Feature
ADVANCED PRACTICE
IN NURSING: FROM
CONCEPT TO REALITY
Marie Cerinus and Paul Wilson explain the development
of an advanced nursing practice model, and the challenges
that healthcare professionals must meet in its implementation
Summary
This article provides an overview of an advanced practice initiative developed
at NHS Lanarkshire. The criteria that must be met when determining advanced
practice roles are discussed, and the management and leadership challenges
inherent in defining and implementing advanced practice in nursing are explored.
The article concludes with an outline of future activities in this field.
Keywords
Advanced nursing practice, nursing roles, clinical practice
ThE NEED to develop advanced practice in nursing
is highlighted in the government report Modernising
Nursing Careers: Setting the direction (Department of
Health (DH) 2006).
The advanced practice concept is also recognised
in the Skills for Health (2006) careers framework and
has been subject to regulatory consideration by the
Nursing and Midwifery Council (NMC 2005).
NHSScotland has taken a lead role in developing
advanced practice on behalf of the UK, with the
launch last year of the Advanced Nursing Practice
Toolkit (NHSScotland 2008), the key components of
which are shown in Figure 1, page 16.
The toolkit emphasises that advanced practice is
a level of nursing practice, not a role for nurses.
There are two reasons for the recognition and
support of advanced nursing practice: to improve
patient safety and experience of care, and to
enable nursing services to develop new service
delivery models.
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This article describes how the director of practice
development and the executive director for nursing
at NHS Lanarkshire have developed a model that
promotes advanced practice in generalist and
specialist nursing roles.
Developing the model
NHS Lanarkshire provides health services
across a large rural and urban population of
around 550,000. It has three district general
hospitals and around 100 community facilities,
and employs about 5,500 nurses, almost
4,500 whole-time equivalents, including
healthcare assistants.
NHS Lanarkshire’s workforce statistics listing
the nursing workforce last July by Agenda
for Change (AfC) pay bands are shown in
Table 1, page 16.
There are 11 types of nursing roles in
NHS Lanarkshire’s nursing role framework:
■■ Healthcare assistants.
■■ Students.
■■ Newly registered nurses.
■■ Nurses in bands 5 and 6.
■■ Associate clinical nurse specialists.
■■ Clinical nurse specialists.
■■ Lead clinical nurse specialists.
■■ Senior charge nurses and team leaders.
■■ Senior nurses.
■■ Nurse consultants.
■■ Associate and nurse directors.
NURSING MANAGEMENT
 JupiterImages
Analysis

The advanced nurse practitioner role combines

the professional competencies and capabilities
of specialist and generalist practice
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Figure 1 The key components of the Advanced Nursing Practice Toolkit Nurse leaders at NHS Lanarkshire wanted both
generalist and specialist nurses to have opportunities
to work as advanced practitioners, so they set out
to ensure that advanced practice is acknowledged as
a level, not as a role.
Definitions The model in Figure 2 shows the trajectory
of advanced practice where processes of care,
Job profile and
which are usually more explicit in specialist
Knowledge and
Links practice, and where patients’ journeys of care,
Skills Framework
which are usually more explicit in generalist practice,
outline
are addressed fully.
The fact that this trajectory is equidistant from
both axes indicates the importance, relevance and
value of generalist and specialist practice, and
Regulatory The advanced practice Activity suggests that both kinds of practice can incorporate
guidance toolkit analysis advanced practice.
A definition of the nurse consultant role was
entered on the trajectory to act as a point of
reference because the essential domains of this role
are also part of advanced practice (Table 2).

Workforce planning Development needs Defining scope of practice

support analysis
Educational
framework
Scottish Government (2008)
Nursing practice at NHS Lanarkshire can be
categorised as either ‘generalist’ or ‘specialist’, where
generalist nurses are defined as those who practise
across patient journeys, and specialist nurses as
those who use their specialist knowledge and skills
to focus on specific aspects of these journeys.
Care should be provided by both generalist and
specialist nurses to ensure that patients’ journeys
are supported at all times by the most appropriate
healthcare professionals.
Recent figures show that NHS Lanarkshire has
140 designated clinical nurse specialists (Scottish
Government 2008), although there are many
generalist nurses who have specialist practitioner,
or equivalent, qualifications and who operate at high
levels of practice.
Using the work of the Association of Advanced
Nursing Practice Educators (2006) and the RCN
(2008), a definition of scope of advanced nursing
practice was formulated at NHS Lanarkshire
(Box 1, page 18).
Advanced practice includes research,
education and management, but its most critical
component is clinical practice, which requires the
highest degree of professional responsibility and
accountability. Consequently, the emphasis in this
definition was placed on the clinical components
of the role.
As a result, there is great breadth and depth to
the advanced nurse practitioner role, which spans
the processes of care and patients’ care journeys,
and combines the professional competencies and
capabilities of specialist and generalist practice.
Identifying roles
Having established a practical definition of advanced
nursing practice, the next challenge was to identify
which of the current nursing roles met its criteria.
Four of NHS Lanarkshire’s 11 nursing roles were
identified as potential advanced practice roles.

