Advanced clinical practitioners (ACPs) are integral in ensuring patient safety within the improved pathways of care, owing to their advanced education and professional development (NHS Employers, 2022). They play the key role of clinical leaders in urgent community response (UCR) services in the UK (NHS England, 2022).
The UCR service is based on an integrated care systems approach and comprises a multidisciplinary team with diverse skills, typically including ACPs, registered nurses, physiotherapists, occupational therapists and healthcare assistants (NHS England, 2022). This service, designed to provide a two-hour crisis response, was introduced as part of the NHS England (2019) Long Term Plan. The plan was committed to increase investment and improve productivity of community health services over a five-year period. This approach is also in line with the National Institute for Health and Care Excellence guidance on meeting the urgent needs of rapidly deteriorating patients (NICE 2017).
Previously, experienced nurses, equipped with clinical examination and diagnostic skills and a non-medical prescribing qualification, were eligible to apply for an ACP position (Care Quality Commission, 2022). However, for the majority of NHS employers, this is no longer the case. Applicants are now required to hold a master's qualification in advanced clinical practice (International Council of Nurses (ICN), 2020).
This criterion is outlined in the multi-professional framework for advanced practice in England (Health Education England (HEE), 2017), which recommends a master's degree (or its equivalent) that covers the four pillars of clinical practice, leadership and management, education and research, demonstrating expertise and capabilities in a specific area.
History of advanced practice
The role of nurses with advanced practice skills was originally acknowledged in the US in the 1960s (Swaby et al, 2022). The recognition of the need for advanced practice development in the UK is attributed to Barbara Stillwell, who established the first training programme for advanced practice at the Royal College of Nursing (RCN) in 1990 (Leary and McClaine, 2019).
Advanced practice became more prevalent after the introduction of the European working time directive, which reduced the number of hours doctors were permitted to work (Evans et al, 2020a; Fielding et al, 2022). This legislation created a shortage of medical cover and resulted in the creation of a host of advanced practice roles to fill these gaps (Cooper and Lidster, 2021; Swaby et al, 2022).
Furthermore, the increasing challenge of supply and demand imbalance is affecting medical and healthcare professionals on a global scale (Mann et al, 2023). The complex health needs of a growing ageing population and workforce shortages is placing additional pressure on the global healthcare environment (Oliver, 2017; NHS Employers, 2022). This critical situation was further aggravated by the COVID-19 pandemic (HEE, 2021; Scott, 2021). While transformation in healthcare practice has always been essential, it has never been more urgent to establish a team of healthcare professionals equipped with advanced education and clinical expertise to deliver optimal patient care (Hill et al, 2021). This calls for the role transition of ACPs to extend and expand their professional boundaries to deal with this increased demand.
What are Advanced Clinical Practitioners?
The term ACP has vast and variable applications (Leary et al, 2017). The ICN (2020) defines an advanced practitioner in nursing as a registered nurse who possesses the clinical expertise and complex decision-making skills necessary to expand their practice and ensure the best possible patient outcomes. ACPs are no longer confined to the nursing field and have extended to various professions including pharmacy, paramedicine, midwifery and the allied health professions (Mann et al, 2023; NHS Employers, 2023). According to Cooper and Lidster (2021), ACPs are autonomous practitioners who confidently make intricate decisions within a wider multi-disciplinary team. The responsibilities of ACPs vary based on their individual roles and contexts (Mann et al, 2023).
Defining the exact professional scope and competencies of ACP practice is challenging (Oliver, 2017) and may be confusing (Evans et al, 2020b). Meanwhile, there is concern that overly restrictive scopes for ACPs may limit their versatility in the role (Torrens et al, 2020). Swaby et al (2022) emphasise that one of the key advantages of the ACP role is its flexibility in accommodating the needs of both patients and healthcare services. ACPs from diverse healthcare backgrounds bring a mix of skills and expertise to the clinical arena. Therefore, maintaining flexibility for ACPs would significantly promote the development of a responsive workforce, capable of meeting the needs of changing populations while ensuring effective delivery of services (NHS Employers, 2022).
This flexibility is a fundamental driver for advanced practice (Peate, 2019). Losing this flexibility could have a detrimental impact on ACPs, leading to a blanket approach that might compromise patient care. Therefore, both HEE (2017) and RCN (2018) assert that advanced practice represents a level of practice, rather than merely a job title.
Various standards of advanced practice in the UK
While the multi-professional framework represents the most widely accepted definition of ACPs (HEE, 2017), further development remains crucial because of a lack of mandatory regulation for ACPs in the UK (Mann et al, 2023). It is noteworthy that the policies of advanced practice differ across the UK (Peate, 2019).
