Ireland has made significant progress in implementing advanced nurse and midwife roles. Denise Doherty reports
Less than a decade ago there was a significantly low number of advanced nurse/midwife practitioners (ANMPs) in Ireland 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. The Government has been investing heavily in the ANMP division over 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 Chief Nursing Officer at the Department of Health, Ms Rachel Kenna. She told the Medical Independent (MI) that Ireland has rapidly become a “world leader” in terms of advanced practice implementation and development.
Investment, policy, and progress
In 2019, the then Minister for Health Simon Harris launched a new model for developing advanced practice with the policy, The Development of Graduate to Advanced Nursing and Midwifery Practice. The document was published following successful pilots of ANMP implementation, and in response to international evidence highlighting the beneficial impacts that practitioners have on health services due to their specialist knowledge and skills, wide scope of qualifications and education, and ability to prescribe and 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 registration as an ANMP 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 an objective to have 2 per cent of the nursing workforce employed as advanced practitioners.
These initial developments set the stage for ongoing investment, including the creation of 52 new ANP posts in 2020. On a global level, the World Health Organisation called for the expansion of advanced nursing roles in its State of the World’s Nursing 2020 report, and in that same year, the International Council of Nurses produced guidelines on advanced nursing practice.
In 2021, the 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, some €11 million was allocated to the HSE to recruit 149 ANPs, and in 2023, a further 80 posts were announced.
Ms Kenna confirmed to MI that 2.5 per cent of the HSE workforce are now employed as advanced practitioners and that “this target will grow” due to the positive impacts ANMPs have had to date.
Recent data from the NMBI State of the Register 2024 report demonstrates this substantial expansion of the ANMP population in Ireland over 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.
According to Mr Ray Healy, Director of Registration, NMBI, the Board “expects to see a continued rise in ANMPs” in Ireland. “The overall register continues to increase by 5 per cent per annum,” he told MI. “This will have an inevitable increase in nurses and midwives moving into advance practice roles.”
‘The envy of the world’
Globally, advanced 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. 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 for the role. Overall, the number of ANPs more than doubled in the US and Canada over the past decade.
Well-documented barriers to successful implementation of advanced practice include inconsistent definitions of the ANP, 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, 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 an early stage. 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 played 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. Ms Kenna told MI that Ireland is “the envy of the world” due to this existing pathway to registration, which is “fully developed and supported with education”.
The NMBI offers two distinct pathways to registration as an ANMP, unlike several other countries. Nurses and midwives who successfully complete the NMBI-approved MSc in Nursing (Advanced Practice Nursing) programme may apply for registration. 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 MI about regulation in Ireland, Ms Mary T Devane, Professional Officer, Education, Policy, and Standards Department, NMBI, said: “The successful regulation pathway of ANMP 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.”
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, describing 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
Recent years have undoubtedly seen an exponential growth in advanced 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 (1), Monaghan (2), and Leitrim (4), 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 MI. “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 ANMPs, Ms Melissa Hammond, there is indeed “work to do” in this area. Ms Hammond, who works as an ANP in general practice, commended the investments and ongoing collaboration that have taken place across secondary care. However, she 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 to 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.”
A 2024 paper from the Organisation for Economic Co-operation and Development (OECD), titled Advanced practice nursing in primary care in OECD countries: Recent developments and persisting implementation challenges, reports that some 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 view ANPs as “a real opportunity to respond to primary care needs and shortages of GPs”.
According to the report, data from these 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 trained in primary care and over 70 per cent of practising ANPs deliver primary care.
Professional Development Coordinator for General Practice Nursing (PDCGPN), Ms Marie Cantwell, told MI 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 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.
Ms Kenna highlighted the Sláintecare-funded Graduate Diploma in Primary Care. The pilot programme between the Department and University College Dublin is in its second year and yet to be formally evaluated. She described 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.”
Overall, Ms Kenna commended the level of education, knowledge, and skills ANMPs possess, as well as their commitment to 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. So, they are fundamental to our understanding in the policy space to be able to deliver policy that’s meaningful.”
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