A Higher Level of Practice

Consultation Document

The UKCC’s proposals for recognising a higher level of practice
within the post registration regulatory framework

Contents

Foreword

Alison Norman, CBE,
President
United Kingdom Central Council for Nursing, Midwifery and Health Visiting

I am pleased to introduce this consultation document on behalf of the United Kingdom Central Council. It forms part of the work we are taking forward in order to test with key stakeholders our proposals for recognising a higher level of practice.

The UKCC recognises that the issues associated with role developments in nursing, midwifery, and health visiting have been of concern to the public, employers and the professions. As a consequence we intend to clarify and update the current post registration framework.

A steering group of Council members, officers and external experts has been taking forward this work. The Council agreed the core principles outlined in this document at its June 1998 meeting. The outcome of the consultation on the steering group’s proposals, which are outlined in the section on applying the principles, will inform the Council’s decisions on the way forward later this year.

The UKCC would welcome your views as to how helpful this consultation approach has been as well as your comments on the specific issues highlighted in the document.

A consultation questionnaire is included at the end of the publication.   We would also welcome written responses.

Responses should be sent by 20 October 1998 to:

SarahWaller
Director of Standards Promotion
UKCC
23 Portland Place
London W1N 4JT
e-mail sarahwaller@ukcc.org.uk

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1.  Summary

The United Kingdom Central Council (UKCC) is the regulatory body for nursing, midwifery and health visiting in the United Kingdom.

This document outlines the key elements of the UKCC’s proposals for recognising a higher level of practice within the system of post registration regulation and seeks comment upon them. The proposals are intended to safeguard the interests of the public and to meet the needs for competent practitioners who are working at a higher level of practice. Subject to the results of this consultation, it is intended that the arrangements for recognising a higher level of practice will be introduced in 2001.

This consultation forms a vital part of ensuring that the UKCC’s proposals meet the needs of the public. It is also essential that the proposals are practical and can be used efficiently and effectively by employers and the profession.

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2.  Introduction

Health care is changing. The work of nurses, midwives and health visitors across the United Kingdom will continue to evolve in response to the needs of those in their care and advances in research, technology and practice.

Registration* is a mark of significant professional achievement and is recognised as such by the UKCC. The UKCC requires all registered nurses, midwives and health visitors to ensure that they develop their knowledge, skill and competence to respond to the needs and interests of their patients and clients.⁽¹⁾

The UKCC’s recent consultations⁽²⁾ have shown that the current arrangements for recognising qualifications following registration (post registration qualifications) are unclear and causing confusion for the public, employers and professionals.

The UKCC has been considering how it might best ensure public protection in the light of developments in clinical practice and support clinical governance arrangements. It proposes to recognise formally those nurses, midwives and health visitors who are working at a higher level of practice (i.e. at a higher level of practice than initial registration).

The framework proposed for recognising a higher level of practice is designed to be capable of protecting the public whilst at the same time recognising the need for flexibility of service provision across the UK, in the wide range of areas in which nurses, midwives and health visitors practise in the NHS, independent and voluntary sectors.

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3. The role of the UKCC

The UKCC’s purpose is to establish and improve standards of nursing, midwifery and health visiting care in order to serve and protect the public. It fulfils this role by maintaining the register, setting standards for education, practice and conduct, providing advice to registrants and considering allegations of misconduct or unfitness to practise due to ill health.

The UKCC sets standards for both pre registration and post registration education that lead to registration and recording on the register.

The four National Boards for nursing, midwifery and health visiting are responsible for approving the institutions and programmes for pre registration and post registration education, thereby ensuring that the UKCC’s standards for education are maintained across the UK.

The UKCC and National Boards together form the regulatory system for nurses, midwives and health visitors. This system of regulation is currently under review by the four government health departments. However, the UKCC believes that the work on regulating a higher level of practice is of particular significance to the Council’s public protection role and that it should continue to be taken forward at this time.

