The evolution of advanced nursing practice: past, present and future (2024)

Although advanced nursing practice has existed in the UK for many years, lack of regulation means there is confusion about what these roles should entail

Abstract

Advanced nursing practice in the UK was pioneered in the 1970s. Advanced nursing roles have grown but the UK lacks a regulatory framework to define advanced practice and the education it requires; this has led to confusion as to what advanced nursing practice comprises, and has implications for patient safety. All four UK countries are developing or have developed frameworks for advanced practice, which should help ensure patients, professionals and healthcare providers benefit from the potential contribution of advanced nurse practitioners.

Citation: Leary A, MacLaine K (2019) The evolution of advanced nursing practice: past, present and future. Nursing Times [online]; 115: 10, 18-19.

Authors: Alison Leary is professor of healthcare and workforce modelling, London South Bank University and University of South-Eastern Norway; Katrina MacLaine is associate professor of advanced practice and course director, London South Bank University, and chair, Association of Advanced Practice Educators.

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Introduction

Mahase (2019) described junior doctors’ concerns about the growth of medical associate professionals (MAPs), for example physician associates. Although there was some confusion in the reported debate about MAPs and advanced practitioners, recent developments have made this confusion and occasional resentment, unsurprising. Junior doctors debating the issue cited situations in which other workforces were competing with or replacing them, denying junior doctors training opportunities or risking patient safety.

Development of advanced nursing practice

Depending on how ‘advanced’ is defined, the roots of advanced nursing practice can be traced back over a century. For many, its development in the UK was pioneered by Barbara Stilwell, who led the establishment of the first advanced nursing practice course in 1990 at the Royal College of Nursing Institute. Manley (1997) gave further formal definition of the role and level of practice.

Despite subsequent international and UK definitions of advanced nursing practice, variation in the understanding of such roles remains, causing ongoing confusion (Leary et al, 2017). In addition, over the past decade, the concept of advanced clinical practice has expanded beyond nurses in all four countries of the UK to include allied health professionals. While this does much to demonstrate the importance of recognising advanced practice as a level of care with common core characteristics across professions, it has added to the complexity surrounding this subject.

There is a long history of advanced nursing practice in other countries. In the US, it has been in existence for several years but expanded under President Obama’s Affordable Care Act. There was a perception that advanced nursing practice was a medical role replacement (Coombes, 2008) but, generally, the role is now accepted.

Recent legislative changes have seen the role thrive as it offers an affordable, well-evaluated healthcare option. In the US, an educational and regulatory framework is administered by the American Association of Nurse Practitioners; it aims to protect the public and the role, and gives it a clearer identity. Other countries, such as Australia, have a similar set-up but the UK lacks such a framework. There is now guidance from Health Education England but no regulatory or legal framework for advanced practice beyond initial professional registration in any UK country. As such, there is little professional or regulatory accountability, particularly for workers using job titles such as associate advanced nurse practitioner or clinical nurse specialist (Jones-Berry, 2018; Leary et al, 2017).

As HEE’s framework was launched when the Royal College of Emergency Medicine’s advanced clinical practitioner curriculum and the Faculty of Intensive Care Medicine’s curriculum were already in existence, two perceptions of advanced clinical practice have been created:

  • As an advancement of professional practice by a professional group;
  • As a generic medical substitute role, particularly in areas such as emergency departments and acute medicine.

There is no doubt that gaps in the medical workforce were one catalyst for rethinking traditional roles and responsibilities. However, in many countries including the UK, advanced practice has evolved to better meet the needs of different populations rather than being part of a strategic workforce plan. As the critical mass has grown, its benefits have been recognised experientially; numerous studies show that, in terms of safety, quality and efficiency, advanced-practice nurses are of great benefit.

Exceptional examples exist – such as Cuckoo Lane, a nurse practitioner-led general practice in London, and specialist nurses advancing practice for patients’ benefit – but these still seem to be unseen by workforce policy makers. This is puzzling as healthcare demand is growing (The King’s Fund, 2016) and advanced-practice nurses and other professionals are in a key position to meet this increasing demand.

