In this guide
Introduction
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The purpose of this document
Advanced practice refers to a level of practice rather than a title, role or specialism.
The purpose of this document is to set out a definition of advanced practice that is clear to the public, along with high-level principles of best practice expected of nurses and midwives working at an advanced level. The principles also seek to provide organisations and employers with the fundamentals which will enable consistent, high-quality, safe and effective delivery of care by advanced level professionals.
This document seeks to support public protection by outlining the common components integral to the safe and effective delivery of high-quality care by nurses and midwives practising at an advanced level. The principles seek to support and maintain confidence in nurses and midwives practising at an advanced level, thereby contributing to a health and social care system that is efficient, effective, equitable, personalised, and trusted by the public.
The principles were developed using our methodology of co-production and collaboration based on feedback from members of the public, professionals, employer organisations, educators, system regulators, and other interested parties.
Aim of the principles
The principles aim to underpin the development, implementation and evaluation of effective governance for advanced level practice and promote excellence. In this way the principles support the development, maintenance and transformation of environments in which advanced practice is delivered.
The principles recognise that advanced level practice happens within inter-connected systems where inter-professional working and learning are key. We would encourage nurses, midwives and their teams to champion these principles to influence their adoption in all settings in the pursuit of best practice.
Context
The principles for advanced practice will provide the foundation for further work as part of our review of advanced practice. As such, the principles are one aspect of a multi-part approach to provide additional regulation of advanced level practice for nurses and midwives. The remaining elements of this approach include:
- Setting standards of proficiency
- Setting associated programme standards that will enable us to approve the programmes delivered by those education institutions which offer the required education to enable nurses and midwives to become advanced practitioners
- Support for existing nurses and midwives practising at an advanced level to transition to our regulatory approach
- Consideration of embedding specific elements into the review of the Code and revalidation
These elements will be introduced in phases to ensure effective development and implementation, and to provide consistency in terms of regulatory expectations for nurses and midwives working at an advanced level of practice.
These principles are purposefully high-level, seeking to provide consistency and clarity. They have been developed to complement but not replace the existing advanced practice frameworks of the four nations of the UK. Advanced level practice is undertaken in an inter-professional landscape and across a variety of settings. Our remit is to develop principles for advanced practice in nursing and midwifery for those professionals on the NMC register. However, we have endeavoured to develop the principles so that they could be adopted by other professional regulators, system regulators and organisations in the future should they wish to do so.
Who this document is for
This document is for:
- People who receive care delivered by nurses and midwives working at an advanced level of practice
- Nurses and midwives working at an advanced level of practice
- Nurses and midwives working towards or undertaking additional education to become advanced level practitioners
- Professionals who work with nurses and midwives practising at an advanced level
- Individuals in organisations who play a role in recruiting, managing, delivering and assuring the quality of governance processes and service delivery for professionals working at an advanced level of practice
- Professional organisations, policy makers and commissioners
- Those who have a role in educating, supervising and supporting nurses and midwives working at an advanced level of practice
Throughout this document where we refer to individual professionals or practitioners, we mean nurses and midwives on our register.
Defining advanced practice
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Through the work we've undertaken to develop the principles for advanced practice, our public advisory group are clear that the definition must set out in plain language what people can expect when they receive services provided by nurses and midwives working at an advanced level.
We recognise that there are several definitions of advanced practice across the UK and globally. These all recognise the higher-level capability, knowledge, skills and expertise required by practitioners to deal with increasing levels of complexity, uncertainty and risk. They also recognise the need for autonomy, accountability, influence and impact within an individual's scope of practice.
Our definition seeks to bring consistency; it makes clear that nurses and midwives working at an advanced level practise across a variety of settings, both clinical and non-clinical, and across all four pillars:
- Clinical practice
- Research
- Leadership and management
- Education
We have a professional version of the definition and a public version, each of which have been co-produced with diverse views from the groups they represent.
Professional and public definitions
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The professional version:
A registered nurse or midwife working at an advanced level is an expert professional with additional post-graduate education and experience. They use their evidence-informed knowledge, skills and capability to influence, shape, deliver and lead safe and effective care, while managing risk, uncertainty and complexity.
