ANNPs contribute to the Tier 1 or Tier 2 medical rota, working in a capacity aligned with roles traditionally undertaken by doctors. It is essential that practitioners and organisations ensure safe care, while also protecting the practitioner who needs to work within their scope of practice. A new process was designed, following media controversy and debate surrounding the knowledge and capability of non-medical practitioners such as physician associates (PA) who work within roles that are traditionally medical. In addition, there was concern around the robustness of the previous governance process for ANNPs moving into a tier two role, who work without consultant on-site presence. This reflection will consider some of the challenges faced during the process and how the new system will strengthen the advanced clinical practice governance process and organisational oversight for the ANNP team.

Background

ANNPs were first introduced in the UK in 1992, when the Advanced Clinical Practice (Neonatal Nurse Practitioner) master’s degree was commenced at the University of Southampton.² Since then, the ANNP role has continued to evolve, with many ANNPs now working in a capacity similar to resident doctors at tier one, or registrar (tier two) level. This workforce model reflects a national picture and is supported by the British Association of Perinatal Medicine’s (BAPM) 2022 Service and Quality Standards for Provision of Neonatal Care in the UK3 with the advanced clinical practitioner (ACP) role being well respected and accepted by nurses and doctors working within the specialty.⁴

Since the introduction of ANNPs, the role has changed significantly and, alongside this, ACP roles across the NHS have increased across many specialties. The NHS Long-term Workforce Plan⁵ suggests the ACP role offers clinical effectiveness, innovation and the reshaping of health services. Publication of the Multi-Professional Framework for Advanced Clinical Practice in 2017 by Health Education England⁶ provided much-needed clarity around the ACP role. However, the UK currently lacks a single regulatory healthcare framework to define advanced practice and educational standards, although the Nursing and Midwifery Council has committed to regulating its registrants, having recently published advanced practice principles.⁷ Therefore, there is currently little professional regulatory accountability for the ACP.

In 2014, the death of a baby from a fatal bowel condition associated with prematurity occurred. The death followed an ANNP decision to remove the endotracheal tube prior to his deterioration and the case made national headlines,⁸ highlighting ANNP clinical vulnerability. More recently, the media have reported six major concerns around the safety and efficacy of PAs in the UK, voiced by UK doctors.⁹ Concerns include patient safety, scope of practice, informed consent, preferential employment conditions, additional workload and impact on medical training,¹⁰ suggesting a backlash against and loss of confidence around non-medical practitioners currently working in medical roles. This could arguably extend to ANNPs.

Review of existing process

ANNPs contribute to the Tier 1 or Tier 2 medical rota, working in a capacity aligned with roles traditionally undertaken by doctors and there were no concerns identified in relation to the competence or capability of the ANNPs. However, changes to the management structure, including the removal of direct line management from matrons to senior ANNPs, alongside the trust’s introduction of the advanced practice facilitator role and the appoint-ment of a new group director for nursing, prompted a review of existing governance arrangements.

At the start of the project, the ANNP competency and sign off process consisted of a locally developed document mapped to the BAPM ANNP capability framework,¹ which was optional and used to demonstrate readiness for progression from tier one to tier two working. There was no formalised process to confirm competence or capability following training completion alongside an assumption by the medical supervisors that there was additional oversight at an organisational level. As a result of the above, a scrutiny process was undertaken by neonatologists, lead ANNPs, senior nursing managers and trust leads for ACP. The opinion was that the while the BAPM 2021 framework reflected the four pillars of advanced practice and provided a clear career framework, the clinical competency component was too broadly defined. It was agreed that a new document would be developed with more specific and measurable ANNP clinical competencies for both tier one (8a) and tier two (8b) levels. In addition, a sign off process was formalised to demonstrate assessment and confirm readiness to work autonomously as either a tier one ANNP following initial qualification, or a tier two senior ANNP. This process was to be overseen by the trust leads for ACP.