Table 1 NHS Lanarkshire nursing workforce

Pay band 2 3 4 5 6 7 8 Not AfC Total
Whole-time equivalents
Hospital 907.92 113.38 10.75 1,515.39 558.10 237.77 22.00 0.53 3,365.85
Community 67.22 132.65 3.25 296.44 408.65 199.30 9.50 6.67 1,123.68
Total 975.14 246.03 4.00 1,811.83 966.75 437.07 31.50 7.20 4,489.53

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Table 2 Nurse consultant domains Education level In addition to having registered,

Expert clinical Nurse consultants must be able to deliver good care, enable
practice other practitioners to maintain professional expertise, and
exercise a high degree of autonomy. At least half of their jobs
must include direct or indirect patient contact.
Leadership Nurse consultants must demonstrate leadership skills, support
and and motivate others to improve practice, care and health
consultancy continually, and act as a source of expertise in their fields.
Practice Nurse consultants must contribute to the development of
and service professional practice through the promotion of evidence-based
development practice, audit and research. They must be influential in policy,
strategy and service development.
Education and Nurse consultants must be able to contribute to the
development education of others by establishing formal links with education
providers and contributing to the development of specialist
staff in their fields.
Adapted from Scottish Executive Health Department (2001)
These roles are:
■■ Clinical nurse specialists.
■■ Lead clinical nurse specialists.
■■ Senior charge nurses or team leaders.
■■ Nurse consultants.
The scope of practice for the other seven framework
roles did not correlate with that of advanced nurse
practitioners, so they were excluded.
The roles on this list that can meet the necessary
criteria for advanced practice will be identified over
the next few months using a survey tool adapted from
an existing advanced practice role review method that
was developed at Greater Glasgow Health Board, now
incorporated into NHS Greater Glasgow and Clyde.
In developing the advanced practice initiative, Figure 2
a number of related issues, such as career level,
education level and development pathway, were
taken into consideration.
all advanced nurse practitioners are expected to
have obtained specialist practitioner qualifications,
including those in independent prescribing, or to
have undertaken master’s level study programmes
that are related to their clinical practice and that
include nurse prescribing.
Development pathway For some advanced
practice roles, there is no single development
pathway and practitioners must draw on
development opportunities in, for example,
clinical practice, clinical leadership, management,
education and research.
For such cases, the Advanced Nursing Practice
Toolkit includes an advanced practice succession
development pathway, developed by NHS Education
for Scotland (2007).
This pathway is based on individual needs
assessments and includes learning programmes
that can be tailored to meet advanced practice
requirements.
At NHS Lanarkshire, it is expected that anyone
designated an advanced nurse practitioner can
demonstrate evidence of:
■■ Experience of clinical practice and clinical practice
development.
■■ Experience of leadership and its development.
■■ Experience of management, education or research
and their development.
NHS Lanarkshire has developed an understanding
of advanced practice in nursing and has made great
progress in translating this concept into practice.
The key components of specialist practice

Career level Advanced nurse practitioners are on

Level 7 of the NHS Careers Framework (Skills for
Health 2006) in recognition of their seniority and of
Depth of practice

the advanced knowledge and skills they require.

Specialists

There is no direct correlation between AfC and

tice
Nu

the NHS Careers Framework, but advanced nurse prac

rse

d
practitioners will be on one of three AfC bands: vance
con

■■ Band 6: some district nurses, public health nurses Ad

sul
tan

or clinical nurse specialists.

ts

■■ Band 7: some district nurse or public health team

leaders, or senior charge nurses.
■■ Band 8: nurse consultants.
It is of greater importance, however, that practitioners Generalists
fulfil the advanced nurse practitioner criteria. In doing
so, some will meet other responsibilities such as Breadth of practice
managing and leading teams.