The public version:
A registered nurse or midwife working at an advanced level of practice is a professional who has completed extra post-qualification education to increase their knowledge and skills, allowing them to deliver and lead expert, higher-level care.
Benefits of advanced nursing and midwifery practice
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Nurses and midwives practising at an advanced level do so in a range of settings and roles as leaders, educators, researchers and practitioners. They may manage complete episodes of person-centred, complex care; design and develop educational programmes; or conduct high-quality research and/or audit that informs policy and practice and optimises people's experiences and outcomes.
They add value and impact to both individuals and environments, and this impact will vary according to their scope of practice and the setting in which they work.
Some of the benefits that nurses and midwives working at an advanced level provide for the public include:
- Public assurance: nurses and midwives working at an advanced level are individuals with additional, recognised post-qualification education and experience which helps to provide assurance of high-quality care/services for people.
- Right person, right time: nurses and midwives working at an advanced level have additional post-qualification, often specialised education and experience with associated knowledge and skills. This helps to ensure people have better access to care/services in a timely and equitable manner.
- Continuity of care: nurses and midwives working at an advanced level can lead and manage complete episodes of care, advocating for and developing partnerships with people, which can lead to improved care.
- Consistency and quality: nurses and midwives at an advanced level integrate their expertise across clinical practice, leadership and management, and research and education in their own area of practice. They consistently provide and ensure safe and effective high-quality care and positively influence and shape future care/service delivery.
- Effectiveness of person-centred care: nurses and midwives working at an advanced level work in partnership with people to lead, facilitate, and safeguard effective care, delegation and service co-ordination.
- Enhancing trust and confidence: nurses and midwives working at an advanced level provide assurance of safe and effective care by tailoring it to the needs of individuals and using an understanding of the wider socio-economic background to optimise people's trust and confidence in their care experience.
- Making contacts count: nurses and midwives working at an advanced level possess a deep understanding of the broader health and social care context in which they operate. By working in partnership with people, prioritising continuity of care, they are uniquely positioned to apply public health principles, guiding individuals and communities towards improved health outcomes.
- Improve health outcomes: nurses and midwives working at an advanced level identify, challenge and seek to reduce health inequalities and positively influence health and social care by working in roles such as practitioners, researchers, educators and leaders.
- Forward thinking practitioners: nurses and midwives at an advanced level are leaders and innovators, using their expertise and broad knowledge to find modern, sustainable and technological solutions to overcome challenges and transform services.
About the principles
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Across the UK, it is well recognised that advanced practice is broadly framed around "four pillars": clinical practice, leadership and management, education, and research. Practitioners working at an advanced level must demonstrate that they practise across these pillars, taking into account individual job planning requirements, skill mixes in inter-professional teams, work setting and scope of practice. The four pillars run through all the principles we have developed.
The principles apply to individual professionals who have attained the capabilities of advanced level practice, rather than those developing the knowledge and skills to practise at an advanced level, but we recognise that these will also be helpful for those aspiring to advanced level practice. Those developing this expert, high-level knowledge and skills will do so through substantial additional post-qualification education – both theoretical (in an academic learning environment) and applied (in both clinical and non-clinical learning environments) with supervision and professional support from employers to ensure their readiness for practice at this level.
In the future, education providers will be required to demonstrate how their advanced practice programmes for nurses and midwives meet the standards of proficiency and associated education programme standards. All programmes must be approved through the NMC's education quality assurance processes in line with our quality assurance framework.
How we developed the principles
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The principles have been developed through the following process:
- Analysis of international policy and context
- Alignment and mapping to the existing advanced practice frameworks of the four UK nations
- Consideration of relevant frameworks from professional bodies and other health and social care professional and system regulators
- Consideration and mapping to current health and social care reports drawing upon research and evidence-informed practice
- Extensive stakeholder engagement with multiple groups of professionals who work at, or impact upon, this level of practice
- Support of expert working groups from each of the four UK nations
- Extensive public engagement through our public advisory group, public voice forum and other networks, including specific feedback on the public-facing definition
The principles are set out under two headings:
- Principles applying to the individual professional working at an advanced level of practice, and
- Principles applying to those organisations that employ individual professionals working at an advanced level of practice (this includes self-employed practitioners).
