Regulation revisited: advanced practice in nursing and midwifery

A critical task for health services is to protect those using its services from the risk of harm and to maintain public confidence in those delivering care. Regulation of health and care professionals has an important role to play in this. However, the growth in new professional roles, changing expectations of many existing roles, and the large-scale migration of clinicians introduce real challenges for the regulation of different staff groups.

Nurses and midwives are increasingly taking on more complex, autonomous and expert roles around assessment, diagnosis and treatment – commonly referred to as ‘advanced practice’. These roles have been introduced for a range of clinical, operational, financial and professional reasons and are intended to benefit service users, practitioners and their employers.

But questions around their regulation remain unresolved and our independent report – commissioned by the Nursing & Midwifery Council (the body that set educational and professional standards for all nurses and midwives and keep a register of who is eligible to practise) – explores key regulatory considerations. As outlined below there is no obvious, single solution to the regulation of advanced practice in nursing and midwifery, but we do find that the status quo is far from optimal and there are lessons for designing and implementing regulatory changes for this staff group as well as others.

What is the situation in the UK?

There is no separate, statutory regulation of advanced practice in nursing and midwifery in the UK. Advanced practice was first formally recognised here in the early 1990s and this is not the first time that regulation of advanced practice has been considered. Alas there are no robust data on the scale in the UK, but we found that around 5% of nursing jobs being advertised in England and Scotland are for advanced practice roles – higher still in general practice – and it is clear the size of this workforce is increasing.

The current arrangements mean responsibilities fall on the individual practitioners (to ensure they work within existing regulatory frameworks) and employers (to, for example, check suitability of any qualifications and experience). These advanced practitioners would typically undertake postgraduate study (a master’s degree), although some may demonstrate their appropriateness through recognition of prior experience. The processes of commissioning and (non-mandatory) accreditation of educational programmes and credentialling (formal recognition of professionals’ competencies) by some professional bodies is also intended to provide further assurances on how advanced practitioners are trained and recognised.

In our work we heard that the current assurances appear, at times, insufficient. This can particularly be the case in some general practice and out-of-hours services, third sector providers and agencies. We found substantial differences in the assurances taken by larger NHS employers too. We heard examples of practitioners using the ‘advanced practice’ title despite, for example, failing to complete the full master’s course or completing only a half-day course. We also heard concerns around, for example, the marked variation in entry requirements and clinical content of master’s courses.

The picture also varies across the UK. Currently, the individual countries oversee the frameworks for, and assurances around, advanced practitioners, and we found some notable differences and heard concerns about risks if they become too divergent, particularly the possibility of limiting movement of staff between the devolved countries.

What do other countries do?

Most nations with nurses working at a similarly advanced practice level have specific regulation for these groups of practitioners. Countries such as the US, Canada, Australia, New Zealand, Ireland and the Netherlands all regulate the scope of practice of advanced nurse practitioners and protect the use of the job title. However, the picture is somewhat different for advanced midwifery practice; Ireland was the only country we identified with specific statutory regulation for that profession.

Despite a comprehensive search, we found the international research on the actual effect of regulation of advanced practice in nursing and midwifery was limited in terms of being scarce and lacking formal evaluations of regulation itself.

What should happen next?

The merits of advanced practice are not in doubt; there is a substantial evidence base on how it can support better delivery of services and improve outcomes.

However, the risk of harm to the public posed by advanced practice in nursing and midwifery needs to be at the forefront of any regulatory considerations. And while there is limited evidence, including internationally, of harm from advanced practice, and previous UK reports on advanced practice have not presented any systematic evidence of harm, our view is that this should not be interpreted as conclusive evidence that no further regulation is needed to prevent harm in the future. So given the lack of assurances around employment and education in some instances, we suggest a precautionary approach to protection of people using services and maintaining public confidence.

The options around statutory regulation include annotating the existing register for advanced practice qualifications or experience, or developing a second tier of regulation for advanced practice. There are also non-statutory options, including strengthening the existing mechanisms around accreditation, credentialling and employment practice. While our research was not intended to define what the single best solution would be – in fact, the limited nature of the evidence around the effects of regulation would have rendered that impossible – it does suggest some parameters that can help define the solution and how it is implemented, including the need for the regulatory approach to be:

• future proofed – particularly given ambitions to expand advanced practice – and provide sufficient assurance for a larger and perhaps more heterogenous set of staff seeking to work in such roles.
• a UK-wide solution, given the scale of migration of nurses and midwives between the four countries. This neither means that responsibility has to lie with a single, UK-wide organisation (noting regulation of social work, for instance, has separate national regulators with an agreed approach) nor that this would unduly fetter the flexibility for each country.
• coupled with a wider strategy to address all the risks raised by advanced practice. Whatever statutory regulation is – or is not – in place, employers and individual practitioners will retain many responsibilities.
• sufficiently consistent with other health and care professions who also have advanced level practice. While regulation alone will not fully address currently limited public understanding of the role, there is a risk that inconsistent approaches across the different regulators could erode it further.  

Whatever the solution, the way it is implemented will be critical; paths to regulation are typically longer, more convoluted and expensive than initially anticipated. There are also potential unintended consequences that will need to be mitigated against, including around the implications for other levels, forms and fields of practice, such as consultant practitioner and health visiting.

Changes to regulation of advanced practice will also need to be mindful of the highly complex and evolving regulatory landscape. There are some intermediate steps that could help, including providing clarity on the protection of the ‘nurse’ title and developing proposals around annotating the register for qualifications relevant to advanced practice. Undoubtedly the situation and appraisal of options is not easy, but complexity is not an excuse to ignore what is an important issue.