Role of Advanced Nurse Practitioner in General Practice in the UK

Abstract

The professional roles of Advanced Nurse Practitioners (ANPs) is a paramount in nursing care especially in the UK ANPs where it has been in existence in one for over 40 years now. The role of ANPs in General practice was brought about due to an increase in financial pressure, shortage in the recruitment of Gps’ with unmet accessibility to quality healthcare by patients. Up to date, the scope, title, and limits of the role of Advanced nurse practitioners have not been fully defined. With no clarity and consistency in the level of competency, these issues are left to be dealt with and to be dictated by individual employers as they see fit within their organisations and to meet their needs.

Method

A systematic review of qualitative studies using the databases of CINAHL, MEDLINE, EMBASE, and Cochrane. The search consisted of free text words ‘advanced nurse practitioner role in Gp practice’, ‘advanced nurse role’, ‘nurse practitioner’, ‘nurse clinician in Gp practice’, ‘nurse practitioner in Gp practice’, ‘advanced practice nursing roles’. Literature between the years of 2000 to 2019 were all considered relevant owing to the fact that not much literature has been written about nurse practitioners in Gp practice.

Introduction

A significant number of people have shown interest in ANP professional for the last o decades where quite a number of them have ended up increasing their skills in nursing practice in response to the change in health care demand, thereby allowing development, flexibility, partnership, openness and innovation of nursing career. According to Wilson-Barnett et al., 2000, nurse practitioner roles came about from the primary nursing model of care in the 1980s. This nursing model was introduced by Stilwell, 1988, with the aim to maintain good access to quality care, patients’ safety and to meet up with the demand of healthcare. The titles of ‘advanced practitioner’ and ‘advanced nurse practitioner’ then appeared in the 1990s. Some important documents were released prior to the emergence of advanced nurse roles in the UK, they included, Vision for the Future (Department of Health, 1993), Post Registration Education and Practice project (PREP), (United Kingdom Central Council, 1994), and the Scope of Professional Practice, (United Kingdom Central Council, 1992). These reports were significant and brought about the momentum for the overall development of Advanced nurse roles.

Nursing and Midwifery Council (NMC), 2005, gave its definition as, a nurse who is highly skilled and educated, with the ability to diagnose and treat healthcare illnesses and is also able to refer patients to relevant specialist teams if needed. Meanwhile, Department of Health (DOH), (2010) defined ANP as a registered nurse who practices at a more advanced level than that of the initial registration, while making use of additional knowledge and skills in developing own practice further. The role of ANPs in Gp practice was brought about due to increase in financial pressure of medical service, shortage in the recruitment of Gps’ with unmet and poor accessibility to quality healthcare for patients especially in deprived areas. One of the responses to tackle these challenges was to extend the roles of nurses to do jobs formerly carried out only by the doctors. The overall expectations were that quality of services will be enhanced, accessibility improved, cost of provision of healthcare reduced and demand for more Gps’ reduced with the new substitution, hence, the introduction of ANPs.

Oldham, 2015 indicated that the issue of Gp shortage will be immediately dealt with if more ANPs are trained and employed, this is because ANPs’ are able to carry out tasks originally done by Gps’ like taking histories, examining patients and making a diagnosis, interpreting results and most significantly prescribe medications without restrictions. Paniagua, (2010) reiterated the same issue point on alleviating Gp shortage with ANPs’. Baileff, (2015) stated that not only can ANPs alleviate the pressure caused by the shortage of Gps’ they fulfill the aim of maintaining good and fast access to healthcare, by reducing the long wait to see a Gp, by providing opportunities for more appointments. Kinnersley et al, 2000 also stated that ANPs’ can see almost all patients requesting on the day acute appointment, allowing Gps’ to deal with more complex issues presented by the patients.

Coombes, 2008 indicated that even though the Gps’ are highly experienced and cannot be compared with nurses, ANPs’ can do almost all that the Gps’ do, thereby represent good value for money as they are considerably cheaper to employ. Vrijhoef 2010 and Martin-Misener et al (2015) alike reiterated that ANPs in their roles are equally accountable and responsible as Gps’ but in comparison to wages ANPs’ are paid significantly less, making them cost-effective healthcare providers. Laurant et al (2007) published a Cochrane report which specified that care delivered by ANPs’ are found to achieve similar and sometimes higher patient satisfaction and better health outcomes, while Horrocks et al, 2002 reported that patients received more information about their condition from ANPs’ and had better communication and advise on self-care and management of their wellbeing, this illustrates quality healthcare that was intended when the role was created. The role of ANPs has remained to be significant in healthcare for long especially at this time when there is a shortage of nurses.

