As part of our review of advanced practice, we commissioned the Florence Nightingale Foundation (FNF) to undertake an independent piece of research to explore the potential implications of additional regulation on internationally educated nurses and midwives working in the UK. This work includes a rapid evidence review, a targeted survey and focus groups. You can read the report from FNFs rapid evidence check here. 

If you are trained as a nurse or midwife outside of the UK and are now practising in the UK, please take part in the survey to let us know about your views and experiences. The survey should take no longer than 15 – 25 minutes. If you do take part, FNF are offering the chance for respondents to win a place on their internationally educated nurses and midwives leadership programme and you will be helping to inform and shape next steps in our advanced practice review.

Complete the survey

To start this review, we commissioned:

  • The Nuffield Trust looked at the existing literature on regulation of advanced practice, and international approaches to regulating advanced practice. It also considered the advanced practice landscape in all four countries of the UK, in conversation with key senior/relevant stakeholders. Read the Nuffield Trust report
  • BritainThinks ran discussion groups with professionals currently working in advanced practice roles, in all four countries of the UK. This is one of several engagement reports we will be publishing. Read the BritainThinks report

We drew on these discussions, the independent reports and other evidence to advise our Council in 2023 about options and next steps. The Council approved the next steps of the discovery phase, including:  

a) Exploring specific key lines of enquiry to inform the decision on the future direction of this work.  

b) The establishment of the advanced practice independent steering group

From November 2023 to February 2024 we engaged with stakeholders to ensure we carefully considered the views of the public and professionals with an interest in advanced practice. This included people from different practice settings and backgrounds.

We engaged extensively in all four countries of the UK, with nursing and midwifery professionals, members of the public including people with lived experience of receiving care from advanced practitioners, and with charities and advocacy organisations.

Thinks Insight & Strategy produced an independent analysis of our stakeholder engagement, identifying common themes. These themes, building on our earlier research, have enabled us to make our recommendations to Council. 

Our key lines of enquiry

We are investigating specific topic areas to further understand the benefits and risk to people who use services, how regulation may mitigate these risks and clarify where others have responsibility.

In order to better understand the risks identified in the Nuffield Trust report (2023) the Council agreed we should undertake a number of key lines of enquiry (KLOEs) to guide phase one of the AP review.

These KLOEs underpin the review and have enabled us to gather existing evidence, test assumptions, identify gaps and gain consensus through engagement with stakeholders. The KLOEs have enabled us to progress through Phase One in order to reach consensus.

Each KLOE paper provides the outputs of the KLOE review which has been gathered using a mixed methods approach, including desk-based evidence gathering, rapid literature reviews, stakeholder engagement and discussions with international professional regulators and professional bodies. The evidence in these papers reflects evidence gathered from August 2023 – February 2024.Then in turn these have undergone, internal and external scrutiny and challenge.

The KLOEs are iterative and have been ‘live’ documents throughout Phase One and as such they continue to be updated with new information as Phase One has progressed. These papers are therefore ‘Phase One – interim’ papers. The KLOEs have supported the development of a number of potential regulatory options. Each KLOE paper can be read individually but helpfully to support the sequencing of our activity should be read prior to the options appraisal paper and the independent analysis of engagement.

Outline and purpose of the key lines of enquiry papers

You can find the indudvidual key line of enquiry papers below.


    1. evaluated the advanced practice frameworks in the four nations of the UK to explore the feasibility and appetite for co-producing a unified UK wide advanced practice framework. 

    2. considered models of regulation used in other countries to determine whether we could successfully adopt any model in the UK. Key lines of enquiry 1 & 2

    3. appraised our current regulatory approach that uses scope of practice to inform what the regulation of an advanced level of practice may warrant. Key lines of enquiry 3

    4. considered and mitigated the risk of regulating advanced practice via specific tasks previously undertaken by other professions. Key lines of enquiry 4

    5. assessed what the implications for supervision and assessment of future advanced practice professionals may be, and options on the need for specific requirements for continuing professional development and revalidation. Key lines of enquiry 5

    6. examined the stance taken by other professional regulators and how other professions inform the assurance of advanced practice within specialities and specialisms. Key lines of enquiry 6

    7. undertook an economic cost/benefit analysis to support our findings and recommendations. This paper will be published in due course

    8. undertook a full appraisal of the proposed regulatory options including the benefits, risks, opportunities and challenges with each. Key line of enquiry 8

    9. explored the implications of additional regulation on internationally educated nurses and midwives. Undertaken by the Florence Nightingale Foundation: Key line of enquiry 9
What has the Nuffield Trust research told us?