Principles for individual professionals
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These principles provide clear expectations for advanced level practice across a range of roles and settings. These roles can span wide areas of health and social care aligned to local and national legal, regulatory, professional and educational requirements. This includes but is not limited to the delivery of safe and effective care for a range of people across the continuum of care with a well-developed understanding of the wider determinants of health to safeguard and promote wellbeing, protect health and prevent ill health.
All nurses and midwives on our register must practise in line with the Code. In addition, advanced level practitioners should:
1. Practise within their individual scope of practice and in line with their level of knowledge, experience, qualifications, training and employment role.
1.2 Demonstrate expertise, confidence, critical thinking, and evidence appraisal and synthesis within their individual scope of practice to lead and influence education, research and practice.
1.3 Demonstrate professional accountability and capability in making complex evidence-informed decisions, managing varying degrees of risk, unpredictability and uncertainty while exercising professional judgement. This includes using initiative, demonstrating significant autonomy and being accountable for their actions.
1.4 Demonstrate self-awareness with compassionate and inspirational leadership within inter-professional teams to influence practice for effective, holistic, person-centred care.
1.5 Demonstrate use of evidence-informed expert knowledge to practise reflectively, identifying areas for self-improvement and improved outcomes for a diverse range of individuals, teams and people.
1.6 Role model reflective and reflexive practice and advocate for access to individualised support and clinical supervision to ensure continuous learning, improvement and professional development across the four pillars.
1.7 Role model professional practice, advocating for and contributing to inter-professional learning and working to provide leadership and effective support and supervision to a broad range of colleagues and learners.
1.8 Use their expert, advanced level knowledge and experience to challenge themselves and others to promote and embed professional curiosity and the principles of equality, equity, diversity and inclusion in their area of practice, seeking and acting upon feedback received from peers, colleagues and the public.
1.9 Support, influence and lead projects in the environments they work in to shape a reflective learning culture where safety, quality, continuous improvement and sustainability are prioritised, including promoting allyship and advocacy for all, speaking up and raising concerns where required.
1.10 Evidence continued capability, reflective and reflexive practice, ongoing learning and professional development at an advanced level, relevant to their scope of practice, through local appraisal processes and through professional revalidation requirements.
1.11 Utilise their expertise and experience to minimise environmental impacts, enhance economic growth and embed sustainable approaches to service planning, delivery and implementation.
1.12 Lead and contribute to the proactive identification and resolution of challenges to health, safety and wellbeing for individuals and population groups, shaping the design and delivery of effective services and policies that promote holistic health and wellbeing.
Principles for employing organisations
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The principles within this section apply to organisations that employ individual practitioners working at an advanced level, including educational organisations and those that manage the learning and working environments of individual advanced practitioners. Individual practitioners who are self-employed should also ensure that they are practising in an environment which enables these expectations to be met.
They also set out our expectations for the effective governance required to ensure care and services are being delivered safely by suitably qualified, competent, skilled and experienced advanced practitioners who receive appropriate support, supervision, training, and professional development.
Advanced practitioners commonly work across traditional boundaries, specialisms, job roles, and settings in innovative ways. The following principles may therefore also apply to organisations who are impacted by or who may influence the delivery of advanced level practice, research, policy, strategy, leadership or education.
To provide an environment where advanced practice can flourish there should be:
2. To provide an environment where advanced practice can flourish there should be:
2.1 Robust governance processes for advanced level practice in line with local and national legal, regulatory, professional and educational requirements, with clear lines of accountability and communication, appropriate resources and processes that facilitate and encourage high performance and optimise autonomy, leading to consistently improved outcomes.
2.2 A culture that supports shared learning and a high standard of working for advanced practitioners within and across inter-professional teams that is safe and effective for all.
2.3 Opportunities for individual practitioners to learn and work at an advanced level within their scope of practice, job role and setting, practising with increased autonomy across the four pillars of advanced practice with support from appropriately qualified, proficient and skilled individuals.
