NMC considers advanced nurse regulation as part of review

However, the overhaul could result in the NMC withdrawing its standards that underpin the education and practice of specialist community nurses such as health visitors and district nurses.

“As part of this review, it is right that we consider our role in regulating advanced practice”

Anne Trotter

The NMC has announced that it is reconsidering the role it plays in regulation beyond initial registration of nurses, midwives and nursing associates.

As part of a wider programme of work to update its standards, the NMC commissioned consultancy firm Blake Stevenson to evaluate its current post-registration frameworks. 

Currently, once a nurse or midwife has qualified they can undertake further training to join the specialist community public health nurse (SCPHN) part of the register. SCPHN is a protected title and encompasses health visitors, school nurses and occupational health nurses.

Alternatively, a registrant can be noted on the register as having a specialist practitioner qualification (SPQ) in nine different areas including district nursing and general practice.

In a report to accompany the review findings, the NMC admitted that the way the register was currently structured and annotated was “confusing and complex”.

“The real danger is you would lose the specialist practice skills, they would start to get diluted”

Cheryll Adams

Through this review it was seeking to address “several long-standing issues” relating to SPQs annotations and SCPHN registration.

One of the questions that Blake Stevenson was asked to explore was: “If the standards for SCPHNs and SPQs were withdrawn what would be the consequences?”

The independent review determined that the SCPHN and SPQ standards, which were last updated in 2001 and 2004 respectively, were “not fit for purpose” and were not widely understood.

Universities were making up for shortfalls by incorporating modern voluntary standards produced by other bodies such as the Queen’s Nursing Institute, and more than half were running additional post-registration courses that did not lead to recordable NMC qualifications, such as masters in public health nursing and advanced clinical practice.

With the exception of the district nursing SPQ, the number of nurses and midwives gaining these specialist qualifications had declined over the past two to three years, the review found.

However, those who had completed a SCPHN or SPQ said the course had been “transformational”. 

“They felt the qualifications were prestigious, had more gravitas, were more legitimate and appropriately recognised their higher level of skills and knowledge,” the review found.

“We are talking about practitioners who are going to be working at the maximum level of autonomy”

Katrina MacLaine

Respondents gave “mixed views” about extent to which the standards provided protection to the public.

The review found two examples of the SCPHN part of the register being used to raise fitness to practise issues.

However, the SPQ annotations were considered to be of limited help because the register did not hold any information about the specifics of the qualification achieved.

While acknowledging “limitations” in the current standards, respondents said dropping them could lead to the deterioration in the quality of post-registration education. 

“Many participants were concerned about the impact on the profession and the fragmentation, dilution and loss of quality of post-registration education if the SPQs/SCPHNs were withdrawn and the NMC stopped regulating this aspect of post-registration education,” the review found.

However, the review noted that there was a decreasing number of universities approved to deliver the SPQ and SCPHN qualifications and alternative, more contemporary programmes were already being used to fill the gap.

“The regulation of all post-registration education and practice needs greater consideration,” it concluded.

Views were gained from universities delivering these courses; nurses holding the qualifications and students working towards them; employers; stakeholders from nursing organisations and government bodies; and members of the public and patients.

alison leary

alison leary

Alison Leary

One thing that came out loud and clear was the desire for the NMC to regulate advanced practice nursing, with some believing this was more crucial to safety. 

Many participants “expressed concern and at times frustration” about the lack of regulation of ANPs, and felt it was being left to local employers to decide who delivered care in what role.

“There are repeated calls from across all stakeholder and registrant groups for the NMC to widen the discussion and become involved in the regulation of advanced practice,” said the review.

“Their feeling was that there is likely to be a greater risk to the public from those practising in the unregulated area of advanced practice,” it added.

“There is a patchwork of education of advanced and specialist practice across the UK and there is the opportunity to draw this together and rationalise under the leadership of the regulator,” it said.

