EVALUATION

doi: 10.1111/nicc.12133

The advance nurse practitioner in

critical care: a workload evaluation
Audrey Jackson and Martin Carberry

ABSTRACT
Background: The Advanced Nurse Practitioner in Critical Care role was developed to support the critical care team by undertaking specific
roles traditionally associated with medical staff in the intensive care unit and high dependency unit. The rationale for the evaluation was to
establish the specific tasks undertaken and scope of workload of these newly created posts.
Aims: To report on an evaluation of the specific activities, workload and patterns of prescribing of advanced nursing practice posts within a
critical care settings
Methods: A data collection form was designed to capture clinically and patient-related activities of these post-holders. Data from 1 week were
recorded on one post-holder and subsequently analysed. During the evaluation the nurse practitioners worked with the consultant anaesthetist.
Data were entered into Microsoft Excel and analysed using descriptive statistics.
Results: The intensive care and high dependency unit ward round attributed to 46% of the nurse practitioners weekly activity and mainly
consisted of patient assessments and prescribing. The rest of the time was mainly split between documentation and unsupervised patient
assessments.
Discussion: The nurse practitioners contributed to the majority of interventions traditionally performed by anaesthetic trainees. Independent
patient assessment was highlighted as a significant part of that workload (12%). The evaluation also highlighted the broad nature required of
nurse practitioner prescribing and thus reinforced the strategic decision not to introduce a restricted formulary.
Conclusion: Advanced nurse practitioners in critical care effectively carried out the traditional medical tasks in which they were trained. As
already experienced nurses with new enhanced skills they successfully contributed to and enhanced the delivery of care to the critically ill.
Key words: Advanced nursing roles • Developing/evaluating nursing roles • Evaluation studies • Intensive care nurses • New roles in practice

BACKGROUND (DoH), 2006; Royal College of Nursing (RCN), 2007;

It is now widely accepted that the European Working
Time Directive (Council Directive, 2000) and Mod-
ernising Medical Careers (Scottish Executive Health
Department (SEHD), 2005a) have resulted in a reduc-
tion in the availability of all levels of trainee doctors for
service provision. This and positive research findings
from other countries have paved the way for the intro-
duction of innovative advanced nursing roles (Stetler
et al., 1998). Advanced roles for nurses have been sup-
ported by professional and government bodies alike,
and were recognized as an important aspect of health
service contribution (Nursing and Midwifery Council
(NMC), 2005; SEHD, 2005b; Department of Health
Authors: A Jackson, RGN, MSc, PG Certificate Advanced Practice,
Advanced Nurse Practitioner Critical Care, Monklands Hospital, Glasgow,
UK; M Carberry, RGN, DCC, BSc, MSc, Critical Care Nurse Consultant, NHS
Lanarkshire, HECT Office, Hairmyres Hospital, Glasgow, UK
Address for correspondence: A Jackson, Certificate Advanced
Practice, Advanced Nurse Practitioner Critical Care, Monklands Hospital,
Monks court Avenue, ML8 Glasgow, UK
E-mail: audreyjackson40@hotmail.com
National Education Scotland (NES), 2008; SEHD, 2010).
In response to these national drivers NHS Lanarkshire
set up an Advanced Nurse Practitioner in Critical
Care (ANPCC) project board consisting of senior man-
agement, human resources and nursing and medical
leads. The role of the project board was to examine
the possible gaps in critical care service provision and
a potential role for the new ANPCC. Trainee doctors
were shadowed across three critical care units by the
nurse consultant in order to establish their daily work-
load. Following this exercise it was accepted that the
new ANPCC role would need to include: advanced
clinical assessment and clinical decision making,
documenting findings, independent non-medical pre-
scribing (NMP) and advanced invasive procedures,
such as central venous and arterial line placement.
The project board subsequently addressed potential
ANPCC education and training needs.
The ANPCC role would also provide experienced
critical care nurses with an alternative route of pro-
motion that remained predominately clinical, a view

