The concept of advanced nursing and midwifery practice is a relatively novel one in Irish healthcare. Less than a decade ago there was a significantly low number of advanced nurse/ midwife practitioners (ANMPs) compared to international figures, with less than 0.2 per cent of the nursing and midwifery population practising at advanced level.
However, momentum in this area has been growing rapidly on both a global and national scale, and the Government has been investing heavily in the ANMP division in recent years as their roles align with various policy priorities and reforms such as Sláintecare, chronic disease management, older persons services, and integrated care.
“This has been an enormously successful area of policy” in Ireland, according to Rachel Kenna, Chief Nursing Officer (CNO) at the Department of Health. She told Nursing in Practice Ireland (NiPI) that Ireland has rapidly become a “world leader” in terms of advanced practice implementation and development.
Investment, policy, and progress
In 2019, then Minister for Health Simon Harris launched a new model for developing advanced practice with a policy entitled ‘The Development of Graduate to Advanced Nursing and Midwifery Practice’. The document was published following successful pilots of advanced practitioner implementation, and in response to international evidence highlighting the myriad beneficial impacts that ANMPs have on health services due to their specialist knowledge and skills, wide scope of qualifications and education, and ability to provide a complete episode of care independently.
The policy streamlined the process by which a nurse or midwife can practice at an advanced level in Ireland, and the Nursing and Midwifery Board of Ireland (NMBI) also approved a revised policy for ANMP registration in 2019. At that time, Minister Harris said the nursing and midwifery profession would be “critical in implementing the Sláintecare health reform programme” and set the objective to have 2 per cent of the nursing workforce employed as advanced practitioners.
These initial developments set the stage for ongoing investments in advanced practice in Ireland, including the creation of 52 new ANP posts (older persons services and chronic disease management) in 2020. On a global level, the World Health Organisation called for the broadening of nurses’ scope of practice and expansion of advanced roles in its State of the World’s Nursing Report 2020, and in that same year, the International Council of Nurses produced guidelines on advanced nursing practice.
In November 2021, then Minister for Health Stephen Donnelly raised his predecessor’s target to have 2 per cent of the workforce practising at advanced level to 3 per cent. In 2022, he allocated €11 million to the HSE to recruit 149 ANPs (of which 12 ANPs were allocated to chronic disease management and 15 to integrated care programme for older persons), and, in 2023, a further 80 ANP posts were announced.
Ms Kenna confirmed to NiPI that 2.5 per cent of the HSE workforce are now employed as advanced practitioners, and that “this target will grow” in coming years due to the positive impacts ANMPs have had on the health service to date.
Recent data from the NMBI State of the Register 2024 Report demonstrate this substantial expansion of the ANMP population in Ireland in recent years. Between 2023 and 2024 there has been a 20 per cent increase in the number of ANPs and a 23 per cent increase in AMPs, while nurse prescribers have increased by 16 per cent, and midwife prescribers by 27 per cent.
According to Mr Ray Healy, Director of Registration at NMBI, the Board “expects to see a continued rise in ANMPs” in Ireland over coming years. “The overall register continues to increase by 5 per cent per annum,” he told NiPI. “This will have an inevitable increase in nurses and midwives moving into advance practice roles.”
‘The envy of the world’
Globally, advanced nursing practice has grown substantially, primarily in response to the ongoing physician shortage, ageing populations, rising prevalence of chronic and infectious diseases, and ongoing reforms in healthcare delivery. Different regions have experienced varying levels of success with advanced practice, and ANP roles exist in many countries – varying in stages of development, regulation, and structure. Countries such as Australia, Canada, and the Netherlands have high numbers of ANPs, well defined ANP roles, educational pathways, and regulatory frameworks, while the UK, for example, has yet to approve regulation. Overall, the number of ANPs more than doubled in the US and Canada in the past decade.
Well-documented barriers to successful implementation of advanced practice include inconsistent definitions of the ANMP, ambiguity around scope and role, limited or no formal regulation, and resistance from physicians and other healthcare workers. Successful implementation appears to rely on clearly defined roles and collaboration between organisations, government regulatory bodies, and key stakeholders.
Describing achievements in Ireland since 2019, Ms Kenna said the approach “has been very successful” and “stemmed in policy from a very early age”. She also identified a range of factors that contributed to accomplishments in implementation, such as “directed investment” and interdisciplinary partnership.
“One of the key success factors in the development of advanced nursing and midwifery in Ireland is that it is done very collaboratively with our medical colleagues. There is no ambiguity around it, it is very clear around the patient cohorts. There’s a huge interconnected and interprofessional learning and supervision approach to it, and I think that has been instrumental to our success. We have walked the path with our medical colleagues in sharing their expertise. The definition of what nurses and midwives do at this level is very, very clear and I think the patients have a good understanding now as well as the medical profession. The nursing and midwifery profession continue to grow within those comfortable boundaries that have been set.”