Strengthening the process

Governance for advanced practice enables consistent, high quality, safe patient care which will support public protection. Furthermore, it promotes continuous improvement and provides a framework for professional accountability.⁷ Over a four-month period (September 2024- January 2025) an extensive amount of work led by senior ANNPs was undertaken in collaboration with the ANNP team, clinical lead for neonatology, medical supervisors, trust leads for ACP and group directors. The work resulted in the production of two documents that were formally reviewed and published as part of trust’s quality processes.

The documents were mapped to the BAPM ANNP capability framework, but with an expanded, more specific and detailed clinical competency element that aligned with the Royal College of Paediatrics and Child Health Neonatal Medicine and ACP syllabus.^11,12 The documents included self-assessment, demonstration of competence and competency sign off by the named medical supervisor followed by a formal sign off meeting. A section for development plans was included should an ANNP be found to require further development.

Implementation and challenges

Once the process and documentation was formalised, all ANNPs were requested to provide evidence of their clinical com-petence using tools such as Mini-Cex, direct observations of procedures (DOP), case-based discussions (CBD), 360-degree feedback, procedure logs and clinical reflections, followed by an official sign off by their medical supervisors and lead ANNPs over a six-month period. Eight ANNPs were required to retrospectively evidence competence (as already working autonomously on the tier one or tier two medical rota), alongside two newly qualified ANNPs who were able to pilot the tier one process as it was designed.

Initially, there were reservations from some of the ANNPs who felt that they were ‘being treated like a trainee again’ or were worried that there were ‘concerns around their practice’. In addition, a substantial amount of work was required by each ANNP to gather the range of evidence required to demonstrate clinical competence. Self-assessment was also a challenge, with some individuals finding rating their proficiency and identifying developmental needs difficult. The two lead ANNPs led the way by building and sharing their evidence with the team.

Nine ANNPs completed their competency mapping in the expected time frame, with the tenth ANNP delayed slightly due to extenuating circumstances. The completed documents and supportive evidence were assessed by their named medical supervisor and subsequently reviewed and final sign off by the neonatal clinical lead, director for nursing and midwifery, with the process witnessed and endorsed by the trust leads for ACP to ensure organisational oversight. Post implementation, ANNP feedback was that they felt more protected.

Discussion

ANNPs are fortunate to have a specialty-specific capability framework available published by BAPM. The aim of the framework was to provide clarity around the roles and responsibilities of ANNPs at varying levels, to ensure consistency of practice and a description of options for development. However, it was argued locally that the clinical pillar within the document was non-specific (despite being fully mapped against the HEE Multi Professional Framework.^1,6

The predominant opinion within the team at that time was that everyone had completed a neonatal specialty-specific master’s qualification in ACP and that this alone was sufficient to evidence competence and capability. However, a new NHS England-endorsed paediatric ACP curriculum has only very recently been published and within this is the neonatal ACP specialty syllabus.¹ As a result, there is variation and inconsistency in the level of quality specialty teaching and assessment across the different Higher Education Institutes (HEI) to date, which will have undoubtedly impacted individual ANNP’s underpinning knowledge and capability. Within our ANNP team, education has recently been provided by four different accredited HEIs, with course length spanning from one to three years. This is likely to change in the future as the updated multi-professional framework6 has fully endorsed the new paediatric and child health advanced practice area-specific capability and curriculum framework.¹²

Developing the ANNP competency document was in part a response to concerns surrounding the governance of PAs, with the goal of strengthening the framework around the clinical practice pillar. In parallel, the NHSE Centre for Advancing Practice published the Advanced Practice Governance Maturity Matrix in 202213 to provide a structured approach for organisations to assess and improve their advanced practice standards.