Hill et al (2021) revealed that some ACPs in England did not obtain a full master's degree because it is not mandated by the regulatory or professional bodies. Conversely, HEE (2017) specifies that having a full master's degree, without the appropriate experience and core competence, is insufficient to justify ACP status.
The ambiguity surrounding regulations for ACPs is not limited to the UK. It has become a global concern, with significant disparity in the specific educational requirements associated with ACPs (Munday and Pow, 2021). The lack of regulation and poorly defined educational standards further contributes to the confusion and ambiguity surrounding the role of ACPs. Such lack of clarity can result in job title inconsistencies and misunderstanding among stakeholders that subsequently hinders the implementation and development of the ACP role (Leary et al, 2017; Leary and MacLaine, 2019). Research suggests that registering with a professional body will protect, clarify and regulate ACP roles (Peate, 2019; Hooks and Walker, 2020; Hill and Mitchell, 2021). However, some ACPs are not convinced of the benefits of registration to patients or themselves (Timmons et al, 2023).
Potential conflict with their existing registers may lead to having to make a choice (primarily because of the consideration of extra cost) between alternative registrations (Timmons et al, 2023). The code of professional conduct published by the Nursing and Midwifery Council (NMC) (2018) covers prescribing practice alongside indemnity. With the introduction of revalidation by the NMC (2018), all registered nurses, including ACPs, are required to provide evidence of their ability to practice safely and effectively in compliance with the code. Adding an extra ACP registration with the NMC is not considered necessary.
Uncertainty of the role of ACPs
While advanced clinical practitioner is a protected title in some developed countries, such as Australia (Mann et al, 2023), the job title is not legally protected in the UK (Cooper and Lidster, 2021). There is evidence of the misuse of ACP job titles in various healthcare organisations and clinical settings (Mann et al, 2023). There are more than 500 different terms for advanced practice in the UK and some non-registered staff members use the advanced practice titles inappropriately (Leary et al, 2017). This inevitably misleads both patients and other healthcare professionals, eroding their trust and confidence in ACPs. It is imperative to safeguard the ACP title to ensure its reliability and validity (Peate, 2019; Swaby et al, 2022).
Countries such as Canada have also encountered similar problems (Black et al, 2020). Ladd et al (2020) identified that a global consensus on protecting and regulating advanced practice across nursing professions is required to eliminate the wide variance in job titles. However, these authors expressed concern that, at present, a variety of policies and regulations for advanced practice still exist internationally.
A report by Nancarrow and Borthwick (2021) noted that Australia had a clearer description of advanced practice roles to facilitate ACPs. In comparison with Scotland, Wales and Northern Ireland, where the professional identity of advanced practice was already recognised, England was the least effective in implementing recognition of the ACP role until the introduction of the multi-professional framework for advanced practice (HEE, 2017).
As such, it may further contribute to confusion and misconception regarding the ACP role. Confusion often arises when differentiating between the roles of clinical nurse specialists (CNSs) and ACPs, and arguably they are sometimes used interchangeably (Simpson et al, 2022). Hooks and Walker (2020) suggested that the practice scope of ACPs tended to duplicate the existing elements of the role of CNSs and implied that ACP role may not be indispensable. This will subsequently exacerbate the varying level of acceptance of the ACP role among colleagues. In addition, there is an overlapping of the extended and advanced roles, which makes it more difficult to distinguishing them (Wallymahmed and Pearson, 2022).
Imison et al (2016) described in their research that CNSs in extended roles could manage tasks beyond their usual practice sphere, without requiring training to a master's degree level. In contrast, advanced roles required a master's education or higher to qualify individuals as ACPs. The report commissioned by the Nuffield Trust concluded that CNSs in extended roles should not be classified as ACPs without a master's degree. However, implementation of the concept remains uncertain and inconsistent (Hooks and Walker, 2020).
A recent systematic review conducted by Cooper et al (2019) also argued that despite some similarities found in the roles of CNSs and ACPs in clinical practice, leadership and education, ACPs exhibit a more substantial leadership strategy than CNSs in clinical settings. Most importantly, while CNSs focus on their specific specialities, ACPs adopt a broadened level of autonomy and responsibilities, including non-medical prescribing (NMP) skills to deliver seamless patient care throughout the entire patient journey (Wallymahmed and Pearson, 2022).