So why is advanced practice not seen as a solution to anything other than a shortage of doctors? This is partly because of the traditional way the healthcare workforce is viewed. Technical skills associated with medicine that generate clinical activity are valued, whereas areas of practice including complex case management, safety and the psychosocial aspects of care appear to carry less value. As a result, activities associated with medicine seem to have higher status.

Thinking of advanced practice in this way also reinforces the concept that there is a simple hierarchy of skills with an associated hierarchy of value. It leads to ‘task shifting’ from medicine to other professions but does not articulate the added value offered by these professions. Employers and policy makers then start to believe they need to only ‘upskill’ other workforces in medical-technical skills to meet demand; they do not realise that those non-physician workforces also bring an important, unique contribution to care (Leary, 2019).

Workers who also see medicine, or an association with it, as desirable or of higher status are more willing to take on a role that is closely aligned with medicine, and not value advancement from within their own profession. First described by Anderson et al (1974), this seeking of higher status condemns their primary profession to a lower status. The collective term ‘non-medical professional’ reinforces this division.

Becoming a substitute workforce, or otherwise entering the jurisdiction of another group, can be risky (Maxwell et al, 2013) as it can lead to issues around power. Studies have shown how certain occupations have controlled the passing of their knowledge to those they consider to be outside the group (Abbott, 1988). The Department of Health’s (2017) proposal to continue including advanced critical care practitioners in the regulation of medical associate professions is the first step towards advanced practice being located under this banner.

Thinking about the future

Although the UK’s four countries have developed or are developing frameworks for advanced practice, there is still a lack of clarity in some key areas. The apparent dichotomy of what advanced practice has become, particularly in England, has contributed to this. We need to recognise that professions tend to grow, die, change, adapt and compete (Abbott, 1988). Is advanced care provision within autonomous nursing practice? Or, as the Royal College of Physicians (2018) asks in its workforce document, is the advanced practitioner simply a tier 1 medical worker dependent on a senior physician to practise?

The misuse of titles such as ‘advanced nurse practitioner’ by employers who do not require staff with that title to have any underpinning education or assessment of clinical competence has serious implications for public protection. This is unlikely to be addressed without regulation. The Nursing and Midwifery Council’s recent decision to look at the post-qualification landscape, including advanced practice, is welcome. The lack of regulation of these roles is not only a workforce issue but also one of patient safety (Kelly et al, 2019; Leary, 2018); with hard-pressed employers trying to deliver services with more efficiency, few seem willing to tackle these issues. The proposal for an Academy of Advancing Practice in England is welcome and may help tackle these issues but needs a mandate to require employer commitment.

The opportunities for advanced-practice nurses to meet healthcare’s growing demand are considerable. With some thought, the profession’s future could be bright and lead to better care for patients and families.

Key points

  • The development of advanced practice in the UK was pioneered in the 1970s
  • In contrast with other countries, the UK lacks a regulatory framework for advanced practice roles
  • Studies show, in terms of safety, quality and efficiency, advanced-practice nurses are of great benefit to patients and services
  • Without a regulatory framework and a protected title there is no protection for the public
  • Advanced practice is often seen as a solution to the shortage of doctors, neglecting the other valuable aspects of practice

References

Abbott A (1988) The System of Professions. Chicago, IL: University of Chicago Press.

Anderson EM et al (1974) Epigenesis of the nurse practitioner. American Journal of Nursing; 74: 10, 1812-1816.

Coombes R (2008) Dr Nurse will see you now. BMJ; 337: a1522.

Department of Health (2017) The Regulation of Medical Associate Professions in the UK: Consultation Document.

Jones-Berry S (2018) The false job titles that are undermining trust in nurses. Nursing Standard. 23March.

Kelly C et al (2019) What’s in a name: should nursing job titles be regulated? Nursing Times [online]; 115: 5, 52-53.

The King’s Fund (2016) Demand and Activity in the NHS: Still Rising.

Leary A (2019) The healthcare workforce should be shaped by outcomes rather than outputs. The BMJ Opinion. 31 May.

Leary A (2018) ‘There is little understanding of the many job titles in nursing’. Nursing Times [online]. 6 September.