© 2014 British Association of Critical Care Nurses 1

 A workplace evaluation of ANPCC work balance
supported by Kleinpell’s (2005), five-year longitudinal
study into nurse practitioner roles.
As a result, NHS Lanarkshire funded the recruit-
ment of nine ANPCCs between 2008 and 2009 in
order to maintain critical care service provision across
three district general hospitals’ critical care areas.
The ANPCC selection process involved psychometric
testing, objective structured clinical examination and
competency-based interviews. This approach ensured
that successful applicants could robustly demonstrate
leadership and clinical skills (Fleming and Carberry,
2011).
Those appointed undertook a locally devised educa-
tional programme, which consisted of a postgraduate
certificate in advanced clinical practice, NMP course,
a clinical competency framework and a programme of
scheduled work shops and tutorials. The postgraduate
certificate attributed points towards an MSc in nurs-
ing. ANPCCs were required to complete a university
accredited masters degree in either advanced practice
or critical care. Clinical supervision and coaching were
provided by a designated consultant anaesthetist men-
tor with professional leadership provided by the nurse
consultant.
Aside from academic assessment, newly appointed
ANPCCs were appraised through direct observation
of procedures, multi source feedback forms which
allowed the whole intensive care unit (ICU) and high
dependency unit (HDU) team to subjectively evaluate
individual performance. Case-based discussions were
also used, supported by a reflective portfolio of evi-
dence (Minarik, 2005). During the period of training,
these posts had supernumerary status which lasted
2–3 years depending on exposure to clinical experience
and competency completion.
Two previous evaluations of trainee anaesthetic
workload had been undertaken in the critical care
areas of the three hospitals. An initial evaluation in
2005 set out to establish the potential ANPCC role,
suitability and sustainability, workforce planning and
a training needs analysis for post-holders. A further
evaluation after 5 years identified further training
needs included:
• Attendance at cardiac arrest calls
• Internal hospital transfer of ICU and HDU
patients
• Request for complicated radiological investiga-
tions
• Insertion of chest drains
• Reporting death to the procurator fiscal
• Authorisation of blood and blood products
• Prescribing unlicensed drugs.
2 © 2014 British Association of Critical Care Nurses
These findings informed a professional, legal and
clinical debate in order to establish what would be
deemed appropriate for ANPCC development.
A number of points were addressed prior to service
evaluation of this role.
A restricted ANPCC prescribing formulary was dis-
cussed but deemed too limiting to address the wide
range of drugs prescribed in a typical day. Limited
exposure to the insertion of chest drains also meant that
these practitioners would be unable to undertake this
procedure and maintain clinical competency so this
task was removed from their training. Patients requir-
ing a chest drain had it inserted by the consultant,
which was normal practice before the development of
these roles, unless the medical trainee was particularly
senior.
The project board considered it inappropriate that
the ANPCCs attend cardiac arrests during the service
evaluation for a number of reasons. Firstly, lack of
exposure to advanced/difficult airway management
at the stage of their training. Secondly, on exami-
nation, a significant number of cardiac arrest calls
were peri-arrest calls requiring consultant-level deci-
sion making. Finally, in peri-arrest situations, the use
of anaesthetic drugs is not uncommon, but these were
prohibited for NMPs at the time of this evaluation
(SEHD, 2009).
Non-medical requests for any radiological investi-
gation, such as chest radiographs, proved problematic
owing to legislation, competence and governance of
role development. Blood and blood product authoriza-
tion was achieved through the provision of a collabora-
tive educational programme and the formation of new
clinical competencies (Green and Pirie, 2009).
While the ANPCC role is not a new role, its imple-
mentation in NHS Scotland was new and hence evalu-
ation was deemed necessary. It was also essential from
a risk management and clinical effectiveness perspec-
tive that the appropriateness of post-holder’s workload
should be examined as part of a wider role evaluation
in NHS Lanarkshire’s three ICU and HDUs.
AIMS
The aim of this paper is to report two key areas of the
evaluation and to determine ANPCC:
• specific activities and workload
• prescribing practice
EVALUATION METHODS
Evaluation of the new service model was planned after
2 years of training as this period of time was consid-
ered to be an appropriate duration to fully prepare