The debate about advanced practice regulation has been ongoing for many years but previous attempts to make this happen have fallen at the final hurdle.

In response to the findings of the report, the NMC has formally agreed to explore the idea. As part of this, the NMC said it would look at whether new post-registration standards should be situated in advanced practice frameworks.

The commitment to consider advanced practice regulation was welcomed by Katrina MacLaine, an ANP, associate professor in advanced practice and chair of the Association of Advanced Practice Educators.

Ms MacLaine was among a team of researchers from London South Bank University alongside Alison Leary who found in 2017 that due to the lack of regulation, hundreds of unqualified staff were working under advanced nurse titles.

Regulating advanced nurses was a public safety issue and leaving it up to employers to manage was not sufficient, Ms MacLaine told Nursing Times.

“We are talking about practitioners who are going to be working at the maximum level of autonomy, they’re making decisions and delivering care in many instances if you think about primary care very much they are the sole lead provider for many of the patients, and it’s absolutely imperative that [they] have been educated and signed off and assessed to do that,” she said.

“If you are complete provider of care, if you are making a decision you have got to be able to be safe to do that, and know your limitations, and unfortunately the difficulty is that people might be going into situations where they haven’t been adequately prepared,” said Ms MacLaine.

She told Nursing Times she believed regulation should focus on the levels of knowledge and skills rather than specialisms. “Specialist practice can extend from some healthcare assistants working in a very specialist way,” she added.

Leading nurse professor Ms Leary, who has just been awarded an MBE in Queen’s birthday honours list, also welcomed the development.

“There is a clear lack of clarity currently around which levels of practice people are operating at with anyone registered or not being able to use titles such as advanced nurse practitioner,” said Ms Leary. “This is certainly an issue of public safety.”

Queen’s Nursing Institute

Crystal Oldman

Source: Kate Stanworth

Crystal Oldman

Meanwhile, Dr Crystal Oldman, chief executive of the QNI, said there was a “clear role” for the NMC in regulating post-registration education in the absence of structures that existed in medicine where specialist royal colleges carried out this function.

She said there needed to be a debate with the profession to determine and agree the high-risk areas of practice that required regulation.

“From the QNI perspective, these include those roles which have a high degree of autonomy and authority in combination with specialist knowledge and skills in relation to assessment, diagnosis, prescribing and care delivery, including the management of risk in environments of care which may not be within the control of the clinician,” she told Nursing Times.

“This includes nurses who lead and manage care in a wide variety of community settings and specifically those who are responsible for the delivery of care in peoples’ homes, such as district nurses, community children’s nurses and health visitors,” she added.

Cheryll Adams, executive director of the Institute of Health Visiting, called for health visitors to be regulated as a sole profession, like they had been before the NMC was formed.

“If something is different you can’t try and make it the same, and I think that’s been the problem,” said Dr Adams. “It’s convenient to say health visitors are nurses, but what is it about what they do that makes them nurses? They are just not nurses.

“They are going out for searching for health needs, nurses have health needs sitting in front of them and they respond to them,” she added.

She backed comments made by respondents to the independent review for a direct entry route into health visiting to be established.

Cheryll Adams, executive director Institute for Health Visiting

Cheryll Adams, executive director Institute for Health Visiting

Cheryll Adams

Asked what the implications would be if the existing standards were dropped, Dr Adams said: “I think the real danger is you would lose the specialist practice skills, they would start to get diluted.”

The NMC will now start an engagment process with external stakeholders on the findings of the review before taking any plans forward. 

Anne Trotter, assistant director of education and standards at the NMC, said: “Our review of post -registration standards is part of our wider education change programme, which also includes our work on the Future Nurse Standards and Future Midwife Standards.

“As part of this, it is right that we consider our role in regulating advanced practice as we have heard some people are keen there is additional regulation for advanced practice, while others don’t think that’s necessary or appropriate,” she said. 

“We will continue to explore what it is people think professional regulation should be doing,” said Ms Trotter.