Non-medical prescribing
It is widely acknowledged that the primary responsibility of ACPs in England is the ability to prescribe independently (Mann et al, 2023). The NMP qualification is considered crucial for ACPs, enabling them to practice autonomously (Oliver, 2017; Hulse, 2022). Since the introduction of NMP to the nursing profession in 2001 (Department of Health, 2001), registered nurses have been encouraged to use their proficient clinical skills to assess, diagnose and prescribe for patients with diagnosed or undiagnosed conditions (Courtenay, 2018). This development has distorted a distinct demarcation between the roles of nurses and doctors. Some doctors perceive ACPs as a potential threat and have expressed concerns about their clinical capabilities (Oliver, 2017). This perspective could be influenced by the belief that ACPs are assuming clinical tasks traditionally performed by doctors, including prescribing, and that the creation of the ACP role is aimed at replacing junior doctors (Cooper and Lidster, 2021).
Research by Noblet et al (2018) counters this concern by confirming the clinical benefit and cost effectiveness of NMP. These researchers advocate that NMP contributes to the effective management of both acute and chronic medical conditions and yields positive clinical outcomes. Spence (2019) predicted that, with the right training (such as NMP, ACPs can competently perform tasks similar to doctors. However, it is important to emphasise that ACPs do not substitute for doctors. In fact, they work in partnership with doctors to alleviate their workload and as such, ACPs are considered maxi-nurses rather than mini-doctors (Oxtoby, 2020). NMP serves as a catalyst for reforming the entire healthcare system and empowers ACPs to thrive as unique contributors and valuable assets in this modern healthcare society.
Positive feedback for the ACP role
Robb et al (2022) stressed that ACPs in the UCR service in Bromley were recognised and highly valued by patients and doctors for their exceptional professionalism and expertise. The evidence shows that ACPs alleviate pressure on GPs and free them up to manage more complex conditions (Timmons et al, 2023). Likewise, ACPs require support from doctors for reassurance (Morris et al, 2021). Better patient outcomes can be achieved through collaboration between ACPs and doctors than by doctors alone (Collins, 2019; Greenwood, 2019). This professional dialogue between ACPs and doctors promotes seamless patient care delivery that is safe, effective and high quality. Morris et al (2021) found that some patients, to a certain degree, preferred to be seen by ACPs rather than GPs, as they felt more comfortable with friendly ACPs.
ACPs spend more time communicating with patients and often deliver a holistic consultation (Greenwood, 2019). A good rapport is easily built, which facilitates person-centred care that is informed by shared decision making (Morris et al, 2021). Owing to the long waiting periods for GPs, patients are more likely to accept an ACPs' consultation for quicker accessibility (Greenwood, 2019; Swaby et al, 2022). This increases patient satisfaction and concordance, and ultimately leads to greater acceptance of the role of ACP (Barratt, 2018; Morris et al, 2021).
Four pillars to ACP role
HEE introduced the multi-professional framework, which consists of four pillars: clinical practice, education, leadership and management, and research (HEE, 2017). While most ACPs in the UK fulfil the first three pillars (Drennan et al, 2019), they still lack confidence in research (Fielding et al, 2022). Mortimore et al (2021) agree that, although there is room for development and progression for ACPs, some areas remain underdeveloped. These authors further assert that it is not necessary for ACPs to reach expert status across all four pillars, even though some have already achieved it.
Despite this, opportunities exist in the daily practice of ACPs that allow them to adopt research and innovation in order to enhance patient care in clinical practice (Fielding et al, 2022). The author has participated in several clinical audits as part of the UCR service, analysed results and disseminated findings within the team, which received positive feedback. As an ACP actively involved in frontline clinical care, the author has been striving to identify potential gaps within the UCR service, with the aim of generating and implementing evidence-based research that can drive transformative change in healthcare. However, securing time for research in a busy UCR service remains a challenge. This necessitates proactively anticipation of any potential obstacles in the planning and implementation of research. Effective time management is achieved by integrating the other three pillars into daily practice.
Conclusions
It is evident that, as healthcare services transform, many opportunities emerge for the creation and development of new roles. With more healthcare professionals participating in ACP training and beginning their practice as ACPs, there is a certain level of urgency for the regulation of the ACP role. Simultaneously, ACPs must offer their insights by urging all stakeholders, including commissioners and policy makers, to acknowledge the role's vulnerability and establish consistent regulation for its protection.
While the entire healthcare service is diligently working to meet the patients' needs, regardless of whoever attends the patients and what their titles are, the key requirement is to place patients at the centre of care. This involves ensuring that patients receive care from the right professionals equipped with the right skills, at the right time and the right place to ensure proper treatment.