Although more nurses and midwives are taking on advanced practice roles, it’s unclear whether people who use health and care services and the public understand this and what it means for them. 

This matters because leading and delivering the level of practice that advanced practitioners are undertaking can carry inherent risks to the public and people using services. However, people may not know what it means when their nurse or midwife describes themselves as an advanced practitioner – and even those who understand can’t necessarily expect the same level of knowledge, skill and experience from different advanced practitioners with similar roles and job titles as responsibility for job titles typically lies with employers. 

The research found variation in how professionals enter and practice in these roles across the UK. It also found a lack of consistency in oversight and governance processes. This means there’s no single definition of advanced practice, nor any consistent outcomes, or standards of education or proficiency. 

For example, current routes to advanced practice status include higher education such as a masters’ degree. However, there’s substantial variation in courses, with some designed to meet different course outcomes than others and therefore including different content. 

The consensus from the interviews and focus groups was that some form of specific regulation was needed for advanced practice in nursing and midwifery.

What did the BritainThinks professional engagement discussions tell us?

Nursing professionals taking part saw autonomy, managing complexity and the need for consistency as the common factors in most advanced practice roles. Midwifery professionals taking part cited caring for women with additional and complex needs as a key factor.

Some professionals highlighted the variation in roles including responsibilities, qualifications and previous experience.

Professionals identified the benefits of advanced practice roles for members of the public, people who use services, their employers and themselves. But they recognised the lack of standardisation and wide variation as a risk.

Overall, professionals were in favour of regulating advanced practice with due consideration to the approach this may take. They see regulation bringing consistency to standards of proficiency that state the knowledge and skills required for the qualification and AP role and in reducing variation that exists currently.

What our engagement told us

There is widespread acknowledgement that APs play an important role in the healthcare system by enhancing capacity for service delivery; helping other health and care professionals to re-prioritise as part of an effective multi-disciplinary team; improving the overall quality of service; and providing pathways for career progression, facilitating workforce development and retention.

All stakeholders felt that as the professional regulator, the NMC was in a strong position to influence change. They emphasised the need to work collaboratively with other professional regulators, the four nations workforce leads and system regulators.

There are concerns, which align with previous evidence. This includes a lack of consistency in education and training, qualifications, responsibilities and governance processes. Although there were many examples of good practice, these were not widely shared. 

Four nation frameworks have improved consistency within countries, particularly within the NHS but there are concerns in other sectors and about variability across the UK as a whole, as well as across professions. This was seen as a key risk for the public, professionals, educators and employers.

There is overall consensus of the need for additional regulation to manage risks and support confidence and trust in our professions. It was also seen as being able to support four nation workforce development plans.

Out of the potential regulatory options shared, some options were received more positively than others, with a general preference for a phased or hybrid approach rather than a singular option, recognising the multi-faceted nature of the AP issue. The options seen as most favourable are enhanced revalidation (with caution to review the current baseline requirements before building on requirements for AP), credentialing and setting education standards.

Stakeholders raised caution about the options for implementation, eg: risks of workforce depletion if provision and support is not given for those currently in AP roles; creating an overly burdensome process; and not including the work that has already been done in the four nations.

Stakeholders also noted the need for: developing a shared definition of advanced practice as a good starting point; distinction between generalist and specialist roles, with consideration to consultant level nurses and midwives; clarity around education level requirements and if education programme standards are developed, careful weighting of education and practice experience; and the need for collaboration with system and other professional regulators to support system wide governance.

There was appreciation of the different stages at which nursing and midwifery professionals are in terms of AP development across the UK, with some noting this as an opportunity particularly for midwifery to develop a shared, consensus approach to regulation across the UK. This was particularly evident as the review progressed, with acknowledgement that the risks were quite similar across professions, and midwifery stakeholders seeing AP as an opportunity to encourage midwives to stay in the profession at a time when there are concerns about maternity services and professionals leaving. 

