The evolving role of the advanced nurse practitioner within UK general practice: A qualitative study on the views of employers, commissioners, GPs, nursing and NHS leaders, and advanced nurses.

Abstract

Background: General practice in the UK is facing unprecedented levels of demand following a sustained period of underfunding. Waiting times to see a general practitioner (GP) can be as long as four weeks in some areas of the country. GP numbers are also declining despite an increase in training places and an emphasis on recruitment and retention. Advanced level nurses such as advanced nurse practitioners (ANPs) have operated within general practice for many years and have arguably played a role in increasing access, changing the way patients are managed within surgeries. These nurses have developed their own roles, trained in specialist areas and increasingly taken previously doctor-only duties to meet demand and respond to changes in the workforce. The well-known issues surrounding the lack of ANP regulation, lack of title protection, variability of the role, and differing educational pathways are key factors when considering future strategy for the role and ensuring patient safety. Studies have tended to focus on patient satisfaction levels, outcomes, consultation styles and direct GP/ANP comparisons in the management of patients. This qualitative research study analysed the views of ANPs in the north of England, as well as the views of commissioners, managers, GPs, National Health Service workforce strategists and nursing leaders, on the evolving role of the ANP within general practice. The introduction of the advanced clinical practitioner (ACP) from a range of allied professional backgrounds and its possible impact on the ANP role is also a key line of enquiry.

Methods: A qualitative grounded theory methodology in two phases was used to ascertain and analyse the views of a range of ANPs working within general practice. Discussion topics in phase 1 included role development, training, support, how the day to day role has changed over recent years, pressures, financial rewards, perceived threats to the ANP role, and what the future may hold for ANPs. Phase 2 interviews included nursing leaders, commissioners, managers and key stakeholders; comparing and contrasting the views of these participants with those of phase one. The areas for discussion with the managerial, leadership and policymaker participants included workforce analysis, the 2019 GP contract, the Health Education England framework for advanced practice, local and national advanced practice initiatives, and the key stakeholders’ views on the ANP and ACP, and how these roles are shaping primary care service provision.

Analysis: Grounded theory methodology was used to analyse participants’ data. Coding, categorisation, thematic content analysis, theory generation and linking findings with established literature were used to validate the findings.
Findings: The data suggested that the ANPs in this study are being used to improve access to general practice and are at the forefront of workforce planning around service provision and dealing with demands. The ANP participants expressed a willingness to retrain, adapt and take on new roles that were previously seen as doctor-only. A reduction in GP numbers and increased demands from patients were key drivers for these changes. The ANPs were also aware that their roles are becoming increasingly medicalised, moving away from a purely nursing model and transitioning to a hybrid role between the nursing and medical domains, blurring the lines between the two professions. There was a contrast in the responses of ANPs and nursing leaders around the future of the role and the nursing background to advanced practice. The introduction of the ACP role, ANP leadership and representation, and the 2019 GP contract were key issues highlighting further differences of opinion between the participants in the two separate phases of the study.

Contribution to knowledge: This study highlights the transitional nature of the ANP role towards a possible medical model of practice and a ‘third space’ between the nursing and medical professions. The introduction of multi-professional ACP training and the standardisation of advanced practice have the potential to improve access and care for general practice patients. Although without strong nursing leadership, recognition that the role is occupying a hybrid domain between the two professions, and a more robust nursing representation, both locally and nationally, there is a risk that the role is misunderstood by national policy makers in their quest to standardise advanced multi-professional practice, whilst not recognising the transition ANPs are experiencing.

Date of Award	24 Jun 2020
Original language	English
Awarding Institution	University of Bath
Supervisor	Nancy Harding (Supervisor) & Nancy Harding (Supervisor)