Critical Evaluation of the ANNP role and its impact upon present and future care provision within local neonatal service delivery
This critical evaluation focuses on the role of the Advanced Neonatal Nurse Practitioner (ANNP) within the authors local Trust. This essay aims to demonstrate the ANNPs impact upon present and future care provision within local neonatal service delivery, focusing on the local and national drivers influencing the role as well as the challenges of maintaining ongoing contemporary practice. It will also explore team dynamics within the neonatal unit and communication factors, scope of professional accountability with relevant legal and ethical issues as well as professional developmental opportunities and future learning requirements within the ANNP role from an individual and collective perspective.
The neonatal unit within the author’s local Trust is a pioneering design which provides a calm, healing environment for premature and sick term newborn infants and their parents. The Local Neonatal Unit (LNU) (Department of Health [DoH], 2009) sits within the Women and Children’s Division and has capacity for 21 cots, including four Intensive Care, three High Dependency and fourteen Special Care cots. In addition, transitional care is provided on the postnatal ward. The LNU works as part of a wider network with the extremely premature infants, newborns requiring further intensive care intervention or surgery being transferred to a neonatal intensive care unit (NICU) within the network.
The nature of the practice of the ANNP within the LNU is multifaceted and includes integration of practice, education, research and management (NHS Education for Scotland, 2012) with a high degree of professional autonomy in independent or collaborative practice. Advanced clinical competencies, critical decision making, health assessment skills and diagnostic reasoning are also important aspects of the ANNP role. The ANNP practice prescribing (DoH, 2006) to allow quicker and more efficient access to medication. The ANNP team at the LNU is currently a standalone service not integrated into the medical rota. However, the medical rota does not meet the requirements to have a dedicated tier one provision 24/7. This shortfall in staff has been on the Trust risk register for some time. The unit is currently planning to increase their ANNP numbers which could support their tier one rota and therefore further developments in this area can be foreseen.
The ANNP has long been recognised as an established member of the workforce (British Association of Perinatal Medicine [BAPM], 2010) yet, there remain differing views on the model of service in which they operate with no consensus on the job role of an ANNP. In response to the recently published NHS Long-Term Plan (NHS, 2019), BAPM has initiated multi-professional discussions to explore alternative models of neonatal care and a clear career framework for all ANNPs to work towards. Further challenges are presented by the absence of statutory standards (McKeon-Carter, 2013; Smith and Hall, 2011). Two recent developments have contributed significantly to the regulation of advanced practice roles and responsibilities in the UK; firstly, the Royal College of Nursing (RCN) credentialing (2017); secondly, the release of the multi-professional framework for advanced clinical practice by Health Education England (2017).
The future looks bright for Maternity and Neonatal care.
set out the Five Year Forward View for NHS maternity services in England (NHS England, 2016) with a national ambition to improve the safety and outcomes of maternal and neonatal care and provide a high-quality healthcare experience for all women, infants and families across maternity and neonatal care settings. The Long-Term Plan (NHS, 2019) supports interventions to reduce the number of deaths in infants and maximising women’s health before, during and after pregnancy. The Maternal and Neonatal Health Safety Collaborative (NHS Improvement, 2017a) is a program led by NHS improvements Patient Safety team and involves all maternity and neonatal services across England. The local Trust is in wave three of the collaborative and currently working towards a project that will contribute to the national ambition set out in
Better Births (
NHS England, 2016)
This is a multidisciplinary project where the ANNP has an active role giving presentations, leading meetings and influencing individuals and groups at a strategic level to take action and make changes.
Maternity and neonatal teams need to ensure that collaborative multidisciplinary reviews of the care provided continue to take place within the Trust’s Perinatal Morbidity meetings. The role of the ANNP is perfectly positioned to help improve safety, quality and continuity of care to halve still births, maternal and infant deaths and serious brain injury. The Long-Term Plan will require every trust to provide an accredited, evidence-base infant feeding programme to help encourage new mothers to breast feed their infant. This has been accomplished by the neonatal team at the LNU who continue to work towards achieving the UNICEF Baby Friendly Initiative.
(NHS England, 2016) highlighted that keeping mothers and newborns together should be the foundation of neonatal care. Working and learning in partnership with multi-professionals (Scottish Government, 2017), the role of the ANNP has contributed in the implementation of transitional care within the LNU avoidingunnecessary separation (BAPM, 2017) and reducing term admissions to 5% since its recent introduction, but there is still more work to be done in this field.
Together with the neonatal team within the LNU, ANNPs strive to provide excellent care and therefore parents are involved early in the decision-making process. This enables the establishment of a relationship of trust between the family and the neonatal team, increasing parental satisfaction and compliance with their child’s treatment that will contribute to the infant’s outcomes (Abdel-Latif
., 2015; Izatt, 2008).