Leary A et al (2017) Variation in job titles within the nursing workforce. Journal of Clinical Nursing; 24: 23-24, 4945-4950.

Mahase E (2019) Medical associates: junior doctors oppose professional equivalency. British Medical Journal; 365: I2265.

Manley K (1997) A conceptual framework for advanced practice: an action research project operationalizing an advanced practitioner/nurse consultant role. Journal of Clinical Nursing; 6:3, 179-190.

Maxwell E et al (2013) Exploring the relationship between social identity and workplace jurisdiction for new nursing roles: a case study approach. International Journal of Nursing Studies; 50: 5, 622-631.

Royal College of Physicians (2018) Guidance on Safe Medical Staffing: Report of a Working Party.

The evolution of advanced nursing practice: past, present and future (2024)

FAQs

How has nursing practice changed over time? ›

Arguably, the most significant change in nursing over the last ten years has been nursing education. More universities have offered specialized degrees, while training has become more formal and complex; at the same time, this education has become more accessible.

What can current and future nurses do to enhance nursing standing as a profession? ›

10 Ways to Boost Your Nursing Career and Get Promoted
  1. Always Have Good Intentions. ...
  2. Go with Your Gut. ...
  3. Advance Your Knowledge. ...
  4. Be Honest. ...
  5. Be a Leader. ...
  6. Respect Your Patients' Privacy. ...
  7. Represent Your Profession Well - In and Out of the Office. ...
  8. Take Time for Yourself.

What is the best method for nurses to prepare for future professional practice? ›

What is the best method for nurses to prepare for future professional practice? Take additional courses in the use of computers. Understand and explore the issues involved in professionalism as nurses. Accept that nursing is a profession.

What are the 4 pillars of advanced practice RCN? ›

These four pillars are: Clinical/direct care • Leadership and collaborative practice • Improving quality and developing practice • Developing self and others.

What future changes are expected in nursing? ›

A growth in telehealth, an increase in online nursing education, expanding nurse practitioner ranks, the movement of nurses into nonclinical careers, growing practice authority, and technological advances are all changing the face of nursing.

What are some nursing practices that are no longer used today? ›

Some of these may surprise you if you haven't been in the field for very long.
  • Reusing Syringes and Urinary Catheters. ...
  • Regulating IV Fluids Manually. ...
  • No Blood Pressure Cuffs. ...
  • Shaving Patients. ...
  • Shaking Mercury Thermometers. ...
  • An Interesting Use for co*ke. ...
  • Treating Congestive Heart Failure (CHF) with Rotating Tourniquets.
22 Oct 2019

What strategies can I use to advance my learning in the future in nursing? ›

Here it goes:
  • 1) Be prepared. Come with clear objectives for the day and work towards completing them.
  • 2) Be knowledgeable. Revise on conditions, medications, care plans etc. ...
  • 3) Be involved and focused. ...
  • 4) Be helpful. ...
  • 5) Be teachable and humble. ...
  • 6) Be positive and cheerful. ...
  • 7) Be communicative. ...
  • 8) Be reflective.
12 Feb 2020

What is the future of nurse practitioners? ›

The U.S. Bureau of Labor Statistics (BLS) predicts the number of nurse practitioners will increase by 34% from 2012 to 2022. This is more than three times the national average of 11% growth expected for all occupations during this time period.

What are the most important areas in your nursing practice that need improvement? ›

Here are the most critical technical nursing skills employers look for when hiring for a nursing role:
  • Basic care skills. ...
  • Urgent care and emergency care. ...
  • Patient movement. ...
  • Patient safety. ...
  • Patient and family education. ...
  • Checking vital signs. ...
  • Technology skills. ...
  • Wound care.

Why are advanced practice nurses important? ›

APRNs treat and diagnose illnesses, advise the public on health issues, manage chronic disease, and engage in continuous education to remain ahead of any technological, methodological, or other developments in the field.

