The role of the ANNP, first observed in the USA in the 1970s, was introduced into the UK healthcare workforce in the late 1980s and the University of Southampton offered the first academic course in 1992.¹ The ANNP is now an integral part of the neonatal team in NHS units of all levels throughout the UK and Northern Ireland. Described as ‘the professional bridging the gap between medical and nursing teams,’ the ANNP provides a flexible solution to workforce pressures.^2-3

ANNPs in the neonatal unit

Utilising their extensive neonatal experience and acquired knowledge of pathophysiology and pharmacology, ANNPs exercise professional clinical judgement in diagnosis and complex decision-making. They provide support at high-risk births in the delivery room and are often the point of medical contact for midwives working in all areas of maternity, including the community.⁴ ANNPs are uniquely placed to contribute a nursing and medical perspective to inter-professional team working as they have evolved and developed from a nursing background, often with many years of neonatal experience.

Within the neonatal unit the ANNP role has many facets, which may include undertaking procedures traditionally performed by medical staff.^5,6 These include:

• intubation
• lumbar puncture
• chest drain insertion
• central venous and arterial access
• exchange transfusion
• ordering and interpreting investigations
• steering medical ward rounds
• being the lead professional in newborn resuscitation.

ANNPs offer a level of continuity in balance to the fluctuating experience of each new cohort of GP, paediatric and neonatal grid trainees moving through the neonatal medical workforce.⁷

Since the implementation of European Working Time Directive in 2007 restrictions have been placed on the number of hours worked by junior doctors. This has resulted in many medical teams, including those working in neonatal environments, experiencing staffing resource issues.⁸ In addition, the Royal College of Paediatrics and Child Health (RCPCH) has reported a shortfall in doctors applying for specialty trainee posts across paediatrics,^9-11 indicating that the situation is unlikely to improve. Increasing ANNP numbers and integrating them into neonatal medical teams has ameliorated the situation by increasing service provision, thus revealing that ANNPs have provided a direct, positive impact on the quality of care being provided in neonatal units across the UK.^2,12

The ANNP workforce

There were an estimated 250 qualified ANNPs in 2009 with more currently in training.¹³ It remains difficult to quantify the exact number of qualified ANNPs currently working in neonatal environments due to the lack of an advanced nurse practitioner professional practice register. The argument for this continues and requests have been made to the Nursing Midwifery Council.^13-15

Progression into advanced practice

The basis for the ANNP role is guided by the four pillars of advanced practice devised by NHS Education Scotland in 2007.¹⁶ These are:

• management and leadership
• education
• research
• advanced clinical practice.

The four pillars are the foundation of the role and underpin the ethos of education of all new ANNPs. It is well recognised that ANNPs provide strong clinical leadership as autonomous practitioners providing evidence-based care while improving practice and progressing change. The reasons for this have been linked to the background from which ANNPs derive. They have, in the majority of cases, worked in neonatal care for numerous years and many have progressed through an enhanced neonatal qualification, post-qualification in neonatal specialty. ANNPs have evolved from a neonatal nursing background and these experienced professionals are often ready to progress their careers but wish to remain in a clinical role. The pathway for this direction is by the popular route of advanced practice. Although these nurses are usually ready to progress to managerial level they choose to do this via an ANNP direction, which combines clinical leadership with a management responsibility while keeping a clinical prominence.

The progression of senior neonatal nurses into advanced practice is often viewed as a desirable route for many younger nurses working their way through the career structure; however, this comes with its own issues. The nursing workforce, already in recruitment crisis, requires active strategies to attract new recruits to the area of neonatal care in order to backfill nursing posts and to develop the next generation of advanced nurses. It has been suggested that some nurses delay applying to ANNP training courses due to the concerns around lack of cover for their absence during the lengthy study period.¹⁷ Due to the nature of the ANNP role, a team commitment remains and following study the ANNP will often return to the same clinical team, albeit in a more hierarchical role.