Methodology

A systematic review was carried out to define the roles of ANPs’ and the factors that surround their practice. The review identified specific qualifications of ANPs which makes them unique and to be used in areas where other nurses may not be able to work in.

Extensive research was conducted before generating the SR where most of the online research was carried out using the google scholar to access a variety of articles which contained information about the various roles played by ANPs in the healthcare sector. Considering that a big number of the article were generated, they were filtered and exclusion criteria applied using the specific search keywords, year of publication and restriction of only UK. Through such filtering, it was possible to make a review of the most qualifying articles in terms of their content.

The research approach was carried out using MEDLINE, CINAHL, Science Direct and Cochrane online database, for specific keywords on matters to do with roles of ANPs in General Practice. The search conducted was able to generate a total of 4959 articles (MEDLINE – 35; CINAHL – 20; SCIENCE DIRECT – 4901; and COCHRANE – 1). In the end, after applying the exclusion criteria, the number of articles left to be reviewed was very limited. With the keywords ‘advanced nurse practitioner in general practice in the UK, it was obvious that not many publications have been made on that topic.

Numerous recommendations are made on how a systematic review (SR) should be structured. They include the use of frameworks, models, theories and illustrations, Illes and Sutherland (2001) admitted that to establish which method is most applicable and suitable can be overwhelming.

CASP, PRISMA, PROSPERO, Cochrane models of systematic reviews considered and discussed as Harris et al 2014 indicated that the use of models in systematic reviews, helps to identify unanswered but answerable questions in an organised way. These models were all considered and briefly discussed below.

Critical Appraisal Skills Programme (CASP) is a method often used as a standard critical appraisal tool to enable analytical evaluation of the quality and effectiveness of published research information in order to reduce bias in the available data. It has 10 Hence, choosing an appropriate critical appraisal tool is an important component of evidence-based practice. It has 10 checklist questions. If the first two questions are answered “yes”, then it is worth going ahead with the rest of the questions.

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) is formulated to ensure transparency in reporting systematic reviews. PRISMA was formulated by a set of 29 review authors, methodologists, clinicians, medical editors, and consumers in 2005 after several poor reviews were reported with the use of QUOROM (quality of reporting of meta-analysis). There are 27 item checklist and a 4-phase flow diagram in PRISMA. It may be considered to be cumbersome and too comprehensive for this review. But the 4-phase flow chart was adopted in this SR. See Appendix I

PROSPERO is a specialized database that contains a systematic review protocol of research studies in health and social care that are in progress. It is required that researchers make it a routine to keep updating the reviews of their progress as they continue with a given research study. Such an update makes it easy for other people to be aware of what is happening on the ground. When carrying out a systematic review, the use of PROSPERO prevents instances of duplicating information which is a common mistake that is involved during the systematic review. It is thus recommended that a person carrying out a systematic review should always register with PROSPERO to ensure that the quality of information collected is not compromised.

While Cochrane is an online database used to generate systematic reviews of primary studies on matters patterning healthcare of human beings and policies that regulate the delivery of healthcare services. All the reviews that are available on Cochrane have an international scope which implies that the information and evidence contained in them is of high standards and deemed “gold standard” (Booth 2012). The users of Cochrane have the advantage of accessing summarized findings which makes it possible and easy to come up with informed decisions about health issues requiring their input to have the problem solved. It, therefore, means that the decisions made while using information from Cochrane are not biased considering that they are based on a lot of professionalism. Each of the reviews that are contained in the database contains a well-structured question which is responses that are sought using high levels of professionalism. Plain Language Summaries (PLSs) are included in the Cochrane and it is used to make it easy for users to get a good understanding of all the research findings and reviews they contain. A standardized technique is used when coming up with both the content and structure, this is also for easy understanding of translation for users.

