Registered nurses have been working in advanced practice roles in North America since the 1960s and were in introduced to the UK in the 1980's, by Barbara Stilwell. Since then, advanced practice masters' degrees, accreditation and credentialling programmes have been developed by the Royal College of Nursing, who also produced standards for advanced level nursing practice (The Royal College of Nursing, 2018). The advanced nursing practice role has developed and become recognised internationally and is supported by the International Council of Nurses through the Guidelines on Advanced Practice Nursing (2020) and the Advanced Practice Nurse Network.
Multidisciplinary advanced clinical practice is designed to enable the safe and effective development of skills, across traditional professional boundaries. This change in national workforce strategy has led to the further development opportunities for nurses and other registered clinicians, such as allied health professionals, into advanced practice roles across the NHS in England (Health Education England (HEE), 2017). The other nations of the UK have also embraced the multidisciplinary advanced practice role (Scottish Government 2017; Department of Health, 2019; Welsh Government, 2020; Scottish Government, 2021), with four nations aligning to the four pillars of advanced clinical practice, with slight variations occurring at the local level (Henderson, 2021).
As per the International Council of Nurses recommendations, within the UK, advanced clinical practitioners (ACPs) should be educated to a MSc level (HEE, 2017; Henderson, 2021). This level of training provides the capability for the ACP to pursue an expanded scope of practice, and undertake roles and responsibilities historically seen as the province of medical staff (HEE, 2017).
In North America, there is a move towards doctoral level preparation for advanced nursing roles (Gloster and Leigh, 2021). While this development has not yet occurred in the UK, the development of the multi-professional consultant-level practice capability and impact framework (HEE, 2020) for advanced practice may contribute to the dialogue around the requirement for doctoral level education for consultant advanced practitioners in the future.
The debate as to whether advanced practice in the UK requires regulation, over and above professional regulation through a relevant professional body, has been ongoing for decades (Henderson, 2021). The discussion around regulation is made more complex by the multi-professional nature of the ACP workforce, as the existing regulatory framework has separate regulators for most of the professions. At present, no additional regulation is required for ACPs and the title is not protected. The UK is not unique, there is global variation in regulatory requirements: some countries require regulation by central government or professional body, and others rely on local governance by employers (King et al, 2017). From a governance perspective within the England, the Centre for Advancing Practice has developed the Governance Maturity Matrix (HEE, 2022)—a self-assessment tool for organisations to use to ensure clarity on the shared responsibilities for upholding safe and effective patient care between advanced practitioners and employers. The assessment tool ensures that the effectiveness of governance is kept under review.
Advanced clinical practice in the UK
As discussed previously, advanced clinical practice was recognised in the NHS Long Term Plan (NHS England and NHS Improvement, 2019) as being central to transforming service delivery and meeting local health needs, as a key part of contemporary workforce planning and the provision of clinical continuity within the NHS; as advanced practitioners do not tend to rotate, doctors in training are required to do. While there is a growing evidence base to support the safety and effectiveness of, and patient satisfaction with, ACP roles, there remains a level of ambiguity and variability within ACP roles nationally (Begley et al, 2013; Evans et al, 2021). Progress is being made towards role standardisation and accreditation (HEE, 2017).
HEE's Multi-Professional Framework for Advanced Clinical Practice (2017) specifies core capabilities across four pillars: clinical, leadership and management, education and research. ACPs are required to demonstrate capability and competence across the four pillars, tailored to the scope and context of their role, profession and practice. Developing and maintaining competence and capability in the clinical pillar is straightforward for ACPs, as practice is the clinical arena. However, achieving and maintaining competence within the other three pillars is also required, with a suggestion in England that job plans should reflect 80% clinical and 20% non-clinical time, although this remains an ambition rather than reality for many (Evans et al, 2021; Fothergill et al, 2022).
Medical staff in the UK are entitled to ‘supporting professional activities’ (SPA) time; for specialty doctors, this is at least one session or ‘programmed activity’ per week, which equates to a minimum of 4 hours (10%), with more senior specialty doctors being entitled to 20% SPA time (in line with consultants) (British Medical Association, 2023). It could be argued that qualified ACPs are senior clinicians, due to the increasing overlap in roles and responsibilities with other medical colleagues, and should therefore have SPA time (at a level of parity) built into business cases and job plans. Given the financial constraints within the NHS, it can be difficult to persuade organisations of the value of facilitating non-clinical time for ACPs, as it can be challenging to demonstrate a return on investment. However, without protected continuing professional development time, it can be challenging to achieve and maintain the capabilities within the multi-professional framework (HEE, 2017) and fully optimise the benefits that ACPs can bring to patient-centred, evidence-based care.
