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The Royal Marsden School

Working at an Advanced level of Practice – a reflective piece

By Francisca Mendes
Advanced level of practice
Mon, 24/08/2020

Advanced level nursing practice encompasses aspects of education, research and management but is firmly grounded in direct care provision. Nurses working at an advanced level use complex reasoning, critical thinking, reflection and analysis to inform their assessments, clinical judgements and decisions. They are able to apply knowledge and skills to a broad range of clinically and professionally challenging and complex situations (Department of Health, 2010 p7).

As a Clinical Palliative Care Specialist Nurse, I autonomously hold a patient caseload and am responsible for excellent standards of nursing care to patients through the planning, co-ordinating, delivering and evaluation of care, by delivering specialist clinical care appropriate to the holistic needs of the patient group. To support my development as an Advanced Practitioner, I undertook the "Physical Assessment and Clinical Reasoning Module", with the objective of refining the clinical skills needed to undertake a comprehensive health assessment of a patient.

I would like to reflect on my development as an advanced practitioner and share my experience of observing and performing an examinations on acutely ill patients and reflect on how different professional groups present different skills levels, and the importance of knowledge sharing and education.

Most of my practice days were spent in a Hospice setting, where my practice facilitator (Palliative Care Consultant, Dr X) works. There I was introduced to two final year medical students, who also wanted to further develop their skills. I was initially very nervous to work alongside - and be observed by - them as they had, by this stage, a lot more practice and clinical knowledge than me.

As the three of us needed to improve our neurological examination skills, Dr X - during the morning "board round” - selected the "most interesting patients" for a neurological assessment. The two selected patients were: a 78 year old gentleman - Mr S - who had had a stroke, and a 59 year old lady - Mrs R - who had a terminal glioblastoma and presented very interesting and abnormal neurological findings.

We proceeded to Mr S's room, where we then introduced ourselves before the medical students asked Mr S if it would be OK to perform a neurological assessment, to which he said yes. The students then performed a full neurological assessment, including cranial nerves, in under 20 minutes and their technique was faultless. I was left with mixed feelings, as whilst I was pleased I observed such a good examination that helped me to consolidate my own knowledge, I was also now even more nervous to be observed and judged by them.

In the afternoon we went to Mrs R room. She was sitting in a chair and was visibly exhausted and struggling to speak, but said "yes" when I asked if I could perform a neurological assessment. As she was growing ever more tired, I was left feeling more anxious and uncomfortable with proceeding with the examination. As a result, I quickly decided to allow Mrs R multiple breaks, asked her to tell me to stop at any time if she felt overwhelmed and tried to engage in meaningful conversations about myself, the course, her life, children, disease progression, hobbies etc. The full assessment took over 2 hours and I felt my "technique" was very poor, but as I Ieft the room Mrs R said "I am the one that needs to thank you for making me feel like I matter again". My practice facilitator called the interaction "inspiring" and said he was very pleased the medical students observed such holistic examination where the patient was treated like a person and not an object. The medical students thanked me for teaching them the importance of seeing the patient as a "human being" and asked me to help them develop their communication skills.

Lord Darzi’ (2008) highlighted that communication should be the highest priority and a key aspect of care for patients in all settings of care. Improving communication is not only about giving patients what they want and value but it is also about optimising the use of scarce NHS resources.

It is essential as a nurse and a leader to be a good communicator, engaging with patients, staff and the entire multidisciplinary team. To take the time to listen to people, being naturally empathic and approachable. Professional relationships are based on respect and dignity and as a leader you gain that respect by setting an example and working as a role model for your team and your patients.

Good communication skills are essential to the delivery of safe and effective care. Therefore, communicating clearly with colleagues, patients and the public by taking reasonable steps to accommodate peoples language and communication needs is crucial. Moreover, it is also key to respect the skills, expertise and contributions of colleagues by maintaining effective communication with them, as espoused by the NMC code (NMC, 2015)

Throughout this course and the accompanying "practice days", I learnt about the importance of active listening and allowing patients to list all of their worries without interruptions, and without focusing on the practical issues that are “easy to fix”.

I also learnt about the vital importance of silence and allowing that silence to happen when patients are distressed in order to allow them to process information and their own feelings. This also allows them the time to think about appropriate answers/solutions to their worries.

It was also very interesting and insightful to watch others and observe other communication challenges and discuss the most appropriate way of tackling them.

As defended by "Health Education England" (2016), "Education and training can break down barriers to providing safe care, creating an environment where all staff learn from error, patients are at the center of care, treated with openness and honesty and where staff are trained to focus on patient needs". It is therefore important to continue to reflect on our own practice and the practice of others and continue to educate in a constructive manner to help improve professionals confidence and patients outcomes.

On reflection I acknowledge that different professional groups undergo different training methods and experiences and we all benefit from spending time together and learning from each other. I learnt a lot about technique and clinical skills with the medical students and I feel I taught them how good communication skills enable us, as professionals, to establish a therapeutic relationship.

Since undertaking the course I feel more confident in tackling my own limitations as a professional and on supporting other professionals with their own limitations. I plan to continue to recognise and develop my own clinical and communications skills by listening, observing , practicing and reflecting on my own, and the wider teams, interactions with patients, to continue my development as a well rounded and safe "Advanced Practitioner".


  • Department of Health (2010) Advanced Level Nursing: A Position Statement. CNO Directorate. Available online at attachment_data/file/215935/dh_121738.pdf
  • The Scottish Governnment  (2008) The Advanced  Practice Toolkit. Available  at
  • RCN (2018) Advanced Level Nursing Practice: Introduction. London, Royal College of Nursing Publications
  • RCN (2018) Advanced Level Nursing Practice: Introduction. London, Royal College of Nursing Publications Department of Health (2008).
  • High Quality Care For All: NHS Next Stage Review final report. London: The Stationery Office.
  • NMC(2015). The Code. Available online at the-code-online/
  • Health Education England (2016).  Improving  Safety  by  Education  and  Training.  Available o n l i n e a t h tt p s : / / w w w . h e e . n h s . u k / s i t e s / d e f a u l t / fi l e s / d o c u m e n t s / Improving%20safety%20through%20education%20and%20training.pdf
  • NMC(2015). The Code. Available online at the-code-online/
  • Health Education England (2016).  Improving  Safety  by  Education  and  Training.  Available o n l i n e a t h tt p s : / / w w w . h e e . n h s . u k / s i t e s / d e f a u l t / fi l e s / d o c u m e n t s / Improving%20safety%20through%20education%20and%20training.pdf