The searches done on MEDLINE gave an opportunity to access to the most relevant studies done to describe various issues that affect the working of ANPs and the measures in place to make sure the output is always optimized and helps to solve the existing health issues. The articles contained information about the educational and prerequisite needs of ANPs, the scope of their roles which differentiate them from roles of other categories of a nurse. Paniaguia (2010) explained that the masters level education is helpful in shaping and influencing the complexity and criticality of the role. Furlong and Smith, (2005), highlighted that crucially, without the non-medical prescribing training aspect of ANPs’ course, a huge barrier will be placed in the effort to provide holistic, proactive and patient care.

MEDLINE was a preferred option in that it allowed a chance to compare the content of different studies. Considering that there was a specific topic that was being investigated, it was possible to identify and analyse articles that were useful and others which contained information which could not be used in the study. The most recent articles were found to be more useful in that they contained updated information about the current trends in nursing and the roles played by ANPs, although older articles were also considered.

Articles explaining the purposes of ANPs were also accessed to help tell some of the factors that stakeholders in nursing should work on in order to make improvement in the manner in which the nurses are able to offer their services to the ever increasing number of patients. Most of the articles reviewed contained studies done to evaluate the various roles of ANPs in the healthcare sector. A variety of the articles reviewed contained information about the current trends in the profession of ANPs hence it was possible to get details of the new introduction in this profession

Qualitative methods were used in the study to get details about ANPS and the perception about their roles, importance, and challenges faced in their profession. In terms of roles, the selected articles gave insights into the expected outcomes of ANPs when they are used to deliver specialized services to the patients. Details from the United Kingdom Central Council 1992 insights into the criteria that have been used to come up with the title used on ANPs with different levels of training and experience. The review was specific to identify the actual considerations that are taken into account to determine the level in which particular ANP qualifies right from the time they get started on their career life. It was also possible to access the guidelines that are used by healthcare stakeholders to evaluate the performance of ANPs as a way to describe the general trends of the prevailing patient outcomes in the UK.

EMBASE and Cochrane allowed for free access of medical articles with a specific selection of those which elaborated on the various instances where ANPs have been used in the healthcare sector to attain certain goals that cannot be attained in their absence. The most compelling fact about the articles accessed was that they contain primary data about the roles of nurses and their reported outcomes when dealing with patients presenting a variety of medical conditions. A Cochrane report published by Laurant et al (2007) stated that care delivered by nurses to patients instead of doctors possibly lead to similar or even better patient health outcome and undoubtedly more patient satisfaction.

Use of specific keywords helps to optimize the searches conducted such that only the articles containing information about ANPs were selected.

Although a number of the articles which are available online tend to be biased, most of them contain information which has some useful information that can be used to get details about the roles of ANPs. Comparing information from different sources is a good way to determine the extent to which the information accessed is valid to help give a true picture of the reality in life. The use of Boolean which is a static compare method to get true or false values in the flow of a data program was applied. Such a comparison helped to discard some of the data presented in some articles which were extremely biased in the manner it was presented. There are common things that are known about the roles of ANPs and it is thus easy to determine the accuracy of the information presented about their roles and expectations. Accessing the right information about ANPs is a good way through which the actual information about their role and associated services can be evaluated. Accordingly, the inclusion criteria for this particular review was limited to quantitative, randomized control trials [RCT] on human cases within the pre-hospital setting, simply comparing the effectiveness of manual versus mechanical chest compressions in terms of ROSC and casualty survival. Creswell (2012) feels quantitative research is the “scientific method of social inquiry” (p.23) and therefore is more suited to this SR.

Conversely, qualitative research would not be included within this SR as it invariably relies upon participant perspectives rather than a practical approach (Denzin and Lincoln, 2005).

When researching a multitude of published work, it is vital that the outcome is reported rather than the hypothesis. Although in high-quality studies they should technically be the same, this is not always the case (Nobre, Bernardo, and Jatene, 2003; McKeon, King and McKeon, 2016).

Considering that the study was interested in matters that are related to the roles of ANPs, articles which contained information about the marketing of ANPs were not used during the review process.