the ANPCC to participate in the service and evalu-
ate their workload. In one unit, the ANPCCs were
involved with both ICU and HDU patients and so cho-
sen for detailed review of their workload. In this unit
the staffing model changed from a traditional medical
model, including: one anaesthetic consultant and one
trainee per day with varying experience from level Spe-
cialist Training 1 (ST) to ST7, to one which included
anaesthetic consultant and an ANPCC (Royal College
of Anaesthetists, 2014).
The evaluation was undertaken over five, 10.5 h day
shifts, covering Monday to Friday from 8 a.m. until
6.30 pm in March 2011. Data were collected by the
ANPCC on duty (total 52.5 h/week). ANPCCs work
4 days/week, so the full 5 days data were collected
as the unit would have one ANPCC on duty every
weekday. A data collection form was developed to
capture clinical tasks, ward round workload and all
drugs prescribed undertaken by ANPCCs. Data entry
included every task and prescription and its dura-
tion throughout their shift and over 5 days. Common
tasks included: insertion of central lines and arterial
lines, intravenous fluid prescriptions and blood prod-
uct authorization. Data collection forms were stored in
accordance with data protection law, kept in a locked
drawer within a secure office. No forms contained
patient or staff information (Data Protection Act, 1998).
Ethics
Following discussion with the local Research and
Development committee, this project was deemed to
be a service evaluation and therefore did not require
research or ethics approval. All three lead consultant
anaesthetists, nurse managers and lead for ANPCCs
were informed of the pending evaluation.
Results
The results presented have been broken down into
three emerging categories. Firstly, week workload by
one ANPCC in one ICU and HDU (Figure 1), secondly
ward round activity (Figure 2) and finally prescribing
activity (Figure 3). The data were collated, uncoded
onto an Excel® spreadsheet for analysis. Following
data entry, results were allocated to specific categories
described above.
Week workload
Figure 1 illustrates the tasks the ANPCC performed
independently and unsupervised after their training
period and competency framework completion,
Activities undertaken related to independent patient
assessments on all HDU patients.
Around one fifth of the time was devoted to clinical
documentation such as:
© 2014 British Association of Critical Care Nurses
A workplace evaluation of ANPCC work balance
• Patient assessments and subsequent management
plans.
• Admission, transfer and discharge documenta-
tion.
• Routine investigation paperwork namely labora-
tory investigations.
A total of 10% of the working week encompassed
data collection and data input, for example, maintain-
ing the Scottish Intensive Care Society (SICS) national
database WardWatcher. Combined invasive lines and
phlebotomy accounted for 6% of ANPCC workload
Ward rounds
Of the working week, 46% was spent participating in
the ICU and HDU ward round. The ward round con-
sisted of a complete patient assessment and detailed
treatment and management plan. In view of this being
the largest component of the week it was deemed
appropriate that more in-depth analysis was required.
Data were subsequently subcategorized into core activ-
ities namely patient assessments, prescribing, docu-
mentation and finally specialist ward rounds such as
microbiology and surgeons’ reviews (see Figure 2).
Ward round activity
The following data reported percentages of the
ANPPC time attributed to tasks conducted on the
ICU and HDU ward round specifically 46% of the
ANPCC working week (Figure 1). The ICU ward
round consumed 35% of that time which entailed con-
ducting supervised patient assessments, examining
and presenting patients and reporting clinical findings.
ANPCC documentation time was low during the ward
round accounting for 4% of workload. Prescribing was
an essential and substantial part of ANPCC workload
at 59% of ward round activity (Figure 2). This result
merited further analysis of prescribing activity in
order to elaborate professional and legal prescribing
challenges.
Prescriptions for antimicrobials contributed to 25%
of all requests (Figure 3). Blood, fluid and electrolyte
prescriptions accounted for 27% of those made by
ANPCCs. While analgesia and sedation prescriptions
contributed to 11% (Figure 3) of the total ANPCCs’
prescribing activity, the majority of which consisted
related postoperative analgesia.
The gastrointestinal drug section totalled 6% of
prescriptions. These drugs included anti-emetics and
laxatives. Ranitidine prescriptions were categorized
in the DVT/Ulcer prophylaxis section. Cardiac pro-
tective drugs included aspirin, beta blockers and
calcium channel blockers accounted for 6% of ANPCC
3
 A workplace evaluation of ANPCC work balance

Week Workload

Assessments
All Documentation Unsupervised
(Excl Wd Round) 12%
19%
Airway / Arrest
4%
All Data Input
10%

Others
3%

All Lines Ward Round

3% 46%

All Bloods
3%

Figure 1 Week workload.