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4. The need to regulate a higher level of practice

The nature of the work undertaken by health care professionals has changed, and will continue to change, in response to the needs of users and developments in research, technology and practice. The changes include:

• increasing specialism in many environments

• developments in medical and other technologies

• increased emphasis on delivering care to users in their own locality - primary and community care

• changes in working arrangements for medical and other clinical professionals

Nurses, midwives and health visitors are increasingly reshaping their practice and sharing a skills base with other colleagues in health and social care. Practitioners are, together with colleagues, determining the most appropriate models of local service delivery and, as a consequence, professional boundaries are becoming less distinct. The recently published policy papers⁽³⁾ from the four government health departments indicate the government’s wish to encourage and support such practice developments within the NHS.

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5.   Developing a framework for recognising a higher level of practice

In 1994, the UKCC agreed arrangements for Post Registration Education and Practice (PREP)⁽⁴⁾ which made continuing professional development mandatory. PREP also described two levels of practice following initial registration - specialist and advanced. PREP set standards for specialist practice and recommended that further work be undertaken on advanced practice. In addition, it defined standards for eight specialist community nursing roles.

Currently the system for the recording* of post registration qualifications is voluntary. The system is also complex and does not ensure clarity or protection for the public, users or employers.

There are a wide range of titles in common use across the UK to describe developing roles in nursing, midwifery and health visiting. Concern has been expressed by users, employers and the professions that there is confusion about what these titles mean, especially those of ‘nurse practitioner’ and ‘clinical nurse specialist’. These titles are not protected and the UKCC does not define standards or specific training programmes for either nurse practitioners or clinical nurse specialists.

In March 1997, following an extensive consultation exercise, the UKCC agreed not to set explicit standards for advanced practice. However it was recognised there were a range of issues relating to specialist practice that needed further consideration, including whether nurse practitioners and clinical nurse specialists could be embraced within the current arrangements. In December 1997, the UKCC agreed that further clarification and development work should be undertaken in this area.⁽⁵⁾

The subsequent work has shown the need for a clear and robust framework across the UK to recognise a standard for a higher level of practice. This standard will be based on clinical competence and build upon the current PREP arrangements. The proposed framework will provide a regulatory mechanism for those nurses, midwives and health visitors who are working at a higher level of clinical practice than initial registration. The UKCC recognises that many practitioners will wish to continue to develop and advance their professional practice in other ways. A number of other professional bodies already recognise the achievements of practitioners who are working in other areas of health care, for example management, education and research.

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6.  The UKCC’s Core Principles

The following core principles have been agreed by the UKCC as a result of its recent work and consultations.

A higher level of practice based on clinical competence

The UKCC has a duty to protect the public. In order to do this, the Council wishes to recognise and regulate those nurses, midwives and health visitors who are working at a higher level of practice. Recognition will be based on demonstrated attainment of clinical competence supported by appropriate post registration education.

A UK-wide standard

The UKCC proposes to set a UK-wide standard for a higher level of practice which is applicable across all health care settings - a generic standard. This standard will describe the level of practice rather than the specialist area in which practice is undertaken.

Regulation of a higher level of practice

The UKCC intends, subject to any necessary legislative changes, to develop a system of regulation for those practising at a higher level.

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7.  Applying the principles

7.1 Setting the standard

The UKCC will specify a UK-wide, generic standard for a higher level of practice which all practitioners seeking recognition will be required to achieve. This threshold standard will cover assessing, planning, implementing and reviewing clinical practice at a higher level. The model proposed by the Council will focus on competence in practice and the outcomes which any practitioner working at a higher level of practice will need to achieve. The level of expected achievement will be defined through the specification of clear criteria.

The UKCC intends that the framework for recognising a higher level of practice should encourage the local determination of appropriate knowledge and skill requirements for particular areas of practice. This could be on a country, regional or speciality specific basis. This will mean that employers and practitioners, in collaboration with educational providers, will need to determine the speciality based knowledge and skill requirements to ensure competence in a particular area of work. The UKCC recognises that a number of bodies across the UK, such as user groups, professional associations and employers, already determine the knowledge and skill requirements for particular areas of practice. It has commissioned work to scope the extent of this activity. The UKCC intends, in collaboration with the National Boards, to give further advice in this area once the main principles of the revised framework for recognising a higher level of practice are agreed.