Several studies have acknowledged the benefits of ACP-developed research, education and leadership skills (Begley et al, 2013; Elliott et al, 2014; Fielding et al, 2022). As autonomous practitioners, it is vital that ACPs can critically evaluate and apply research findings to practice. This would drive change and help identify gaps in research knowledge, design and conduct, which, in turn, would help the development of a wider the evidence base. Such development requires further education to help:
- Develop the skills and knowledge to identify, evaluate, interpret, synthesise and apply research findings to practice across the breadth of research methodologies
- Design and lead on studies that address questions arising in clinical practice (Fielding et al, 2022).
It has been suggested that while ACPs can achieve and maintain the capabilities required within the leadership and management, and the education pillars within their clinical roles, they find the research pillar more challenging.
This is due to a lack of confidence and a reduced freedom to allocate time to develop this aspect. This is true for all sectors of practice (Begley et al, 2013; Fielding et al, 2022; Fothergill et al, 2022) and further afield, as demonstrated in Ireland (Begley et al, 2013; Casey et al, 2019) and in the US (Braun-Inglis et al, 2022).
Therefore, it can be argued that ‘protected time’ is a necessary requirement to enable ACPs to develop research capabilities and undertake research activity, and meet the wider capabilities required within the research pillar (HEE, 2017) or relevant national requirements (Table 1). It is likely that, until protected time is mandated, opportunities will be limited. As advanced practice becomes more widely understood by employers and standardised across employment sectors, opportunities for protected non-clinical time and the development of research capabilities may increase. In the interim, alternative methods for engaging with research can be explored.
Table 1. The Research Pillar
| Health and care professionals working at the level of advanced clinical practice should be able to: |
|---|
| 4.1 Critically engage in research activity, adhering to good research practice guidance, so that evidence-based strategies are developed and applied to enhance quality, safety, productivity and value for money |
| 4.2 Evaluate and audit own and others' clinical practice, selecting and applying valid, reliable methods, then acting on the findings |
| 4.3 Critically appraise and synthesise the outcome of relevant research, evaluation and audit, using the results to underpin own practice and to inform that of others |
| 4.4 Take a critical approach to identify gaps in the evidence base and its application to practice, alerting appropriate individuals and organisations to these and how they might be addressed in a safe and pragmatic way |
| 4.5 Actively identify potential need for further research to strengthen evidence for best practice. This may involve acting as an educator, leader, innovator and contributor to research activity and/or seeking out and applying for research funding |
| 4.6 Develop and implement robust governance systems and systematic documentation processes, keeping the need for modifications under critical review |
| 4.7 Disseminate best practice research findings and quality improvement projects through appropriate media and fora (e.g. presentations and peer review research publications) |
| 4.8 Facilitate collaborative links between clinical practice and research through proactive engagement, networking with academic, clinical and other active researchers |
Research in advanced clinical practice
Within England, the National Institute for Health Research (NIHR) introduced the 70@70 Senior Nurse and Midwife Research Leader Programme to support the development of research-led care environment and drive change across the NHS (NIHR, 2019). This was followed by England's chief nursing officer's strategic plan for research (NHS England and NHS Improvement, 2021), which highlighted the value of nursing engagement in research through leading, participating and delivering research across the NHS. This plan applies to all professional fields, as well as those actively seeking to advance and improve practice.
This value of multidisciplinary research engagement is supported by the Academy of Medical Sciences (2020), who acknowledge the significant benefits of research-active healthcare settings in terms of patient outcomes, better care and patient engagement. The academy has identified how research-active staff could facilitate the promotion of evidence-based practice, aid in the adoption and spread of effective innovations, stop the use of ineffective interventions and offer financial benefits to NHS trusts by revenue generation through research studies. However, this conflicts with the view of NHS Employers (2021), who consider that competence in the four pillars ‘can be demonstrated in different ways depending on the setting or role the ACP is practicing, which means that there is flexibility for employers to determine how ACPs demonstrate these capabilities'. There is an intrinsic conflict between the employer's need to maximise the clinical workforce delivering direct clinical care and the professional's need for development.