Ms Kenna also emphasised that the current education programmes and formal regulation process for ANMPs in Ireland play vital roles in the successful implementation of policy. “Regulation makes a huge difference in terms of enabling practitioners to stretch themselves and in providing the public with protections,” she said.
The NMBI offers two distinct pathways to registration as an ANMP, unlike several other countries. Nurses and midwives who successfully complete the NMBI-approved Master of Science in Nursing (Advanced Practice Nursing) programme, which is offered in an array of leading higher education institutions across the country, may apply for registration as an ANMP. Alternatively, a developmental pathway also exists for practitioners who have completed a collection of courses, that when combined, meet the NMBI advanced practice standards and requirements.
Speaking to NiPI about ANMP regulation in Ireland, Ms Mary T Devane, Professional Officer, Education, Policy and Standards Department at the NMBI, said: “The successful regulation pathway of Advanced Nurse/ Midwife Practice has been driven by clear legislative and policy frameworks, including NMBI’s Standards and Requirements for Advanced Practice (2017), which establish the competencies and capabilities required for registration.
Flexibility in education and training has allowed education bodies and practice partners to develop evidence-based programmes, aligned with the competencies set out in the NMBI Standards and Requirements for Advanced Practice, that equip nurses for autonomous and expert practice. Ongoing professional development, clinical supervision, and adherence to the Code of Professional Conduct and Ethics and the Scope of Practice Decision-Making Framework have further supported ANMPs in reaching their full potential.”
In Ireland, registered ANMPs work closely with their medical peers, but are educated to the standard whereby they can manage patients autonomously, prescribe medications, and complete full episodes of care to complex patient populations. Ms Kenna told NiPI that Ireland is “the envy of the world” due to this existing pathway to registration, which is “fully developed and supported with education”. She also described the positive impacts this pathway has on the recruitment and retention of nurses and midwives in Ireland.
“It creates an opportunity for nurses and midwives to design a pathway towards advanced practice early in their careers. Most countries don’t have that in place or it’s done in an ad hoc way. We have a very structured programme. A lot of nurses, particularly the new and younger generation, want to stay in clinical practice and want the opportunity to work in clinical leadership roles but don’t want to be in management or education, they want to stay in clinical practice and work at the top of their license.”
Positive outcomes to date
Since the launch of the policy in 2019, the impacts of developing advanced practice “are beginning to demonstrate”, Ms Kenna said. “This has made a significant impact on the overall ability to deliver care across complex groups of patient needs,” she added, and described ANPs as an “instrumental solution” in the reform and delivery of population health.
“We did an early evaluation to determine the broader impacts of having a percentage of our workforce operating at that really high level. We have evidence of improved access for patients across a range of services and conditions. ANPs have been shown to reduce waiting lists and hospital readmission rates, particularly in those ‘front-door’ areas such as critical care, general practice, and emergency departments. The patient satisfaction and patient empowerment aspects of being linked in with an ANP is second-to-none in terms of the evidence. Patient safety and satisfaction is in and around 98 per cent.”
Regional and clinical disparities
The last five years have undoubtedly seen an exponential growth in advanced nursing and midwifery practice in Ireland; however, developments, and the associated benefits, have not been experienced in equal measures, either geographically or clinically. A significant variation exists in the distribution of ANMPs across the country, with the vast majority of practitioners located in urban regions – primarily Dublin (294), Galway (63), and Cork (50). Many rural counties have notably low figures of practising ANMPs, such as Carlow (one), Monaghan (two), and Leitrim (four), while Longford has none.
Ms Kenna clarified that evidence has shown the need for “a critical mass” of ANMPs to achieve optimal outcomes, and that initial implementation of policy has been based on this principle, with the view to continue expansion. “Having one or two ANMPs in specialist areas isn’t as effective,” she said. “Ideally, we need to build up four or five so that they have that shared expertise and cover a range of geography that will allow them to deal with population-based disease”.
“Spreading out from the cities, where we have high populations, to more rural areas, and bringing the access to patients, is ultimately where we want to go,” Ms Kenna told NiPI. “Supporting the generalist community care models that are out there and having the ability to have a layer of ANPs available for patients in every area of the country; that’s our objective.”
According to the Chair of the Irish Association of Advanced Nurse Midwife Practitioners Melissa Hammond, there is indeed “work to do” in this area. Ms Hammond, who works as an ANP in general practice and is also a committee member of GP ANP Ireland, commended the investments and ongoing collaboration that have taken place across secondary care, but emphasised that “very few ANMPs are practising in the community, particularly in general practice”.
Notable differences exist between primary and secondary care settings in Ireland, with only around 25 registered ANMPs in general practice compared with approximately 1,000 in secondary care.