7.2 Regulation

The UKCC intends, subject to any necessary legislative changes, to develop a system of regulation which would require those practising at a higher level to notify the UKCC of their intention to be recognised as practising at a higher level and their wish to continue to practise at this higher level. This notification would be linked to the three-yearly re-registration cycle.

This system of regulation would support both clinical governance and lifelong learning: clinical governance through a system of enabling the evaluation and improvement of standards of clinical care, and lifelong learning through linking regulation requirements and practice developments to continuing professional development.

The UKCC proposes that practitioners who have been recognised as meeting the standard for a higher level of practice should have this marked on the register.

Consultation question 1

Do you agree that nurses, midwives and health visitors who are working as higher level practitioners should have this marked on the Register?

The UKCC proposes that those practitioners who have been recognised as meeting the standard for a higher level of practice would be required to notify the UKCC on a regular basis of their intention to continue to practise at this level, otherwise their recognition would lapse.

Consultation question 2

Do you agree that they should be required to notify the UKCC on a regular basis of their intention to continue to practise at this level?

The UKCC recognises that to ensure clarity, changes need to be made to the current system of recording. It has been considering how it might best introduce a mechanism for marking the register to denote those practitioners who have been recognised as meeting the standard for a higher level of practice. The UKCC is considering that, subject to necessary legislative changes, a simple suffix (H) be used following a practitioner’s initial registration. This would ensure clarity and easier confirmation both by the public and employers.

The UKCC wishes to ensure clarity and is considering whether those practitioners who have been recognised as meeting the standard for a higher level of practice should use the suffix (H) after their initial registration.

Consultation question 3

Do you agree that those practitioners who have been recognised as meeting the standard for a higher level of practice should use the suffix (H) after their initial registration?

Consultation question 4

The UKCC is required by legislation to record certain qualifications on the register (eg. prescribing). It proposes also to mark higher level practice on the register. Do you have any views as to what else, in the public interest, should continue to be recorded on the register?

7.3 Assessment

The UKCC intends, in collaboration with the National Boards, to develop a quality assured valid, reliable and rigorous assessment process for applying the UK-wide, generic standard. It is likely that the UKCC, in collaboration with the National Boards, will commission an appropriate organisation(s) to perform the assessment function on its behalf.

There will not be a specific course that leads to recognition. The UKCC intends to develop an assessment approach which will place considerable emphasis on individual practitioners collecting evidence of their own practice competence in a clinical setting.

Practitioners will be required to provide evidence from their practice and of their knowledge and understanding. This will be assessed against the standard of a higher level of practice. It is likely that the UKCC will require confirmation of the practitioners current responsibilities. This confirmation might be both from clinical colleagues and employers. As the UKCC is interested in future as well as current competence, practitioners will also be asked to produce a personal development plan.

Proposals for assessment currently include:-

1. presenting evidence of practice and knowledge against the criteria specified for a higher level of practice, possibly in a portfolio;
2. the production of a written reflective account in a supervised setting; and
3. final assessment at a panel interview.

The UKCC proposes that the assessment system for those practitioners wishing to be accredited as higher level practitioners should be founded on the attainment of clinical competence supported by post registration education.

Consultation question 5

It is proposed that the assessment process should combine evidence presented by practitioners from their clinical practice, reflective accounts in a supervised setting and a final oral assessment by a panel. What are your views on this proposed assessment process?

7.4 Prerequisites

In order for practitioners to enter the assessment process, it is proposed that they will meet the following prerequisites. The practitioner must:

1. have current first level registration with the UKCC.
2. spend the majority of their practice planning and organising, carrying out and evaluating work related to improving health and well-being;
3. hold a UK degree or equivalent in nursing, midwifery, health visiting or health related subject or hold a UK degree
   or
   equivalent in any other subject together with the successful completion of a post-registration education programme in their area of practice; and
4. have practised for a specified minimum period of time in their chosen area of practice; it is anticipated that practitioners will need to have at least 5000 hours - the equivalent of three years full time in order to collect the required evidence.