Remuneration

In many units ANNPs are incorporated within the junior and middle grade medical rotas, according to their level of experience. This demonstrates that they are vital to the workforce arrangements in many NHS teams but one area of discontentment is the wide difference in ANNP roles and responsibility, resulting in variation of salary and grades. In addition to this ANNPs are paid from both nursing and medical budgets often causing them to have more than one line of management to report to. It has been suggested that this has resulted in discordance between the remuneration of ANNPs and doctors working on the same rota.³

Education: establishing a national standard

ANNP courses vary significantly in content and duration, with trainees often deemed competent to work as independent ANNPs following successful completion of a post-graduate diploma. Although it is now an expectation that the ANNP student will continue their education to finish with an MSc award in advanced practice. However, the discourse between education levels of ANNPs currently working in practice coupled with the level of unit in which training is undertaken gives rise to the potential for disparity in skill and knowledge. This has resulted in competency being brought to the forefront of discussion.¹⁸ Some local neonatal units have reported issues with staff retention associated with the need for ANNPs to consolidate their training and leaving to achieve this at a tertiary unit or one that has a higher rate of cot activity.⁵ The education of advanced practice in many higher education institutions follows a medical model, leaving role adaption to the individual working within a variety of settings. In 2017 Health Education England implemented a multi-professional framework for advanced practitioners.¹⁹ Establishing a national standard of entry and qualifications while moderating the quality of academic and professional practice ensures practitioners have the ability to synthesise their knowledge and clinical skills at an advanced level. Confidence in the ANNP role has developed from this structured education coupled with the extensive neonatal experience that ANNPs possess.² The aspects of the ANNP role that continue to cause dialogue and discontentment are the wide disparity in roles, grade and structure within teams. This coupled with the changing landscape of neonatal nursing and continued issues in recruitment and retention, has highlighted an urgent need to evaluate the role.

A BAPM Working Group to develop an ANNP career framework

BAPM is seen as the most relevant body to generate much needed dialogue and data to drive a more structured approach to the ANNP career pathway. Committed to collaborative working between health professionals and families to provide family-centred care, BAPM’s mission is to improve standards of perinatal care by supporting all those involved in perinatal care to optimise their skills and knowledge, deliver and share high quality safe and innovative practice, undertake research, and promote the needs of babies and their families.²⁰

The BAPM annual general meeting is well attended by relevant bodies, and representatives can be seen from major institutions including the RCPCH, Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Neonatal Nurses Association, Perinatal Pathology Group, British Association of Paediatric Surgeons, Royal College of General Practitioners, Royal College of Anaesthetists, National Perinatal Epidemiology Unit and the Department of Health and Social Care.

BAPM is closely involved in syllabus setting and accrediting training posts for the neonatal specialists of the future. The recent rise in nurse members and the constant drive to encourage both medical and nurse collaboration set a relevant and appropriate platform for the much-needed investigation into the role of the ANNP.

In 2018, BAPM identified a gap in current data regarding ANNP job roles in the UK and embarked on a project to generate further information, hypo-thesising that there is no single direct way in which ANNPs are working in the UK and the format of this diverse role varies between trusts. The area of neonatal care is not alone in experiencing a dearth of this information – there is a lack of data on advanced practice across all specialties.

Now a BAPM Working Group has been formulated consisting of the BAPM Nurse Representative, ANNPs from across the UK and representation from the Royal College of Nursing and higher education. The plan for this group is to create a career frame-work for ANNPs working across England, Wales, Scotland and Northern Ireland. In order to embark on this scheme of work, further information is required in order to generate current representation of ANNP working. The progression of this scheme of work will be published in forthcoming issues of Infant.

The landscape of ANNP training appears to be changing – what was once deemed a pathway of learning for experienced neonatal nurses is now being accessed by more junior neonatal staff. This has to be recognised and in order to retain this younger, motivated workforce there needs to be a set route for progression and promotion. In order for this to occur and a clear career pathway to be developed, further data are required. The project currently being undertaken by the BAPM Working Group will clarify the situation, support nursing staff develop-ment and improve staff experience to sustain high quality care.