Ward Round Activity equivocal results for the role of the nurse practitioner
Ward Round Documentation when compared with senior trainee medical staff or
4%
Specialist wd rd physicians assistants (Rudy et al., 1998; Burns et al.,
2%
2003; Hoffman et al., 2003; Kleinpell, 2005). The com-
Supervised Patient Assessment pletion of this audit revealed key issues that addressed
35% the aims of the project, namely three key areas of
the ANPCC workload, daily activities, workload and
Prescribing
59% prescribing practice.
Independent patient assessment was highlighted
Figure 2 Ward round activity. as a significant part of ANPCC workload (12%).
Moreover, the ANPCCs’ independent patient assess-
Prescribing Activity ments and action plans allowed prompt review by
Analgesia/ the consultant, informed decision making, prioritiza-
Sedation Others
11% Antimicrobials tion of patient reviews and discharge planning. The
3%
25%
Meds consultants in general documented assessments and
Reconciliation treatment plans for ICU patients; this may explain
13%
DVT / Ulcer the low percentage of ANPCC documentation time
Steroids Prophylaxis
3%
during the ward rounds of 4%. Data collection and
6%
Cardiac Blood/ IV Fluids/
input were seen as a valuable use of ANPCC time
Protection Electrolytes (10%) and may have impacted on data collection stan-
6% 27%
dards into various databases such as Ward Watcher by
GI Drugs
6% the Scottish Intensive Care Society Audit Group
(SICSAG, 2012). Rudy et al., (1998) also demon-
Figure 3 Prescribing activity. strated that nurse practitioners spent more time in
administrative and research tasks than their medical
prescriptions. Perhaps most noteworthy was the sig- counterparts.
nificant time spent with medicines reconciliation. The ANPCCs were qualified independent NMPs as
Thirteen percent of ANPCC prescribing time was of July 2010. In Scotland, NMPs can prescribe any drug
used to discontinue drugs, change drugs, doses or within their field of competence including off-license
rewrite drug cardexes; this was recorded as medicines drugs (SEHD, 2009).
reconciliation. Off-license prescribing refers to prescribing a drug
out with its licensed indication for use, e.g. using intra-
venous paracetamol for longer than 48 hrs. NMPs in
DISCUSSION Scotland were not permitted to prescribe unlicensed
The available literature surrounding nurse practi- drugs at the time of the evaluation. NHS Lanark-
tioners in ICU is varied and extensive; however, shire has since allowed NMPs to prescribe unlicensed
the majority of studies have shown favourable or medicines and opiate infusions. These changes came in

