The NHS is facing significant difficulties in meeting healthcare demands due to changing demographics and financial constraints (Hammond et al, 2017; Reynolds and Mortimore, 2018). This has led to a requirement for workforce redesign, including the development of advanced clinical roles within nursing and allied healthcare professionals which is explicit in the NHS Long Term Plan.
Advanced clinical practice
While the concept of advanced practice in healthcare has been around for many years, the title has been used inconsistently and the role poorly defined. However, in 2017, Health Education England (HEE) published the Multi-Professional Framework for Advanced Clinical Practice in England, which details not only an agreed definition of advanced clinical practice but also a framework focusing on four pillars of capability (HEE, 2017). Advanced clinical practice is defined as being characterised by a high level of autonomy and complex decision-making delivered by experienced, registered health and care practitioners who are educated to a Master’s level or equivalent and which encompasses the four pillars of clinical practice, leadership/management, education and research. The framework states that:
“Advanced clinical practice embodies the ability to manage clinical care in partnership with individuals, families and carers. It includes the analysis and synthesis of complex problems across a range of settings, enabling innovative solutions to enhance people’s experience and improve outcomes.”
Capability statements, to be evidenced, relating to the four pillars are set out in detail (with 11 capability statements each for clinical practice and leadership/management, and eight statements each for education and research). The framework relates not only to nurses but also to other healthcare professionals such as Health and Care Professional Council (HCPC) registrants; for example, physiotherapists. All must evidence the same level of capability regardless of discipline. The Royal College of Nursing (RCN, 2018) mirrors these sentiments in relation to the four pillars and a Master’s level education but also includes the need for a prescribing qualification, which HEE states may not be required as, currently, not all disciplines are legally authorised to have Non-Medical Prescribing qualifications.
Advanced Clinical Practitioners (ACPs) have been shown to have a positive impact on the patient experience in terms of reducing length of stay, continuity of care, timely access to treatment and increased patient satisfaction (Williams, 2007; Pearce and Breen, 2018). In addition, ACPs report increased job satisfaction and career progression (Hooks and Walker, 2020).
Both the NHS Long Term Plan (NHS, 2019) and the Multi-Professional Framework (HEE, 2017) acknowledge that ACPs are central to transforming the workforce and service delivery to meet healthcare needs. This raises the question of how this will impact on nurses working in senior clinical roles in specialities such as diabetes.
Similar challenges are evident in the delivery of diabetes care, for which inpatient staffing deficiencies are common and Diabetes Specialist Nurse (DSN) posts remain unfilled (NHS Digital, 2020, Hicks and James, 2020; Bossman et al, 2021).
Diabetes is a common long-term condition, affecting approximately 3.9 million people in the UK and with an additional estimated 1 million people who are currently undiagnosed (Diabetes UK, 2021). Its prevalence is predicted to increase to 5.5 million by 2030. Life expectancy is reduced with this condition and it is estimated that people with type 2 diabetes are 50% more likely to die prematurely that those without diabetes. Approximately 10% of the NHS budget is spent on diabetes, with the greatest personal and financial burden being due to complications. In addition, approximately one in six hospital beds are occupied by a person with diabetes and, worryingly, almost one third of inpatients with diabetes experience at least one medication or management error during their hospital stay (NHS Digital, 2020).
All of this supports the need for high-quality diabetes care delivered by skilled and knowledgeable staff. The aim of diabetes care is to improve patient outcomes by providing evidence-based care to optimise glycaemic control and reduce vascular risk factors, thereby reducing the burden of diabetes on the individual and the NHS. This is not without its challenges and it requires a patient-focused, multidisciplinary approach. The role of the DSN within the multidisciplinary team is undisputed, and the role has evolved and diversified to meet the shifting challenges of diabetes care.
The majority of DSNs work exclusively in diabetes care; they work across a variety of settings and may specialise in specific areas of diabetes care, such as inpatients, insulin pumps and structured education. A recent audit of 1872 nurses indicated that DSNs are employed under a wide variety of job titles (117), not all of which include the word specialist (Hicks and James, 2020). The authors acknowledge the confusion that this can cause for both patients and other healthcare professionals, and this may become more confusing as other roles such as ACPs become more commonplace.
The NHS Long Term Plan acknowledges the importance of growing the workforce and expanding the scope of practice of current staff. This is particularly important for a long-term condition such as diabetes, not only in light of the rising incidence and cost implications but also because of the skills needed to manage these patients effectively, considering the array of possible complications and comorbidities. This provides an additional challenge to nurses working in diabetes, many of whom currently could be considered to be working in advanced roles.
Specialist versus advanced roles
It may be beneficial to consider the difference between specialist and advanced practice and the concept of specialist advanced practice. To do this, it is useful to briefly reflect on the history of the DSN role. DSNs have been around since the 1950s, with the original focus being on education (Walker, 1953). The 1980s witnessed a marked rise in clinical specialism in many areas of nursing, the main impetus in diabetes being the changeover to U100 insulin (from the earlier 40 units/mL and 80 units/mL preparations), followed by home insulin starts and the introduction of home blood glucose monitoring.
