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Nigel's surgery 66: Advanced Nurse Practitioners (ANPs) in primary care
This issue of Nigel's surgery has been updated to include information about the RCN credentialing programme and the HEE/NHSI multiprofessional document.
Nurses are increasingly extending and expanding their scope of practice beyond initial registration with the Nursing and Midwifery Council (NMC).
They are now commonly working at an advanced practice level in general practice.
The ANP role
The role has developed partly to address demand and workforce issues. In general practice it is generally understood to mean a nurse who has undertaken extra training in clinical assessment, including history-taking and physical examination, so they can safely manage patients presenting with undifferentiated and undiagnosed conditions.
- prescribe any medicine for any condition within their competence (including some controlled medicines) provided they have completed an Independent Prescribing qualification
- see patients with undiagnosed, undifferentiated medical conditions and make treatment decisions, including ordering necessary investigations
- refer patients to secondary care, although this can vary depending on local arrangements and protocols
- undertake appropriate home visits
- provide care to pregnant women if this involves assessment of the pregnancy, unless they are also a practising midwife meeting the NMC requirements of registration
- sign Fit Notes (only medical practitioners can do this by law)
The role develops from competencies common to all registered nurses. In primary care, ANPs operate as generalists and provide care for patients of any age with a wide variety of both acute and long-term medical conditions as well as health promotion.
This should be within clearly defined boundaries agreed with the employer so each practice will have its own arrangement for the ANP's case-load and how it is organised. For example, the ANP might see each patient requesting a same-day appointment and, after initial assessment, decide whether to manage the patient’s condition or to refer.
Qualifications and professional standards
ANPs must be Registered Nurses with the NMC and must also register their prescribing qualification with them. The ANP qualification itself is not recorded on the NMC register for the individual nurse so, in theory, anyone can call themselves an ANP. However, the RCN are developing a system of quality assurance, called credentialling, for ANP training and qualifications.
Credentialling is the process of assessing the background and legitimacy of nurses to practice at an advanced level through assessing their qualifications, experience and competence. It allows nurses to gain formal recognition of their expertise and skills in clinical practice, in a way that is recognisable to colleagues, employers and the public.
The professional standards of practice and behaviour contained within the NMC Code apply to the ANP role. In particular, this includes the sections on recognising and working within the limits of competence and the standards regarding keeping clear and accurate records. The ANP should be:
- included in communication with the local medicines management team and have opportunity to review their own prescribing practice (such as the rate of antibiotic prescribing) and whether it is in line with local guidelines.
- supported by the practice to stay up to date to fulfil the requirements of NMC re-registration (including revalidation) and part of a system of appraisal to identify and address future learning needs
- supported within the practice and have a system for seeking help when necessary from a medical colleague. Ongoing clinical supervision may include reviewing patient consultation records and audit of the ANP's practice to benchmark against established best practice
All nurses must have adequate medical indemnity as part of the requirement to re-register with the NMC. Medical indemnity for nurses may be included under a group scheme provided to the partners at the practice. However, this does not usually apply to nurses working in advanced roles such as the ANP and the organisation providing indemnity cover may insist on a separate policy.
The ANP is responsible for making sure that they have the appropriate cover for their role and scope of practice; this should be relevant to the risks involved so it is sufficient if a successful claim is made against them.
We consider how services make sure that staff have the skills, knowledge and experience to deliver effective care, support and treatment as part of Key Line of Enquiry (KLOE) E3.
Providers employing nurses in this extended role should be able to demonstrate:
- the underpinning training the ANP undertook
- how they support their continuing professional development
- how they assure themselves on an ongoing basis of the competence of nurses practising at an advanced level
Training records and proof of qualifications should be made available.
Health Education England’s Multiprofessional framework for advanced clinical practice in England states:
"employers carry responsibility and vicarious liability for practitioners and must be responsible for ensuring that all advanced clinical practice roles, both those that are existing and those of the future, do not compromise safety"
- Advanced Nurse Practitioner competencies RCGP/RCN (2015) - specific to general practice
- An RCN guide to advanced nursing practice, advance nurse practitioners and programme accreditation (RCN 2012)
- Department of Health Advanced Practice position statement (2010) - gives specific descriptors for advanced practice across four domains: clinical practice, leadership and collaborative practice, improving quality and developing others
- Standards of proficiency for nurse and midwife prescribers (NMC) 2006
- The Code: Professional standards of practice and behaviours for nurses and midwives (NMC) 2015
- Health Education England: Multi-Professional Framework
- Last updated:
- 3 May 2018