How can I improve my nursing practice? ›

How to Improve Your Skills for Nursing
  1. Continue Your Education. ...
  2. Explore Advanced Nursing Education. ...
  3. Learn How to Effectively Communicate. ...
  4. Join a Professional Nursing Organization. ...
  5. Make a Commitment to Service and Knowledge.
23 Mar 2022

Why is professional development important for nurses? ›

Professional development in the nursing profession brings us up to date on the latest techniques, technology and evidence to be able to provide quality care to patients. It also fosters career advancement and leadership growth for nurses who wish to elevate responsibilities.

What are the four roles of the advanced practice nurse? ›

There are four types of roles for an Advanced Practice Registered Nurse (APRN): clinical nurse specialists, certified registered nurse anesthetists, certified nurse practitioners, and certified nurse midwives.

What are advanced nursing skills? ›

Advanced practice nurses require skills that allow them to promote disease prevention and health management while also treating medical conditions. Among the hard skills advanced nursing professionals need are those related to: Diagnosing illness. Prescribing medication. Encouraging preventive care.

What are the roles and responsibilities of the advanced nurse practitioners in prescribing? ›

Provide patients with information, warnings, and instructions. Monitor the patient regularly. Consider drug costs when prescribing. Use appropriate tools, such as prescribing software and electronic drug references, to reduce prescription errors.

What is the most relevant future trend in nursing? ›

1. Looming Nursing Shortage. The statistics point to a national nursing shortage: More RN jobs are expected to be available by 2022 than in any other profession, according to the American Nurses Association.

What does the future of nursing hold? ›

Leading Beyond Typical Boundaries. Nurses can also lead beyond traditional healthcare boundaries in both public and private sectors. They can hold positions in local, state, and national government organizations in human services, education, and public health departments.

What do you think are the biggest challenges that nurses are facing today? ›

Biggest Challenges Nurses Faced In 2021 And How To Become More Resilient In The Future
  • Emotional Trauma. Nurses and public health workers experienced increased mental health problems due to COVID-19 in 2021. ...
  • Fear of Contracting COVID-19. ...
  • Exhaustion and Overworking. ...
  • Staffing Issues. ...
  • Underpayment.
4 Jan 2022

What factors influence changes in nursing practice standards? ›

Many factors influence changes in nursing practice, including professional associations, new and unfamiliar ethical dilemmas, credentialing requirements, funding for ''public-health"-related activities, and overall changes in health care delivery.

What are nursing best practices? ›

Best practices comprise recent, relevant, and helpful nursing practices, methods, interventions, procedures or techniques based on high-quality evidence. Best practices should be implemented to improve individual patients' health outcomes the overall quality of health care, and to strengthen the health system at large.

How can nurses keep up with the latest research and best practice? ›

Nurses can look to professional associations, journals, blogs, social media, videos, podcasts, continuous education courses, events and colleagues to stay up-to-date. Professional associations support the interest of a particular field and its members.

What strategies can the student use to advance their learning? ›

  • Spaced Practice. Space out your studying over time. ...
  • Retrieval Practice. Practice bringing information to mind without the help of materials. ...
  • Elaboration. Explain and describe ideas with many details. ...
  • Interleaving. Switch between ideas while you study. ...
  • Concrete Examples. ...
  • Dual Coding.
11 Dec 2016

Why is it important for nurses to engage in lifelong learning? ›

Lifelong learning gives nurses the critical-thinking and problem-solving skills needed to resolve issues they may encounter while taking care of patients.

What resources are available to help the new nursing student learn and enhance their nursing school success? ›

Here are some excellent options you can find at Rasmussen University (and beyond).
  • Student mentors and tutors. ...
  • Nursing blogs and websites. ...
  • Your instructors. ...
  • Mobile apps for nursing. ...
  • University resource guides. ...
  • Library staff. ...
  • The Learning Nurse Resource Network. ...
  • Working nurses.
23 Aug 2021

What is the importance of a nurse practitioner? ›

Professional Role

NPs provide a wide range of health care services including the diagnosis and management of acute, chronic, and complex health problems, health promotion, disease prevention, health education, and counseling to individuals, families, groups and communities.