Consultation question 6

It is proposed that there should be four prerequisites which practitioners will need to meet to enter the assessment process. Do you agree with the prerequisites stated that the practitioner must

1. have current first level registration with the UKCC?
2. spend the majority of their practice planning and organising, carrying out and evaluating work related to improving health and well-being?
3. hold a UK degree or equivalent in nursing, midwifery, health visiting or a health related subject or hold a UK degree or equivalent in any other subject together with the successful completion of a post-registration education programme in their area of practice?
4. have practised for a specified minimum period of time in their chosen area of practice?

7.5 Funding

Subject to outcomes of the current consultation and once the revised framework and assessment systems have been piloted, the UKCC is considering how the assessment process should be funded and if those wishing to be recognised as higher level practitioners should be asked to make a contribution to the assessment cost.

The UKCC is considering whether a charge should be made for the assessment process.

Consultation question 7

Do you think that a charge should be made for the assessment process? If so, in principle, do you think that those wishing to be recognised as working at a higher level of practice should pay the full cost of assessment or part of the cost with the remainder funded from the UKCCs general income generated by periodic registration fees?

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8.  Implementation

Specialist practice qualifications

The UKCC is committed to ensuring that the framework for recognising a higher level of practice builds on the current PREP arrangements. As a consequence, practitioners will be able to use specialist practice qualifications and other post registration education as part of their assessment evidence.

The UKCC does not intend to change the current arrangements for specialist practice education and training. They will stay in place unless and until it is demonstrated that they are no longer needed.

Further work

During this consultation the UKCC is continuing work on its proposals for the revised framework for a higher level of practice. In particular the advice of the National Boards is being sought on a range of standards and assessment issues.

Timetable

The UKCC will review its proposals in the light of the responses to the consultation in December 1998. It is intended that the Council will then agree firm proposals for the standards, assessment and regulation of a higher level of clinical practice.

It is intended that there would then be a series of pilot projects to test the rigour, practical implications and costs of the assessment processes. These would take place during 1999/2000 with the revised arrangements for recognising a higher level of practice commencing in 2001. There will be no transitional arrangements.

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9.  Further information

The UKCC would be pleased to supply further copies of this document and any further information, including a copy of the background paper discussed by the Council in June. We would welcome any comment you may have on the above proposals. Responses should be sent by 20 October 1998.

References

1. The Scope of Professional Practice, UKCC 1992
2. UKCC CC/98/19, Higher Level Practice (Specialist Practice Project - Phase II)
3. Department of Health, 1997, The New NHS: Modern, Dependable, CM 3807, London, The Stationery Office;
   The Scottish Office & Department of Health, 1997, Designed to Care: Renewing the National Health Service in Scotland, Edinburgh, The Stationery Office;
   The Welsh Office & NHS Cymru Wales, 1998, NHS Wales: Putting Patients First, London, The Stationery Office;
   DHSS, Northern Ireland, 1998, Fit for the future
4. The Future of Professional Practice - the Council’s Standards for Education and Practice following Registration, March 1994
5. UKCC CC/97/46: PREP - specialist practice: Consideration of issues relating to embracing nurse practitioners and clinical nurse specialists within the specialist framework.

*Registration - being entered on the Register which has been prepared by the UKCC in accordance with the Nurses, Midwives and Health Visitors Act 1997

Recording* - additional qualifications obtained by registrants following the completion of certain National Board approved programmes which are recorded on the Register maintained by the UKCC

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10. Consultation Workshops for Higher Level Practice

The UKCC is holding a series of consultation workshops around the country to allow people to contribute their ideas on its proposals for a higher level of practice. If you would like to attend one, please contact Katrina Neal at the UKCC (fax:0171 333 6538).

For Nurses, Midwives and Health Visitors (practitioners)

For Employers

 For Nurses, Midwives and Health Visitors (practitioners) and Employers

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United Kingdom Central Council for Nursing, Midwifery and Health Visiting.
Original text document August 1998

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