NURSING MANAGEMENT April 2009 | Volume 16 | Number 1 17

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Box 1 The scope of practice of advanced ■■ Completion of a scoping exercise to identify

nurse practitioners
Advanced nurse practitioners can:
■■ Take comprehensive histories.
■■ Carry out holistic examinations.
■■ Use their expert knowledge, skills and clinical
judgement to identify potential diagnoses.
■■ Refer patients for appropriate investigations.
■■ Make final diagnoses.
■■ Decide on and initiate best-practice treatments,
including the prescribing of medicines.
■■ Refer patients to appropriate specialists.
■■ Plan and provide expert care to meet patients’
health and social care needs, involving other
members of care teams when appropriate.
■■ Ensure continuity of care including the provision
of follow-up visits as necessary.
■■ Evaluate with patients the effectiveness of
treatments and care, and makes changes
when required.
■■ Work independently although be part of teams.
■■ Provide leadership and consultancy functions.
■■ Make, and be accountable for, professionally
autonomous decisions.
■■ Screen patients for disease risk factors and early
signs of illness.
■■ Provide counselling and health education.
■■ Admit or discharge patients from caseloads or
refer them to other healthcare professionals.
Plans for the future include:
■■ Working in partnership with the local education
provider, the University of the West of Scotland,
to ensure that educational opportunities are
provided to current and future post holders.
which roles operate at advanced-practice level and
which would do so after development.
■■ Provision of professional guidance on advanced
practice and related role developments to enable
nurses and their managers to provide better services.
■■ Responding to, participating in and influencing
other national developments related to advanced
practice, for example regulation issues or issues
arising from developments in other parts of
the UK such as Towards a Framework for Post-
Registration Nursing Careers (DH 2008).
Conclusion
This article describes the experiences of
advanced practice to date in one NHS board in
Scotland and highlights some of the challenges
inherent in defining and supporting advanced
practice in nursing. Although it is not research-
based, it draws on the experiences of nurses,
patients and service managers.
Implications for practice
Advanced nursing practice can help improve
patient safety and experiences, and can underpin
service modernisation.
Further reading
Marie Cerinus is director
For more information on the development of of nurse, midwife and
advanced nursing practice in Scotland, visit allied health professional
the Scottish Government sites www.scotland. practice development
and Paul Wilson is
gov.uk/publications/2006/08/31120554/0 and
executive director of
www.aanpe.org/LinkClick.aspx?fileticket=giFsLijsCR nurses, midwives and
w%3D&tabid=1051&mid=2508&language=en-US allied health professionals,
both at NHS Lanarkshire

References
Association of Advanced Nursing
Practice Educators (2006) Advanced
Nursing Practice. www.aanpe.org/
advancednursingpractice/tabid/721/default.
aspx (Last accessed: March 5 2009.)
Department of Health (2006) Modernising Nursing
Careers: Setting the direction. www.dh.gov.uk/
en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_4138756
Department of Health (2008) Towards
a Framework for Post-Registration Nursing
Careers: Consultation response report.
www.dh.gov.uk/en/Consultations/
responsestoconsultations/DH_086465
(Last accessed: March 5 2009.)
NHS Education for Scotland (2007) Pilot Succession
Planning Development Pathway for Advanced
Practice. www.nes.scot.nhs.uk/nursing/
roledevelopment/advanced_practice/documents/
Post_Consultation_Succession_Planning_Pathway.
pdf (Last accessed: March 5 2009.)
NHSScotland (2008) Advanced Nursing Practice
Toolkit. www.advancedpractice.scot.nhs.uk
(Last accessed: March 5 2009.)
Nursing and Midwifery Council (2005)
Implementation of a Framework for the
Standard of Post Registration Nursing:
Decision. www.aanpe.org/LinkClick.
aspx?fileticket=giFsLijsCRw%3D&tab
id=1051&mid=2508&language=en-US
(Last accessed: March 5 2009.)
RCN (2008) Advanced Nurse Practitioners:
An RCN guide to the advanced practitioner role,
competencies and programme accreditation.
RCN, London.
Scottish Executive Health Department
(2001) Consultant Nurse/Midwife Guidelines.
www.sehd.scot.nhs.uk/mels/HDL2001_52.htm
(Last accessed: March 5 2009.)
Scottish Government (2008) Supporting
the Development of Advanced Nursing
Practice: A toolkit approach. www.aanpe.org/
LinkClick.aspx?fileticket=giFsLijsCRw%3D
&tabid=1051&mid=2508&language=en-US
(Last accessed: March 5 2009.)
Skills for Health (2006) Career Framework
for Health. Skills for Health, Bristol.

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