Why are APRNs important in healthcare? ›

Broadly speaking, the nurse practitioner of today is an advanced practice registered nurse (APRN) who provides acute and primary care to people across the lifespan by: Listening to patients, families and communities to understand their health needs and offer emotional support. Diagnosing and treating health conditions.

What is the role of the APRN in 21st century healthcare? ›

Growth and advancement in the 21st century

APRNs are extremely valuable to today's healthcare system. They hold critical roles in addressing the rise in chronic medical conditions, expanding access to healthcare and meeting population health needs, especially for aging or underserved populations.

What are your goals for professional development in nursing? ›

Some common nursing goals include:

Fulfilling continuing education unit requirements (CEUs) Refining interpersonal skills. Honing a specific skill set to an expert level. Taking a management/leadership position.

What is a common desire of successful nursing students? ›

Your success in nursing school will ultimately be driven by your passion for the career. If you're earning your nursing degree, you are most likely passionate about the healthcare field and caring for others and want to pursue a rewarding career in this after graduation.

What are the benefits of nursing? ›

Benefits to Pursuing a Career in Nursing
  • Excellent Security, Salary, and Benefits. Nurses are always in demand. ...
  • Flexible Schedule. ...
  • Rewarding Career Path. ...
  • Opportunity for Advancement. ...
  • Several Ways to Become a Nurse. ...
  • Learn Transferable Career Skills. ...
  • Choose or Change Your Specialty. ...
  • Travel Opportunities.

What is your definition of advanced practice nursing? ›

A registered nurse who has additional education and training in how to diagnose and treat disease. Advanced practice nurses are licensed at the state level and certified by national nursing organizations.

Why are advanced practice providers important? ›

With the ability to direct patient care and generate revenue, advanced practice providers (APPs) – including nurse practitioners (NPs) and physician assistants (PAs) – are critical members of this team and can play an important role in the transformation of care delivery and the achievement of key quality, access, ...

What is the difference between nursing practice and advanced practice nursing? ›

RNs deliver direct patient care as specified in a patient's medical plan, while APRNs create this patient care plan alongside other advanced practice providers, and supervise other medical staff, including RNs and medical assistants.

What is the best method for nurses to prepare for future professional practice? ›

What is the best method for nurses to prepare for future professional practice? Take additional courses in the use of computers. Understand and explore the issues involved in professionalism as nurses. Accept that nursing is a profession.

How has nursing practice evolved over time? ›

Arguably, the most significant change in nursing over the last ten years has been nursing education. More universities have offered specialized degrees, while training has become more formal and complex; at the same time, this education has become more accessible.

How can nurses improve quality of care? ›

Safe: Avoid injuries to patients from the care that is intended to help them. Effective: Match care to science; avoid overuse of ineffective care and underuse of effective care. Patient-Centered: Honor the individual and respect choice. Timely: Reduce waiting for both patients and those who give care.

What can current and future nurses do to enhance nursing standing as a profession? ›

10 Ways to Boost Your Nursing Career and Get Promoted
  1. Always Have Good Intentions. ...
  2. Go with Your Gut. ...
  3. Advance Your Knowledge. ...
  4. Be Honest. ...
  5. Be a Leader. ...
  6. Respect Your Patients' Privacy. ...
  7. Represent Your Profession Well - In and Out of the Office. ...
  8. Take Time for Yourself.

What is nursing Short answer? ›

Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. It includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people.

How is nursing knowledge developed? ›

Nursing knowledge is drawn from a multifaceted base and includes evidence that comes from science (research and evaluation), experience and personally derived understanding. Scientific knowledge is developed through enquiry and can use the research approaches discussed throughout this book.

What is an advanced practitioner? ›

Advanced clinical practitioners (ACPs) are healthcare professionals, educated to Master's level or equivalent, with the skills and knowledge to allow them to expand their scope of practice to better meet the needs of the people they care for.

How many types of APRN are there? ›

There are four types of advanced practice registered nurses: Nurse practitioners. Clinical nurse specialists. Certified registered nurse anesthetists.

What issues do nurse practitioners face in the 21st century? ›

Abstract. Nurse leaders face a myriad of challenges in the 21st century such as nursing workforce shortages, negative affectivity, generation workforce concerns, changing delivery systems, and increasing clinical practice complexity, to name a few.