“We need people to know the benefits of what we are doing in general practice,” said Ms Hammond. “We are regulated, accountable, indemnified, and qualified, just like our peers in secondary care. Collaboration is improving, but we don’t share the same equity and access to resources. We also need funding to promote the role publicly, which we feel is lacking in Ireland, and to recruit more advanced practitioners to general practice. Sometimes it feels as though we are invisible workers in the background.
“We have been working hard to highlight the role of the general practice ANP in improving access to care. Patient experiences and feedback are positive, as are outcomes, but we need support to capture the data. We have met with key stakeholders and submitted to the strategic review of general practice from an advanced practice vision. It’s great to see such positivity from the CNO and we look forward to future collaboration and developments.”
A 2024 Organisation for Economic Co-operation and Development (OECD) paper, entitled Advanced practice nursing in primary care in OECD countries: Recent developments and persisting implementation challenges, reports that leading countries have “accelerated the use of ANPs” in primary care, while others “are still debating the pros and cons” or remain in early implementation phases. Countries that have achieved successful implementation, collaboration, and task sharing between GPs and ANPs – such as the US and Canada, where advanced practice began nearly 60 years ago – view ANPs as “a real opportunity to respond to primary care needs and shortages of GPs”.
According to the report, data from these and other leading countries indicate that ANPs play a useful role in providing more timely access to primary care, supporting health promotion and disease prevention, promoting continuity of care, reducing hospital admissions/readmissions, and achieving higher patient satisfaction.
No evidence of any negative impact on quality of care or patient safety is associated with adequately trained ANPs. Almost 90 per cent of the 355,000 registered ANPs in the US are educated and prepared in primary care, and over 70 per cent of practising ANPs deliver primary care.
Professional Development Coordinator for General Practice Nursing (PDCGPN) Marie Cantwell told NiPI that the addition of the ANP role to general practice is “essential in Ireland” in view of the rising complex and ageing population, increased workload, and declining GP population. “We must evolve and develop a fit and sustainable workforce,” she said.
In their recent submission to the strategic review of general practice, PDCGPNs advocated for the adoption of the national policy on the development of graduate to advanced nursing and midwifery practice at general practice level, and called for a formal career pathway in primary care. Ms Cantwell said that a structured professional pathway would “acknowledge the unique challenges faced by general practice nurses” and support standardised education for practitioners in primary care.
“The development of the ANP role in general practice is a viable solution for many practices in Ireland. Current arrangements are primarily driven by ambitious nurses, many of whom study in their own time and at their own expense to develop their practice. Adopting the Department of Health policy of identifying service need, developing posts in response to same, and recruiting and supporting candidates and ANPs in practice to meet that need could be a solution.”
Future directions
Responding to the deficit of ANMPs in general practice in Ireland, Ms Kenna admitted “there are obviously a few financial and governance issues that we need to break down in this area” in view of the fact that GPs are private practitioners. “This is not a barrier, but more a huge opportunity from my perspective,” she emphasised.
“If you really focus on the patient, of course the major front door access is the GP, so it seems very sensible to put advanced practice at that point… We will be looking at this from the GPs’ perspective – how we support them to have ANPs in their practices, because they are expensive and there is a requirement to maintain support for their ongoing education. That has implications, particularly for smaller practices. We’ve got to get into that space and have a look at it. That will be our next move because it’s so important to have ANPs in the community.”
Addressing equity and access for nurses in general practice, Ms Kenna said that all nurses and midwives should be educated to the “one standard that is set by the regulator”, and that practice nurses should have access to the same education as those working in the HSE. “GP nurses that are moving towards advanced practice shouldn’t be excluded from that and we have to move into that space. I’ll be looking at how we resolve that,” she said, and described steps taken to date.
Ms Kenna highlighted the Sláintecare-funded Graduate Diploma in Primary Care – a pilot programme between the Department and University College Dublin – which is in its second year and yet to be formally evaluated. She described development of the programme as “the first step towards building access into advanced practice training in primary care”.
“We have been thinking about how to approach this and started with the education level below advanced practice. This is something we will be looking at this year – how do we now copper-fasten an access route into advanced practice? The purpose was to have a standardised, across-the-board education module for general practice and community nurses. This will be an important platform for us to look at access routes to advanced practice, so, let’s see how that plays out.”
Overall, Ms Kenna emphasised the level of education, knowledge, and skills ANMPs possess, as well as their commitment to lifelong professional development. “The work they do is phenomenal,” she said, adding that practitioners themselves would be a vital aspect of future developments.
“We are looking at evaluating the roles again this year. A big part of that is stakeholder engagement and, of course, the practitioners themselves are key stakeholders in relation to that. Professionals that are practising at this level have a huge amount of knowledge about what works and what doesn’t work. So, they are fundamental to our understanding in the policy space to be able to deliver policy that’s meaningful.”
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