As senior neonatal nurses, ANNPs have already developed in depth neonatal skills, knowledge and understanding prior to advanced practice training. Therefore, they have a strong understanding of nursing issues within the LNU and are able to holistically manage the care of the infant and their families, building on established working relationships with all members of the multidisciplinary team (Spinks, 2009). ANNPs do not rotate within the hospital and hence their professional credibility is enhanced by their constant presence within the service providing continuity of care that enable them to analyse, synthesize and process complex information influencing key decisions (Imison
., 2016; Kennedy
, 2015; McDonnell
., 2014; Hall and Smith, 1995).
The ANNP role is comprehensive and involves collaborative working across professional, organisational and system boundaries, influencing strategic policy making at a local and national level. ANNP engagement with maternity and community services is fundamental to building professional working relationships and influences the improvement of health outcomes and healthcare delivery systems to both the infant and mother, supporting increased accountability in practice (NHS Improvement, 2017a; Scottish Government, 2017; NHS England, 2016). Where complex and unpredictable care arises, the ANNP uses their own professional judgement to manage the event and act appropriately within the boundaries of practice.
The need for the advanced practitioner to be professionally accountable and make autonomous decisions is recognised by the RCN (2012). However, the Nursing and Midwifery Council (NMC) (2015) discusses the need to practice within the practitioner’s realm of competence and not to exceed the limits of their role, experience and training.This is important as one of the critical links between advancing practice and accountability is a standard of practice (Cornock, 2017). ANNPs will be evaluated against those who are skilled in that particular treatment, not necessarily against their own professional group. Additionally, ANNPs are judged against someone who practices without advanced skills, however, if a health care practitioner presents themselves as an expert or specialist, they will be judged against an expert or specialist in that practice. Therefore, an ANNP who demonstrates competence and has a logical basis for his actions should easily achieve the standard of accountability to which they are being held
Essentially, ANNPs are accountable to patients and their families; the public, particularly through professional regulatory bodies such as the NMC; employers, who may dispense disciplinary action and the law, which may issue criminal charges and/or civil actions brought by patients.
ANNPs work in fast-paced environments, which can be complex, highly charged and emotionally driven. For the novice ANNP it can be challenging to address all of the domains from the outset (Kennedy
., 2015), hence the importance of providing consistence clinical supervision to aid accountability, which would help maximise the impact of the role and ensure the delivery of quality of care (Driscoll et al, 2019: Bifarin and Stonehouse, 2017). Recognising the valuable contribution that clinical supervision brings to professional development and delivery of care, managers within the LNU need to continue to encourage this practice.
Regionalised care is vital for the successful outcome of the neonates (DoH, 2009), but this brings challenges in terms of staff retention. Many ANNPs move towards tertiary units in order to consolidate their training and maintain their skills set. Therefore, for staff in LNU where there can be a lack of opportunities to increase and sustain skills, it is pivotal that networks are developed to provide support, skills maintenance and training. This could be provided through regularised rotation into larger units.
It has been suggested by Doerksen (2010) and Mayes (2014), that increasing managerial support as well as the provision of protected time to both learn and undertake research may result in the ANNP being able to improve their public profile and continue to share best practice both nationally and internationally.The LNU is planning to allow the distribution of allocated non clinical time in order to fulfil the other requirements of the role such as research and education on completion of the ANNP training.Nonetheless, in times of financial austerity, having access to funding for continuing education remains a concern.
Job satisfaction is an important component of role actualization and impacts how individuals project the role to others (Freed
., 2010).From a personal perspective and after a consolidation period on the new role, the author will continue to seek opportunities to participate on the advancement of neonatal practice and contribute to the ANNP vision within the LNU with the possibility of further academic training to purse a nurse consultant role. The ANNP can develop and evaluate own and other’s skills and knowledge across professional and organisational boundaries as well as participate on the provision of educational programmes to meet the demands of the neonatal service, and development of strategies and policies for neonatal service improvement at local and national level. The Work by (Skene,
2012) has inspired the author to work on a future project to lead innovation within neonatal care at the local Trust. A neonatal clinic led by a team of ANNPs would help to reduce neonatal readmissions to hospital as well as facilitate early discharge from the LNU. These interventions further support avoiding separating infants form mothers (NHS Improvement, 2017b).
In summary, the ANNP role enables the maintenance and improvement in quality of neonatal care provision. To continue to promote future growth and development of ANNPs the next step is to address the challenges of providing more secure professional integration and role definition at a local, regional and national level.
Sound regulatory processes are required in order to enhance the sustainability and transferability of the ANNP role. It could be argued that in order to increase public protection and endorsement for the advanced practice role, the RCN (2017) system of Credentialing will soon be compulsory.
Career development opportunities, continuous appraisal of the needs of the service, the unit, and the individual as well as maintaining the skills and knowledge of those working in less acute environments are also required. Ongoing work to further develop and improve neonatal service delivery is essential with the ANNP collaborative working with multi-professionals to improve the safety and outcomes of maternal and neonatal care.
At a personal level, it is the author’s intention to maintain and continually review the acquired skills and knowledge during training in order to underpin professional responsibility and influence the provision of high quality, safe and innovative patient centred care delivery, to the ultimate benefit of newborns and their families.
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