2.4 Development of new and existing advanced practitioners to provide effective leadership and management that ensures co-ordinated care across professions and teams to a high standard of professional practice.
2.5 An open and honest culture for advanced practitioners with opportunities for feedback from other professionals at all levels and members of the public which then encourages reflective and reflexive evidence-informed practice and supports professional development across the four pillars.
2.6 A reflective environment that facilitates access to individualised support and/or clinical supervision for advanced practitioners across the four pillars throughout their career.
2.7 An environment that enables and sustains shared learning for advanced practitioners along with other professionals, to optimise effective teamwork, use of resources and improved outcomes, demonstrating impact and value.
2.8 Equity of opportunity for individual practitioners to access advanced practice education, qualifications, ongoing professional learning and opportunities to practise at an advanced level to maintain capability. Professional curiosity should be encouraged and the principles of equality, equity, diversity and inclusion embedded at all levels.
2.9 An open culture where individuals are encouraged to actively seek and receive feedback, reflecting on their experiences, actions and decisions; where safety, quality and continuous improvement are valued and prioritised; and where advanced practitioners feel safe to act as advocates, speak up and raise concerns.
2.10 An environment where interprofessional learning is prioritised and valued and with robust local governance processes to support, attain and maintain competence, capability and professional development, in line with revalidation requirements.
2.11 Systems, processes and resources for advanced level nurses and midwives to lead and support the delivery of sustainable practices and minimise environmental impacts in health and social care in collaboration with others.
2.12 Opportunities and support for nurses and midwives working at an advanced level to lead effective change where health and social care challenges have been identified, transforming services today and in the future.
Glossary
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Clinical learning environments
Clinical learning environments are learning environments where practice placement learning takes place that are also settings where clinical care is being delivered, such as hospitals, general practice surgeries, clinics and nursing homes.
Clinical supervision
Clinical supervision is a formal process of professional support, reflection and learning that contributes to the individual professional development of health and social care professionals.
Complete episode of care
An episode of care includes all the services provided to a person to treat a clinical condition or procedure. The services included in an episode of care occur within a specific period of time and from a range of organisations that make up an integrated system. A complete episode of care is all the stages of identifying, assessing, treating and managing a condition from start to finish of the process.
Inter-professional teams
Teams made up of professionals from two or more different professions. In the context of health and social care this would mean a team made up of individuals from two or more different health and social care professions who develop and have a shared understanding of each other's roles and responsibilities to achieve better outcomes for people. Inter-professional teams exist in the context of both working and learning.
Non-clinical learning environments
Non-clinical learning environments are environments where learning takes place that are not settings where clinical care is being delivered. This would include educational environments such as university lecture theatres and classrooms. The term may also include settings where learning experiences take place but where clinical care is not being delivered, such as in research, policy development and strategic leadership roles.
Organisations
In the context of these principles, this refers to any organisation involved in the employment and/or deployment of the advanced and consultant practice workforce. This includes, for example, organisations in acute care, primary care, community care, social care, and mental health, as well as private, voluntary and independent sectors and practitioners working at an advanced level of practice via locum contracts that provide NHS services. It also includes educational establishments and organisations involved in the education and ongoing training and development of individuals working in advanced practice roles.
People
Individuals or groups who receive services from nurses and midwives practising at an advanced level, healthy and sick people, parents, children, families, carers and representatives, including educators, students and others within and outside the learning environment.
Person-centred care
An approach to care delivery where the person is at the centre of the decision-making processes and the design of their care needs, their nursing care and management plan.
Principles of equality, equity, diversity and inclusion
This term describes policies and initiatives that support and promote fairness, and the representation and participation of different groups of individuals regardless of age, race, religion and belief, ethnicity, gender, gender reassignment, sexual orientation, pregnancy and maternity, marriage and civil partnership or disability. It will also cover other non-protected characteristics such as geographic location or socio-economic status.
Reflective and reflexive practice
Reflective practice is a retrospective act of looking back on something, while reflexive practice is a continual process that brings reflection into the present moment (this could be portrayed as 'reflection on action' and 'reflection in action').