Based on the thematic analysis from the engagement, the following recommendations emerged:

  • consensus on the need for additional regulation;
  • the requirement to define the advanced practice role and tailored to specific audiences;
  • develop a process for transitioning those currently in advanced practice roles (‘grandparenting’);
  • further consult on proposed regulatory option/s and approach.
Yr hyn ddywedodd ein gwaith ymgysylltu wrthym

Rhwng mis Tachwedd 2023 a mis Chwefror 2024, buom yn ymgysylltu â rhanddeiliaid er mwyn sicrhau ein bod yn rhoi ystyriaeth ofalus i safbwyntiau’r cyhoedd a gweithwyr proffesiynol sydd â diddordeb mewn uwch-ymarfer. Roedd hyn yn cynnwys pobl o wahanol leoliadau ymarfer a chefndiroedd. Buom yn ymgysylltu’n helaeth ym mhob un o bedair gwlad y DU, gyda gweithwyr proffesiynol nyrsio a bydwreigiaeth, aelodau o’r cyhoedd gan gynnwys pobl sydd â phrofiad bywyd o safbwynt derbyn gofal gan uwch-ymarferwyr, a hefyd gydag elusennau a sefydliadau eirioli.

Cynhyrchodd Thinks Insight & Strategy ddadansoddiad annibynnol o’n gwaith ymgysylltu â rhanddeiliaid, gan nodi themâu cyffredin. Mae’r themâu hyn, ynghyd â’n hymchwil cynharach, wedi ein galluogi i wneud ein hargymhellion i’r Cyngor.

Yr hyn ddywedodd ein gwaith ymgysylltu wrthym

Ceir cydnabyddiaeth eang bod uwch-ymarferwyr yn cyflawni rôl bwysig yn y system gofal iechyd drwy wella’r capasiti ar gyfer darparu gwasanaethau; helpu gweithwyr proffesiynol iechyd a gofal eraill i ail-flaenoriaethu fel rhan o dîm amlddisgyblaethol effeithiol; gwella ansawdd cyffredinol gwasanaethau; a darparu llwybrau ar gyfer cynnydd gyrfa, hwyluso datblygu a chadw’r gweithlu.

Roedd yr holl randdeiliaid yn teimlo bod yr NMC, yn rhinwedd ei rôl yn rheoleiddiwr proffesiynol, mewn sefyllfa gref i ddylanwadu ar newid. Roedden nhw’n pwysleisio’r angen i gydweithio â rheoleiddwyr proffesiynol eraill, arweinwyr gweithleoedd y pedair gwlad a rheoleiddwyr y system.

Mae pryderon i’w cael, sy’n gyson â thystiolaeth flaenorol. Mae hynny’n cynnwys diffyg cysondeb mewn addysg a hyfforddiant, cymwysterau, cyfrifoldebau a phrosesau llywodraethu. Er bod nifer o enghreifftiau o arfer da, nid oedd y rhain yn cael eu rhannu’n helaeth. 

Mae fframweithiau’r pedair gwlad wedi gwella cysondeb o fewn y gwledydd, yn enwedig o fewn y GIG, ond mae pryderon mewn sectorau eraill ynglŷn ag amrywiaeth ar draws y Deyrnas Unedig gyfan, yn ogystal ag ar draws proffesiynau. Roedd hyn yn cael ei weld fel risg allweddol i’r cyhoedd, gweithwyr proffesiynol, addysgwyr a chyflogwyr.

Mae consensws cyffredinol ynglŷn â’r angen am reoleiddio ychwanegol er mwyn rheoli risgiau a chynnal hyder ac ymddiriedaeth yn ein proffesiynau. Gwelwyd hefyd y gallai hynny gefnogi cynlluniau datblygu gweithlu’r pedair gwlad.