At this time, such roles were considered to be specialist; however, now they are often carried out by other members of the healthcare team, thereby facilitating DSNs to move into more complex areas of diabetes care, such as global risk factor management or initiation and management of insulin pump therapy (Wallymahmed et al, 2011; Hicks and James, 2020). This mirrors the concept of workforce development and advancing practice whereby DSNs are developing new competencies, enabling then to take on roles previously considered to be the remit of medical staff, and thereby demonstrating the dynamic nature of not only the DSN role but healthcare in general. This is reflected in Benner’s (1984) model of expertise, assessing competence and professional growth from novice to expert. However, it has been suggested that the transformation of nursing practice has been so vast that Benner’s model does not accurately represent roles such as advanced practice and consultancy, and that two additional levels of practice – advanced expert and international influencer – should be added (Mortimore et al, 2021). This will reflect not simply expanded or extended roles but the autonomous clinical decision-making expected of advanced practitioners. Many DSNs will currently be progressing through Benner’s five levels of practice advancement, which are echoed in the Competency Framework for Adult Diabetes Nursing (TREND Diabetes, 2021). Interestingly, this framework includes an overarching statement for nurse consultants acknowledging the expert clinical role and emphasising the strategic/research/service-development role, which is in keeping with the views of Mortimore and colleagues.
So, are specialist nurses working to an advanced level? Pearce and Breen (2018) suggest that there are distinct differences in the roles of ACPs and specialist nurses, whereby ACPs use critical thinking, complex reasoning and analysis to inform assessment and decision-making. They refer to the example of nurse-led clinics where, for ACPs, the patient’s pathway is devoid of medical intervention and is managed entirely by the ACP, whereas nurse specialists may undertake clinics to support specific aspects of the pathway. In relation to diabetes, this may include structured education and support with insulin and GLP-1 receptor agonist starts, while the ultimate responsibility for the patient’s pathway lies with medical staff. This view, although agreed by Mortimore et al (2021), is of course a generalisation and it must be acknowledged that the roles of DSNs vary considerably; nonetheless, it is food for thought.
It is speculated that the ACP role is better suited to generalist practice than specialist practice. The rationale behind this is that patients present with a variety of undiagnosed conditions; therefore, a generic higher level of expertise rather than highly specialised expertise is required (Hooks and Walker, 2020). This was borne out in a recent study, in which participants considered the ACP to be a broad, generalist role rather than a specialist one (Hooks and Walker, 2020). These views may be influenced by the well-established roles of specialist nurses, suggesting that advanced roles are not needed. In addition, there is the debate around extended roles, involving practitioners taking on roles traditionally seen as beyond their scope of practice, versus advanced roles, which require education at Master’s level or above (Imison et al, 2016). However, at times, there appears to be a blurring of what is an extended and an advanced role. A recent systematic review reported similarities in the role of the specialist nurse and ACP in areas of patient care, leadership and education; however, ACPs were more likely to demonstrate strategic leadership roles (Cooper et al, 2019). Again, there was a focus on specialist nurses working within one specialty, whereas ACPs were more likely to be educated to a Master’s level and to work in generalist areas.
There is a paucity of literature exploring the transition from specialist nursing to advanced practice, although one paper, relating to the gastrointestinal consequences of cancer treatment, suggests the focus should be on the development of advanced practice clinical skills and role relationships, and that this requires local support strategies (Gee et al, 2018). In addition, Fowler (2021) makes the case for an ACP team, led by a nurse consultant, in haematology and oncology. The team works autonomously, and its role includes carrying out several clinical procedures. Clearly the specifics of the role will differ according to the speciality.
The Centre for Advancing Practice
The Centre for Advancing Practice (available at: https://advanced-practice.hee.nhs.uk) has been established by HEE to oversee advanced-level workplace transformation by:
- Establishing and monitoring standards for education.
- Accrediting advanced-level education programmes.
- Supporting and recognising educational and training equivalence.
- Growing the advanced and consultant practice workforce.
In addition, it is setting up an Advanced Practice Directory for those who have successfully completed an ACP programme accredited by the centre. The centre also acknowledges that there are experienced practitioners who may not have completed an accredited ACP programme but who have significant experience and evidence that can be mapped against the Multi-Professional Framework (HEE, 2017). Such practitioners may be able to gain accreditation via the ePortfolio (supported) route.
Advanced clinical practice is currently unregulated, and the establishment of the Centre for Advancing Practice may go some way to addressing this, ensuring only those with a recognised qualification use the title. Indeed, the Nursing and Midwifery Council (2020) strategy for 2020–2025 includes a plan to review advanced nursing practice and consider if regulation is needed.
The debate about advanced clinical practice and its associated titles is in many ways similar to previous debates around what constitutes a specialist nurse. Interestingly, one of the contentious issues on introduction of the Nurse Consultant role was the title; however, it may be that a distinct title such as consultant dictates a greater understanding of the role, especially if used only by those individuals who have been appointed to an approved post (Wallymahmed, 2003). It is a pity that mistakes from the past appear to have been repeated in advanced clinical practice, where titles are used without any real definition of the role (Hooks and Walker, 2020).
In diabetes there is always going to be a need for nurses working at a variety of levels. This is important for a clear career pathway. The view that advanced clinical practice is generalist needs to be challenged as diabetes is complex and often complicated by multiple comorbidities. In addition, there are many subspecialities within diabetes care. Many DSNs are responsible for whole episodes of care, including diagnosis, clinical management, prescribing and discharge; this is autonomous practice. So a plea from one of your own (one of the authors had a clinical career in diabetes which spanned over 30 years, with 16 years as a nurse consultant):
Do not be left behind. Fly the flag for advanced specialist practice or ACPs with a special interest in diabetes – although it may not feel so comfortable!