This article relates to the CQC key question: Is your practice effective?
Nurses in a range of health care settings are increasingly extending and expanding their scope of practice beyond initial registration with the Nursing and Midwifery Council (NMC). Nurses 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 the ANPs role 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 varies on a local basis.
- 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.
However, 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.
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 for ANP training and qualifications.
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.
Guidance for practices
The RCN have produced competencies to guide commissioners of training programmes for advanced nursing practice. The Department of Health position statement (2010) gives specific descriptors for advanced practice across four domains: clinical practice, leadership and collaborative practice, improving quality and developing others. The RCGP and RCN have just published ANP competencies which are specific to general practice.
Under key line of enquiry 3, in the effective domain, we look at whether staff have the right qualifications, skills, knowledge and experience to do their job.
Providers employing nurses in this extended role should be prepared to demonstrate the underpinning training the ANP undertook and how they support their continuing professional development. Training records and proof of qualifications should be available.
- An RCN guide to advanced nursing practice, advance nurse practitioners and programme accreditation (RCN 2012)
- Department of Health Advanced Practice position statement (2010)
- RCGP/RCN (2015) Advanced Nurse Practitioner competencies
- Standards of proficiency for nurse and midwife prescribers (NMC) 2006
- The Code: Professional standards of practice and behaviours for nurses and midwives (NMC) 2015
Elaine Biscoe is national nursing advisor at the CQC
More CQC resources
- View the full CQC Essentials series on Medeconomics
- CQC's recommended reading to help practices meet regulations and prepare for an inspection
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