 Oldham, 2015 indicated that the shortage of nurses is a serious problem requiring an audience of stakeholders

The obligations and commitment of ANPs were deduced from the selected resources and grouped based on their similarity and relevance to the topic. ANPs were portrayed as the most immediate personnel in determining the course of action to be taken to help improve the overall health of various patients presenting varied medical conditions. The review of the articles was also interested in finding details of how the ANPs end up making their changes in their normal processes. The nursing practice uses a lot of tools to help the nurses perfect in their roles and thus the need to identify the specific tools that are available at any one time. The study was interested in identifying the specific tools that must be available to make sure that the roles and commitment of ANPs are not compromised or delayed in any way. Attention was also given to the manner in which the ANPs work together with other medical staffs to help optimize the manner in which medical services are offered. The role of ANPs in the acquisition of the health system was also investigated to determine how well the nurses, and mostly the ANPs, can be used to improve on the current healthcare systems.

According to Kinnersley, (2000), the roles of ANPs are worth considering to identify the specific areas they are involved where then clinicians cannot function. Details of areas of specialization where ANPs are used required the searchers to be optimized to get access articles containing information about their specialized roles and the expected roles. Attention was given to the details that the ANPs are always looking for inpatients and the main reasons as to why they are used to ma toke such consultation bearing in mind that consultation is mainly meant for doctors and clinicians. ANPs were assumed to have a wide range roles they play in the healthcare sector and thus the need to have a better understanding of such roles.

The PICO model was selected as a useful method to come up with clinical questions that were used to collect data about the roles of ANPs and their impact in improving the health standards of a given population. The questions sought to identify the processes and tools used by ANPs in identifying the various problems presented by patients. Such an understanding helped to identify what they end up looking inpatient and the manner in which they describe and present the conditions identified (Leonardo, 2018). The description of the medical issues in patients helps to determine the appropriate course of action to be taken to have the ill conditions treated.

The PICO model also allowed a chance to identify the criteria the ANPs use when selecting a suitable intervention to treat the problem identified in the patients. There was interest in identifying standard procedures used when determining the right interventions that nurse should use to make sure that the problems of patients are completely solved. It was possible to understand the manner in which the selected interventions are compared with other probable options that could also be used to treat the identified problem. It was also possible to get details about the expected outcomes following the selection of a given intervention.

Data Analysis

The use of systematic reviews in the healthcare sector has been used long. The technique is considered to be useful in that it allows the researcher to come up with evidence-based decisions or conclusions. The important thing about systematic reviews is that they allow the researcher to make use of empirical evidence as opposed to knowledge that has been preconceived. Systematic reviews are preferred research techniques because they are very transparent and objective in the manner. It is thus a useful technique for use when carrying out a meta-analysis in both qualitative and quantitative studies. The fewer costs incurred when using SR is an advantage which makes it useful when carrying out studies which require high levels of accountability.

When using SR, it becomes possible to analyse the variables included such that a person is able to generate informed answers to the research questions used in different studies. It is a method that allows for critical analysis of all facts included in any document research study in order to the usefulness and accuracy of the findings generated. The review allows for a clear understanding of the steps involved in generating the results to help identify cases of bias that might have been involved. It is thus possible to make good use of both inclusion and exclusion criteria when analysing the intended resources. SR is thus a technique that is used to generate the information necessary for a given study in a way that safeguards both integrity and validity of the information or findings accessed. The meta-analysis procedures is a good way through which useful information and data can be sought to help come up with a clear understanding of the actual roles of nurses with special attention to the involvement of ANPs in the healthcare sector.

The high-quality information generated using SR is important when making decisions meant to describe the prevailing trends in the nursing profession and the changes being made from time to time. SR is thus a good technique for use in policy-making to allow for use of evidence-based information to make sure that the developed succeed to solve the existing problems.

It is a fact that the process of carrying out clinical trials is prone to a lot of bias which affects the integrity of the information that is available to describe a particular trend in the healthcare sector. Some of the bias that is involved is not intentional and SR helps to detect such cases to make sure that the information that is used at last is precise and a true indication of real happenings. SR remains to be a preferred technique for use in carrying out clinical trials and related analysis.

In cases where there are lack of defined protocols of carrying out research studies, the researcher has high chances of involving a lot of errors which leads to generation of findings which can be misleading to some extent. There is thus a need to embark on a technique that can help identify such error in order to come up with informed decisions. Misleading data can end up introducing a lot of problem in the healthcare sector especially in cases where critical decisions need to be made. SR offers a chance to identify any missing data in a given resource hence a good way to avoid findings that lacks a strong backing of the data generated.

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