O blith yr opsiynau rheoleiddio posib a rannwyd, cafodd rhai opsiynau dderbyniad mwy cadarnhaol na’i gilydd, gyda dull fesul cam neu hybrid yn cael ei ffafrio fwy na dewis sengl, gan gydnabod natur amlweddog uwch-ymarfer. Yr opsiynau sy’n cael eu ffafrio fwyaf ydy ail-ddilysu uwch (gan gymryd gofal i adolygu’r gofynion sylfaenol presennol cyn datblygu ar y gofynion ar gyfer uwch-ymarfer), gwirio cymhwysedd a gosod safonau addysg.

Cododd y rhanddeiliaid bryderon ynglŷn â’r opsiynau ar gyfer gweithredu, e.e.: risgiau y gallai’r gweithlu grebachu os na roddir darpariaeth a chefnogaeth ar gyfer y rhai sydd mewn rolau uwch-ymarfer ar hyn o bryd; creu proses orfeichus; a pheidio â chynnwys y gwaith sydd wedi’i wneud eisoes yn y pedair gwlad.

Nododd rhanddeiliaid yr angen hefyd i: ddatblygu diffiniad ar y cyd o uwch-ymarfer fel man cychwyn da; gwahaniaethu rhwng rolau cyffredinol ac arbenigol, gan ystyried nyrsys a bydwragedd ar lefel ymgynghorwyr; eglurder ynglŷn â gofynion lefelau addysg ac os caiff safonau rhaglenni addysg eu datblygu, pwysoli addysg a phrofiad ymarferol yn ofalus; a’r angen i gydweithredu â rheoleiddwyr y system a phroffesiynau eraill er mwyn cynnal llywodraethiant ar draws y system.

Roedd cydnabyddiaeth o’r camau gwahanol y mae gweithwyr proffesiynol nyrsio a bydwreigiaeth arnynt o safbwynt datblygu uwch-ymarfer ar draws y DU, gyda rhai’n nodi bod hwn yn gyfle, yn enwedig i fydwreigiaeth, i ddatblygu ymagwedd gyson, ar sail consensws at reoleiddio ledled y DU. Daeth hyn yn arbennig o amlwg wrth i’r adolygiad fynd rhagddo, gyda chydnabyddiaeth bod y risgiau’n eithaf tebyg ar draws y proffesiynau, a rhanddeiliaid ym maes bydwreigiaeth yn gweld uwch-ymarfer fel cyfle i annog bydwragedd i aros yn y proffesiwn mewn cyfnod lle mae pryderon ynglŷn â gwasanaethau mamolaeth a gweithwyr proffesiynol yn ymadael. 

Ar sail y dadansoddiad thematig o’r gwaith ymgysylltu, daeth yr argymhellion canlynol i’r amlwg:

  • consensws ynglŷn â’r angen am ragor o reoleiddio;
  • yr angen i ddiffinio rôl uwch-ymarferwyr gan deilwra ar gyfer cynulleidfaoedd penodol;
  • datblygu proses ar gyfer trosi’r rhai sydd mewn rolau uwch-ymarfer ar hyn o bryd (‘llwybr teidiau a neiniau’);
  • ymgynghori ymhellach ynglŷn ag opsiynau ac ymagweddau rheoleiddio arfaethedig.

Camau nesaf

Gwnaethom argymell i’r Cyngor felly y dylai ymchwilio i gyfuniad o ymagweddau tuag at reoleiddio uwch-ymarfer, gan gynnwys:

·       datblygu safonau hyfedredd ar gyfer ymarfer ar lefel uwch (a safonau rhaglenni cysylltiedig)

·       mabwysiadu dull cydweithredol o ddatblygu fframwaith egwyddorion uwch-ymarfer ar gyfer y DU gyfan, gan ymgorffori safbwynt neu ddiffiniad cyffredin o ymarfer ar lefel uwch

·       sicrhau y caiff gofynion ymarfer ar lefel uwch eu cynnwys yn yr adolygiad ehangach o ailddilysu a’r Cod sydd yn yr arfaeth ar gyfer 2025/26.

Cytunodd y Cyngor â’r argymhellion hyn ar 27 Mawrth 2024.  Byddwn yn mynd ati nawr i ymgysylltu ymhellach gyda’n partneriaid cyn ymgynghori’n gyhoeddus ynglŷn ag unrhyw newidiadau arfaethedig.