4 © 2014 British Association of Critical Care Nurses


the years 2011 and 2012 (SEHD, 2006). Any unlicensed
medicines were prescribed by the consultant during
the evaluation period.
The evaluation highlighted the broad nature
required of ANPCC prescribing and thus reinforced
the strategic decision not to introduce a restricted
formulary. Although the ANPCCs were independent
NMPs, they were also supervised at consultant level
and all prescriptions were written in accordance with
a documented treatment plan, enhancing safety for the
patient and the novice NMPs.
Competence to authorize blood and blood products
was an important aspect of the ANPCC role adding to
seamless and consistent care delivery (Green and Pirie,
2009; SEHD, 2006). ANPCCs were the first critical
care nurses in Scotland trained to authorize blood
and blood products. Blood product prescribing was
included within the 27% of time needed for all IV
fluids. Antimicrobial prescribing was a significant
workload issue within critical care, a task which was
carefully considered when developing the ANPCC
role (Lawrence and Kollef, 2009). Many critically ill
patients presented with severe infections requiring
a multitude of complex antimicrobial therapies. The
ANPCCs attended additional intensive pharmacy led
training sessions in antimicrobial prescribing in order
to support their prescribing practice.
It should be noted that NMPs were not legally
permitted to prescribe continuous intravenous opi-
ate infusions or anaesthetic drugs at the time of the
service evaluation (SEHD, 2009). These restrictions
meant that the consultant had to prescribe these drugs.
These shortfalls in prescribing have recently been
resolved, and ANPCCs can prescribe any drug includ-
ing unlicensed medicines within the scope of their
competence.
During the service evaluation only a few tasks had to
be performed by the consultant for example: advanced
radiological investigations such as CT scans and diffi-
cult airway skills.
These tasks were decided upon at the ward round
and so incorporated within it. It was decided that
owing to a limited exposure to experience the insertion
of chest drains would remain a medical procedure.
Certification of death was solely a medical task,
unremarkable in terms of workload during the service
evaluation. Medical staff continued to report appropri-
ate deaths to the Procurator Fiscal (Coroner).
Fleming and Carberry (2011) interviewed ANPCCs
before their training to examine if expectations of
their new role matched the reality 1 year later. It
was originally anticipated by ANPCCs at the begin-
ning of their training that a significant part of their
role would be inserting invasive lines such as arterial
© 2014 British Association of Critical Care Nurses
A workplace evaluation of ANPCC work balance
and central lines and intubating patients. Results, as
demonstrated here showed this was not the case, and
that after 2 years training only 6% of the ANPCC
weekly workload consisted of invasive line insertions
or phlebotomy. Advanced airway management was
also a rare occurrence (4%). During the evaluation,
ANPCCs had not been yet been trained to insert dialy-
sis lines or use the subclavian vein as a route for central
lines, which may have accounted for the lower than
anticipated result. Infrequent exposure of ANPCCs to
advanced or difficult airway procedures made main-
taining these competencies difficult. Airway training
was included in the ANPCC programme and it would
appear from the results that the decision to make it
a long-term plan was indeed appropriate due to the
infrequency of experiences (DoH, 2008). ANPCCs did
not attend cardiac arrests as the anaesthetic trainee car-
ried the on-call pager in theatre and always attended
alone.
ANPCCs were not trained to request radiological
investigations of any kind; this was due to changes in
the regulation and monitoring of the legislation of The
Ionising Radiation (Medical Exposure) Regulations
(Statutory Instrument 1059, 2000) in NHS Scotland.
These issues were resolved shortly after the comple-
tion of this evaluation in late 2011, ANPCCs can now
request simple X-rays, e.g. chest, abdomen bones.
Complex studies such as computed tomography (CT)
scans remain consultant to consultant requests as
before.
It appeared from the service evaluation results that
ANPCCs delivered a significant and important role in
critical care service provision.
There were no adverse patient events reported dur-
ing the evaluation period, although rates of adverse
events were not recorded pre-evaluation.
LIMITATIONS
This evaluation was limited by the following factors.
This was a small evaluation which was confined to
one centre in Scotland. The training package although
drawn from other work and local experts was directed
to the needs of the unit involved. Data collection was
limited to 1 week and consequently the results may
not be generalizable or representative to other critical
care areas.
CONCLUSION
The outcomes of this evaluation demonstrated that
ANPCCs could be trained to match the roles of the
trainee doctor in critical care with only a few tasks
transferred to the consultant on duty. ANPCCs also
5
 A workplace evaluation of ANPCC work balance

added to unit efficiency by taking over responsibility
for and monitoring of national data input which was
lacking in consistency before.
ANPCCs and NHS Lanarkshire have addressed
some of the issues raised by this service evaluation.
ANPCCs can now request X-rays and prescribing of
unlicensed medications and opiate infusions are now
permitted (The Misuse of Drugs (Amendment No. 2)
to safely contribute to service provision.
2012).
• Experienced critical care nurses can be trained
to effectively perform the roles traditionally per-
formed by medical trainees.
• The ANPCC role has provided experienced criti-
cal care nurses with an alternative route of promo-
tion that remains predominately clinical.
ANPCCs could be utilized in any ICU/HDU setting

ACKNOWLEDGEMENTS
FUTURE PLANS
We wish to thank NHS Lanarkshire intensive care unit
Future plans for ANPCCs included: working in unsu-
staff. We particularly acknowledge the contribution
pervised sessions in HDUs, ICU follow-up services and
from the advanced nurse practitioners working in the
taking direct ICU referrals. ANPCCs have now begun
intensive care units who gave their time in a busy
to take ICU referrals and have provided regular unsu-
work schedule to participate in this evaluation. This
pervised sessions in HDU. ANPCCs are now using
evaluation received no specific grant from any fund-
their training and skills to teach junior doctors invasive
ing agency in the public, commercial or not-for-profit
line skills and critical care assessment and care plan-
sectors.
ning.

CONFLICT OF INTEREST
IMPLICATIONS FOR PRACTICE No conflict of interest has been declared by the authors.
This evaluation has several implications for clinical
practice:

WHAT IS KNOWN ABOUT THIS TOPIC?

• The reduction in the number and experience of junior medical staff in critical care has led to new advanced role opportunities for critical
care nurses.
• Roles to address the shortfall of junior medical staff have been developed but not frequently evaluated.

WHAT THIS PAPER ADDS

• This service evaluation provides analysis of the roles and tasks undertaken by ANPCC which could be used to inform service providers
and prospective employers of the value of these posts in critical care.

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