Advanced practice has been evolving in Scotland for many years. Although they are not as widespread in England, educational programmes have been in existence in Scotland since the late 1990s. Originally established at degree level, the move to MSc level preparation was made in 2004, to align with the International Council of Nurse's (ICN) stipulation for MSc level preparation for advanced practice nurses' (ICN, 2001).
Although roles have existed for many years, the focus on advanced practice became more evident with the development of the Advanced Practice Toolkit in 2008. While the toolkit was initially developed as a Scottish resource, the contents were seen as relevant UK-wide and the UK Chief Nursing Officers consequently endorsed it (NHS Education for Scotland (NES), 2018). The toolkit detailed the four pillars of practice (clinical practice; facilitating learning; leadership; and evidence, research and development), which originated from Manley's (1997) conceptual framework: ‘operationalizing an advanced practitioner/nurse consultant role’. Although the pillars are utilised UK-wide, the exact terminology used varies slightly across each country.
Programme development
In 2017, the ‘Transforming Roles’ (TR) programme was introduced in Scotland. The programme initially focused on advanced nurse practitioners (ANPs) and aimed to support role development. Its impact has been substantial.
Programmes of education across Scotland have been aligned to the requirements outlined in the TR policy documents (Scottish Government (SG), 2017). The Scottish Government committed to funding 500 advanced practitioner roles—many practitioners had previously undertaken components of advanced practice programmes prior. Within NHS board areas, work was undertaken to ensure titles and roles aligned with the new policy direction.
Two main roles currently exist for advanced practice nurses in Scotland: the ANP and the advanced clinical nurse specialist. Paper 7 of the TR programme reiterates the generalist nature of the ANP role and details five main groups of practitioners:
- Adult
- Paediatric
- Neonatal acute care
- Adult and paediatric mental health
- Adult and paediatric community care (SG, 2021a).
In addition, guidance is provided within this policy paper about use of metrics for measuring outcomes to detail the impact of ANPs on quality of care and patient outcomes. A recommendation for non-clinical time for ANPs is also established within this policy document. This is a unique approach within the UK and represents the importance of dedicated time for non-clinical work. The policy direction within paper 7 of the TR programme reflects a move towards multiprofessional advanced practice (SG, 2021a).
Paper 8 of the TR programme, published in 2021, consisted of a review of the clinical nurse specialist (CNS) and nurse practitioner roles within Scotland (SG, 2021b). The paper distinguished between CNSs and advanced clinical nurse specialists (ACNS), and detailed the variation in roles in terms of scope of practice and complexity of decision-making. Because of its increased complexity, the ACNS role is seen as an advanced nurse specialist role. This paper includes role definitions, required competencies, and education and governance requirements for both CNS and ACNS roles.
Remote and rural development
In response to remote, rural and island healthcare needs, a collaboration between multi-agency partners and NHS Education for Scotland's Remote and Rural Healthcare Alliance led to the development of the Multidisciplinary Rural Advanced Practice Educational Pathway (NES, 2021a) and the Multidisciplinary Remote and Rural Capability Framework for primary and community care (NES, 2021b). This has culminated in the establishment of an MSc Rural Advanced Practice that has been commissioned by NES and recently approved for delivery at the University of the Highlands and Islands. The investment in remote and rural advanced practice includes the development of a supervision hub, which is currently under construction. The hub will include detail of rural advanced practice governance and supervision requirements, as well as wider continued professional development (CPD) opportunities.
Higher education institutions
There are currently 10 higher education institutes (HEIs) in Scotland that offer advanced practice programmes. In March 2021, the Scottish Advanced Practice Educators Network (SAPEN) was established. SAPEN is multiprofessional and includes representation from all the HEIs in Scotland that offer advanced practice programmes in/for:
- NES nursing, midwifery and allied health professions
- Pharmacy
- Remote and rural leads
- Colleagues from regional NHS board areas who lead on advanced practice for the boards
The main aim of SAPEN is to provide a coordinated approach to the development of advanced practice education in Scotland, influence and support the development of advanced practice and advanced practice education programmes, as well as ensure the quality and consistency is maintained throughout the country. SAPEN's current focus is on the development of a national portfolio, national CPD programme, and learning disabilities and autism capabilities.
Wider work
Currently, there is national work ongoing to refresh the advanced practice toolkit. This work is being led by NES, supported by an editorial board and a user experience group. Subject matter experts have been employed to develop content. Links to national groups such as SAPEN and the national Advanced Practice Doctoral Support Network (that was also established in 2021) have reinforced this content development and enabled close links with evidence development.
Mental health
Mental health advanced practice is an area of growth within Scotland and a national Mental Health Advanced Practice Support Network was established in 2021. This network comprises of nurses and pharmacists working across Scotland in mental health settings. These meetings are well attended and and presentations from colleagues within the network are encouraged. The network has started to consider further collaborative scholarly developments.
Academies
To support the development of advanced practice across Scotland, three multidisciplinary advanced practice academies were established in 2017 and 2018. The academies cover the North, West and East of Scotland. The academies are chaired by NHS leads and function as collaborations between regional NHS board staff and HEIs. The main aim of the academies is to support governance and CPD of advanced practice. Membership is multidisciplinary and inclusive.
While the academies usually meet separately throughout the year, they have met jointly on a few occasions. The chairs of these academies value collaboration across Scotland and work together on a number of key areas, such as research development. The academies supported and endorsed the development of a national advanced practice newsletter that is produced for advanced practitioners in Scotland twice annually. The newsletter provides detail of the multiprofessional developments in Scotland in terms of the four pillars and encourages contributions about research developments and student dissertations.
National collaboration
The Association of Advanced Practice Educators UK committee has UK-wide multi-professional representation, which enables regular engagement with advanced practice educator colleagues across the UK. There are two Scottish committee members who provide country-specific feedback and support collaborative developments. One example of this collaboration is the production of a student handbook that is housed on the Association of Advanced Practice Educators UK (AAPE UK) website.
The Welsh Advanced Practice Educators Network (WAPEN) was established in 2020 and collaboration between WAPEN and SAPEN occurs at regular intervals. Main areas of focus are CPD developments and scholarly activities to progress advanced practice.
Internationally, colleagues from AAPE UK, WAPEN and SAPEN are collaborating on an active learning programme. This programme aims to facilitate student nurse practitioners' understanding of global healthcare systems, foster the development of critical thinking and cultural competence, and share international educational opportunities. These collaborations have resulted in regular case-based discussions, conference presentations and journal article submissions.
Additionally, the chairs of SAPEN and WAPEN are co-chairs of the comms sub group of the International Council of Nurses Nurse Practitioner Advanced Practice Nurse Network (ICN NPAPN Network) and work with colleagues to raise the profile of advanced practice within their respective countries.
Looking forwards, Scotland will soon host the 2024 ICN NPAPN Network conference, which was successfully bid for by the North of Scotland Advanced Practice academy. We are looking forward to hosting this international conference for the first time in Scotland, as well as continuing to innovate and develop the advanced practitioner role with our UK and international colleagues.