This maturity matrix is divided into eight domains against which health and care provider organisations can self-assess their progress:

• Governance
• Leadership
• Workforce
• Business case and funding
• Training and assessment
• Clinical practice
• Supervision
• Continuing professional development (CPD)

The domains of clinical practice, supervision and training and assessment have been strengthened and directly link to the newly designed competency and sign off process. As part of the trust’s ongoing ACP strategy, developing specialty-specific competencies and processes was identified as a key action. The ANNP team has successfully led this innovation, collaborating with several stakeholders. This involved producing several drafts and carefully considering all feedback until a final consensus version was reached.

Despite initial concerns expressed by the ANNP team regarding what was viewed as increased and unnecessary workload, all members fully embraced and completed the process. A systematic literature review undertaken by Khaw et al¹⁴ studied reactions towards organisational change and the mechanisms that promote that process smoothly. They argue that a reaction towards a change is a cognitive and behavioural response influenced by how a change is introduced. Furthermore, a negative reaction towards change happens when it is expected to result into more workload, uncertainty and fatigue, especially when change is rapid. Indeed, retrospective evidencing and mapping of competency was time consuming for all team members, therefore initial reactions were unsurprising.

According to Albrecht et al,¹⁵ practitioners are likely to accept and develop willingness to change when they understand the need for change. Consistent communication across the team was key to ensure that all ANNPs understood why the new approach was required and how it would benefit individuals, the team and patients over the long term. Alongside this was a need for reassurance that this was not because of concerns around individual competency or capability.

Barrow and Annamaraju highlight that consistent leader engagement throughout the change process greatly improves the likelihood of success.¹⁶ In this case, the lead ANNPs were also required to retrospectively evidence and complete the new competency documents, thereby leading by example. The lead ANNPs provided regular ongoing communication, including the sharing of resources and ideas. This was further facilitated by the trust and neonatal service supporting 20 per cent non-clinical time to meet the leadership, education and research pillars, alongside a commitment from all medical supervisors to invest in, engage in and support the new process.

An additional consequence from this work was that an e-portfolio was built using the Microsoft One Note facility utilising resources provided by the Neonatal Nurses Association ANNP group. As a result, ANNP portfolios are now organised and up to date, with a range of evidence replacing an often disorganised paper folder consisting of procedure logs, appraisal paperwork and certificates. With the Nursing and Midwifery Council’s regulation in the pipeline, maintaining an up-to-date portfolio of evidence will help to enable a smoother transitional arrangement process.

Conclusion

Developing and implementing the area-specific capabilities and the final end-of-training or progression sign off process was a significant collaborative effort involving teams across the perinatal, ANNP and trust ACP leads. Additionally, this process allowed the lead ANNPs to further strengthen their leadership capabilities and gain valuable experience in project and change management. It also enhanced their skills in collaboration and communication within their teams and with wider stakeholders, alongside providing a deeper understanding of advanced practice governance.

Despite initial reticence, the process was embraced and understood by the ANNP team, and a clearly defined career development structure has now been established.

Next steps

• The new process introduced will now form part of our standard ANNP management and career development.
• The team will support the trust leads for ACP to roll out a similar model across other AP specialties.
• Development of a tier three version ref-lecting the BAPM framework is planned.
• The ANNP e-portfolio will continue to be developed, producing an annual review of clinical practice to align with the yearly ACP appraisal and alongside guidelines including the minimal yearly expected type and variety of evidence, for example number of DOPs, CBDs, reflections.

Acknowledgements

The author would like to thank the following for their contributions: Lucy Bradley, Senior Advanced Neonatal Nurse Practitioner and Lead ANNP; Dr Puneet Nath, Consultant Neonatologist, Neonatal Clinical Lead; Andrea Hargreaves, Group Director of Nursing and AHPs; Jenny Abraham, Consultant Nurse, Bariatric and Practice Facilitator for Advanced Clinical Practice; Rachael Lee, Advanced Clinical Practitioner Renal and Practice Facilitator for Advanced Clinical Practice; all from University Hospital Coventry and Warwickshire NHS Trust.