criticism?
There has been criticism on social media in recent months, some of which has come in the context of the ongoing debate about the role of PAs. In one discussion on Reddit, doctors complained ANPs were costing them vital training experience, because, they said, nurses were seeing patients that should have been seen by junior doctors.
One wrote: ‘I can say without hesitation that ANPs have had a detrimental impact on my training.’
Another said that if nurses wanted to be doctors they should go to medical school. ANPs, they said, are getting too big for their boots.
On X, formerly Twitter, nurses have complained that anti-nurse rhetoric is increasing and that some BMA council members were publicly targeting ANPs.
Consultant practitioner Clifford Kilgore, who has worked as an ANP and has sat on advisory groups about the role as part of his involvement with the British Geriatrics Society, says the criticism has been unfortunate and there is a big difference between ANPs and PAs.
‘The role of PA was created to support doctors, but they may have worked beyond their scope of practice. That is what has caused the problems. ANPs are trained to do the job they are doing.’
The BMA has distanced itself from criticism of ANPs, saying its objections relate solely to the role of PAs and other medical associate professions, such as anaesthesia associates.
A spokesperson for the union says: ‘We support the use of a range of different clinicians as part of a multidisciplinary team, working within clearly defined scopes of practice and with appropriate supervision.
‘Our concerns have always focused on medical associate professions, which ANPs are not.’
‘Advanced practice roles do not replace medical staff, but add professional diversity and skill mix to the team’
Neal Aplin, emergency department advanced practitioner and member of the RCN’s ANP forum
Is there friction with doctors over the ANP role?
Despite the BMA position, Mr Kilgore certainly thinks so – but he says only a minority of doctors have a problem.
‘Some still question whether nurses should be working at this advanced level,’ he says.
Although much of the online criticism appears to come from early-career doctors, some of whom are concerned about how the presence of ANPs might affect their own training, Mr Kilgore feels those with an issue are more likely to be the older doctors.
‘They’re perhaps fearing what it will mean for their jobs, but that is misguided when you consider how short of staff the NHS is,’ he adds.
‘There is not much you can do about that, sometimes you just have to get on with it. The vast majority recognise the role ANPs play and work alongside them with no problems.’
Emergency department advanced practitioner Neal Aplin, a member of the RCN’s ANP forum, says much can depend on the area in which ANPs work.
The ANP role is well established in the ED, but can be unfamiliar to doctors coming from outside emergency care
Picture credit: Tim George
Advanced nursing roles were first trialled in the UK in the late 1980s in general practice, with the RCN starting its first nursing practitioner training course in the early 1990s.
In time, they became more specialised and prevalent in both primary and secondary care, in response to growing pressures in the NHS.
The term advanced nursing (or nurse) practitioner (ANP) began to be used.
Even nurses were sceptical in the early days
Paediatric ANP Coral Rees, who started working as a trainee ANP in 2004, says in those early days, even nurses themselves were suspicious of the new role.
‘I think it was to do with experienced nurses feeling threatened,’ she says.
‘It was new to secondary care, but it didn’t take long to win over the older generation of nurses. Once they saw what our roles brought to their wards and units, they didn’t want us to leave.’
Working at an advanced level across professions
In recent years, the term advanced clinical practitioner has come into use, reflecting the fact that other professionals such as physios and paramedics have started working at advanced levels.
Advanced clinical practice was highlighted in the NHS Long-Term Workforce Plan as being important to the future of the NHS by providing enhanced capacity and capability to meet the growing needs of the population.
‘In emergency departments, this role is well respected and understood,’ he says.
‘The relationships are generally good, but sometimes there can be challenges with medical staff who do not work in ED, as they may not fully understand the scope of practice and level of training we engage in.
‘It must be remembered advanced practice roles do not replace medical staff, but add professional diversity and skill mix to the team.’
How do patients perceive ANPs?
When it comes to interactions with patients, again Mr Kilgore says there are times when ANPs can find themselves facing doubters.
‘Some patients question why they are not seeing a doctor,’ he says.
‘There is still a perception the workforce is divided between doctors, nurses, physios and so on.
‘Younger ANPs are more likely to face this, I think. The important thing is to explain what you are trained to do, that you will never do or recommend something you are not sure of, and how you will consult with senior colleagues if you need to.
‘On the whole, I find people are less bothered about your title and more what you can do for them.’
Fellow RCN ANP forum member Katie Brown, who practised in other parts of the UK before taking her current role at a GP surgery in Northern Ireland, says she has found a difference depending on where in the UK she is working.
‘In England, the patients were more informed and had more encounters with ANPs, so they rarely had an issue,’ she says.
‘In Northern Ireland, I encounter this more often, probably one to two times a month on average, it varies. I get this most when I am doing telephone triage and patients are already frustrated at trying to get a call back.’
She says that when patients do complain, she explains her role and what she can do for them, and most are happy.
On the rare occasions when they insist on seeing a doctor, she obliges. ‘The doctor usually suggests the same treatment plan and this instils confidence.
‘I don’t take offence, as you see this when patients want to see the consultant instead of the registrar as well. This issue is simply around awareness of the roles.’
‘I have no problem saying no to undertaking anything that is not within my scope as an ANP’
Coral Rees, paediatric ANP based in Wales
Are ANPs being asked to work beyond their scope?
Ms Brown says it is hard to judge. ‘There is such a vast amount of different ANP roles across many clinical specialties. It’s not unusual for those roles to vary from place to place and clinician to clinician.
‘I may be competent to treat some conditions that my colleagues are not and vice versa.
‘This means that we may be asked if we can see or do certain things. The ANP needs to explain where their sphere of knowledge and competence lies.
‘I think, as an ANP, while there can be pressures related to workload and staffing levels, it’s vital that we are able to say no and seek help where things go beyond what we are able to do.’
Paediatric ANP Coral Rees, who is based in Wales, agrees. ‘As an ANP I’m aware of what my scope is. It’s my responsibility to work within this and demonstrate my competence through my advanced portfolio.
‘I have no problem saying no to undertaking anything that is not within my scope. Perhaps this is easier when working in secondary and emergency care.’
Is additional regulation of advanced practice needed?
Earlier this year the Nursing and Midwifery Council (NMC) announced it would be pushing ahead with a system of additional regulation for advanced practice.
This followed its review of advanced practice, which found there was great variation in the routes into roles and what advanced practitioners were doing, and this in itself could damage confidence and trust.
Mr Aplin broadly welcomes the NMC move, but also urges caution. ‘The NMC should be careful not to cause too much overlap with other already established governance strategies’ he says.
He cites the RCN credentialling for advanced practice alongside the specialist Royal College of Emergency Medicine and Faculty of Intensive Care Medicine specialist versions.
‘These processes are thorough and involve a great deal of workplace assessment. To ask nurses who have completed this, then to complete further work for the NMC will be duplicating already established systems.’
