Advanced practice toolkit

Most Clinical Nurse Specialists (CNSs) work at an Advanced Practitioner level of practice (Level 7). Advanced Clinical Nurse Specialists have a wider scope of practice than CNSs at level 6 and will manage greater complexity (CNOD 2021).

“The Advanced Clinical Nurse Specialist (ACNS) is an experienced and highly educated registered nurse working within a specific field of practice. They manage, deliver, advise on and support the care for people within a specialist area. Educated to at least Postgraduate Diploma level in an appropriate subject, they are assessed as clinically competent in their defined specialty. They have a wider scope of practice than the clinical nurse specialist at Level 6 and will manage greater complexity.

As a clinical leader they have the autonomy to act and accept responsibility and accountability for their actions, acting as an expert advisor or resource for others. This includes specialist assessment and treatment using a holistic approach to managing complex, multidimensional situations. This may require management of care over a prolonged period of time. They have the authority to refer, admit and discharge within appropriate clinical areas. Their practice is characterised by a high level of clinical decision making based on in-depth, expert knowledge in their specialism of care delivery.

Working as part of the multidisciplinary team, they can work in or across all settings, including non-clinical areas, dependent on their area of expertise.” (CNOD 2021).

Transforming Roles Paper 8 sets out the core competencies for any ACNS. To these additional specialist competencies are added. The competency framework needs to be completed before a new ACNS can be regarded as appropriately prepared.

Included with the advanced clinical nurse specialist title is the Advanced Critical Care Practitioner (ACCP) role. The Faculty of Intensive Care Medicine (FICM) defines ACCPs as clinical professionals responsible for patients' care during their critical care admission. They are highly experienced and educated practitioners who have developed their skills and theoretical knowledge to a very high standard. They are empowered to make high-level clinical decisions to ensure that patients receive timely, personal, and effective care.

FICM have developed an ACCP curriculum and a National Education and Competence Framework for Advanced Critical Care Practitioners.

The environment in which advanced nursing role’s function remains complex and demanding. As a result, advanced level practice requires evidence of working across the four pillars of practice. The four pillars of practice define the core role and function of advanced practice and more detail related to the pillars can be found in the Pillars section of the toolkit.

A recent addition is the development of metrics to demonstrate safe, effective and person-centred care. Metrics should be both qualitative and quantitative and triangulated to demonstrate effectiveness. Examples that teams could use are included in Paper 7.

If you are in an advanced role, you should have a named clinical supervisor and be offered at least four clinical supervision sessions per year. The clinical supervision structure must include a competent senior clinician (Medical/Nursing/AHP/Pharmacy) to give “sign off” and regular review of competence. Further information on supervision can be found in the Facilitation of Learning pillar.

Advanced nursing practice is not regulated currently by the Nursing and Midwifery Council (NMC), but a review of this position is underway. The individual’s responsibility for competence remains embedded within the NMC Code

Another area of nursing practice worth defining is the Clinical Nurse Specialists (CNSs) and Nurse Practitioners (NPs). They are registered nurses with relevant experience and post-registration education for working within a specific area of practice. They assess, manage, deliver care, advise on, and support the care for people within a specialist area (Chief Nursing Officer Directorate, Transforming Roles Paper 8, 2021).

As a Level 6 Senior Practitioner they work under guidance in a peer relationship with other members of the multidisciplinary team. They have the autonomy to act and accept responsibility and accountability for their actions, acting as a skilled advisor or resource for others. This includes specialist assessment, informed decision making, and treatment using a personalised approach to care for patients’ multidimensional presentations. This may require supporting specialist care over a prolonged period of time. They have the authority to refer patients and may admit or discharge within appropriate clinical areas of practice. This is characterised by a level of decision making based on detailed knowledge and understanding of their area of practice. As part of the multidisciplinary team, they can work in or across many settings, including non-clinical, depending on their area of expertise and scope of practice.” (CNOD 2021)

Transforming Roles Paper 8 sets out the core competencies for any CNS or NP. To these additional specialist competencies are added. The competency framework needs to be completed before a new CNS or NP can be regarded as appropriately prepared.