What is an example of an advanced practice nurse? ›

Within the category of APRNs are specialty areas that include nurse practitioners, certified nurse-midwives, certified registered nurse anesthetists, and clinical nurse specialists. Read more about the different types of Advanced Practice Nurses.

What are the four roles of the advanced practice nurse? ›

There are four types of roles for an Advanced Practice Registered Nurse (APRN): clinical nurse specialists, certified registered nurse anesthetists, certified nurse practitioners, and certified nurse midwives.

Which action should the Advanced Practice Nurse take to be successful in socialization? ›

Developing skill in empathic communication does lead to successful socialization.

Which of the following is a reason for increasing the use of advanced practice nurses? ›

Which of the following is a reason for increasing the use of advance practice nurses? -A 2010 Institute of Medicine report encouraged nurses to practice to the full extent of their education. -Advance practice nurses serve as an extension of physicians.

What is the turning point in nursing history? ›

Florence Nightingale's legendary mission during the Crimean War was a turning point in the history of nursing, leading to the creation of standards for the profession.

What was nursing like 50 years ago? ›

Fifty years ago, doctors still treated nurses as assistants, and the role was seen as an extension of women's caregiving instead of as a career. The role required less formal education, and nurses had just a "rudimentary" understanding of scientific medical care, according to Minority Nurse.

How has nursing changed in Australia? ›

Early nursing in Australia was influenced strongly by the British nursing tradition, characterized by an apprenticeship style of nurse education. However, this influence has been replaced by the transfer of all registered nursing education into the higher education sector.

What is the full meaning of nurse? ›

1 : a person skilled or trained in caring for sick or injured people. 2 : a woman employed for the care of a young child. nurse. verb.

What is nursing Short answer? ›

Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. It includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people.

What do we learn from nursing history? ›

Nursing history provides the knowledge needed to understand nursing profession, learn from its past, and inform patients and others about the significant role it plays in health care.

Who was the first nurse in history? ›

Florence Nightingale (Figure 1), the founder of modern nursing of professional nursing, was born in Florence, Italy, on 1820, in an English family; she was named of the city of her birth.

What is modern nursing? ›

The modern nurse is the coordinator and the connector of the evolving health care system. ‍ Florence, "The Lady with the Lamp," taking care of British soldiers during the Crimean War during the 1850s.

What is the history of nursing in the world? ›

The first known documents that mention nursing as a profession were written approximately 300 AD. In this period, the Roman Empire endeavored to build a hospital in each town that was under its rule, leading to a high requirement for nurses to provide medical care alongside the doctors.

Is there a significant difference between nursing from the past and nursing today? ›

Women were caretakers, so nursing was just an extension of what their roles at home were anyway. Today, the nursing profession has changed drastically. There are extensive training programs, more diversified staff, and a level of prestige associated with this area of the medical field that wasn't there before.

What are the perspectives of nursing? ›

This chapter presents the nursing perspective as configured by four ideologies: holism, health orientation, person-centeredness, and caring.

What is scope of practice in nursing Australia? ›

Definition from Registered Nurse Standards of Practice: “Scope of practice is that in which nurses are educated, competent to perform and permitted by law.

Which past events have influenced the development of professional nursing? ›

The Civil War, for all of its destruction and horror, helped to advance the cause of professional nursing as these leaders, even though largely untrained, demonstrated dramatic improvements in care. The success in the reform of military hospitals served as a model for reform of civilian hospitals nationwide.

Which historical period has the greatest contribution with regards to nursing practice today? ›

Important nursing reforms occurred in the middle of the 19th century. Leading the way was a visionary named Florence Nightingale. She was part of a group of female nurses that went to Turkey in the middle of the Crimean War to treat British soldiers who were battling with the Russians.

What historical trends have shaped the development of nursing knowledge? ›

The shift toward science as the basis for developing nursing knowledge was influenced by the involvement of nursing in the two world wars that occurred during the early 20th century. The wars created social circ*mstances that brought about substantial shifts in roles for women and nurses.

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