Clinical academic roles
One option for enhancing ACPs' opportunities to develop their capabilities within the research pillar is through a specific clinical academic role. The ACP role is closely aligned with a clinical academic role, in that both require clinical practice, research, education and leadership. These roles provide the opportunity to demonstrate the required competence and capabilities across all four pillars, yet are not common in advanced practice, or indeed in the nursing, midwifery and allied health professions (NMAHPs) in general; they have traditionally been the preserve of the medical profession. Nurses are commonly found either in the role of a clinical research nurse, supporting others' research, or being employed as a nurse researcher within the higher education sector, rather than having research as an intrinsic part of their job role within the NHS (Bradbury et al, 2021).
Barriers to access
A recent study compared the experiences of medical clinical academics with NMAHPs pursuing a clinical academic career in the NHS in the East Midlands region of England (Trusson et al, 2021). This multi-method study found that medical clinical academics were younger and combined clinical and academic training from as early as medical school or the academic foundation programme route. In contrast, NMAHP clinical academics were experienced in their clinical roles and embarked on their clinical academic careers much later in their career; both routes faced financial and personal consequences/obstacles in pursuing such a path. Similar issues in relation to lack of opportunities, organisational culture and infrastructure were found in a systematic rapid evidence assessment of clinical academic careers for nurses in primary care in the UK (Bradbury et al, 2021).
A significant barrier to ACPs fully embracing the research pillar and pursuing a clinical academic career is the financial disparity between the ACP salary within the NHS and other research roles. While the agenda for change's 8a salary band (£48526–54619) is standard for ACPs in England (with senior ACPs being band 8b (£56164–65262)), a clinical lecturer role, with a research component, in a higher education institute (HEI) has a more limited salary (£30–53,000) and often requires a PhD and a formal teaching qualification. Alongside the clinical lecturer role, an associate professor has a more substantial salary (£56–63000), yet requires a significant post-doctoral portfolio of research and teaching (Jobs.ac.uk, 2022). HEI terms and conditions are not equivalent either, particularly in respect of pensions. The financial disparities between NHS and HEI salaries pose a significant barrier to ACPs taking up research posts in HEIs.
This barrier could be addressed by increasing the number of honorary academic appointments and keeping the ACP on their substantive NHS contracts. This would allow research time to be built into their job plan, which would enable ACPs to access the HEI infrastructure and let them maximise their research and develop capability (Iles-Smith and Ersser, 2019; Academy of Medical Sciences, 2020).
A further barrier to research engagement is accessing the education (a doctoral level study) required to develop towards becoming an independent researcher. Undertaking a PhD, both in terms of tuition fees and the time commitment required, is challenging. The NHS does not currently have the research infrastructure to support NMAHPs to pursue research as part of their roles or have any career pathways that are supported by funding at doctoral and post-doctoral levels (Academy of Medical Sciences, 2020; Trusson et al, 2021). ACPs can explore funding opportunities from HEI stipends and non-government organisations to undertake doctoral level study, but these usually involve a significant fall in income, so this route may not be accessible for those reliant upon their salary.
The challenges in developing clinical academic careers, incorporating research and clinical practice are not unique to the UK. A qualitative study in the Netherlands concluded that nursing culture was a barrier to developing clinical academic career pathways for nurses, with the themes of perceived importance, leadership and infrastructure emerging as barriers to developing non-clinical aspects of nursing (van Oostveen et al, 2017); in contrast, the US offers some doctoral development opportunities for nurse scientists through the National Institute of Nursing Research (2023). While innovations in developing clinical academic careers for ACPs have been identifies in countries such as Australia and Sweden, many countries do not consider preparing ACPs to act as principle investigators, or drive them to lead research in their field of practice (Iles-Smith and Ersser, 2019).
Recent developments
However, there is a drive to increase non-medical participation in research (Academy of Medical Sciences, 2020; NHS England and NHS Improvement 2021; Health Education England and the National Institute for Health Research, 2022). One option for ACPs in England to develop research capabilities is through a clinical academic career pathway, such as the HEE-NIHR Integrated Clinical and Practitioner Academic programme (Health Education England and the National Institute for Health Research, 2022). This programme provides research training awards for NMAHPs who want to combine research with clinical practice. The available schemes are the:
- HEE Internship Scheme: a 6-month programme for those with little clinical research training
- HEE/NIHR Pre-doctoral Clinical and Practitioner Academic Fellowship (PCAF) Scheme: a programme supporting the development of a doctoral fellowship application and academic training; time funded varies as to the applicant's needs
- HEE/NIHR Doctoral Clinical and Practitioner Academic Fellowship (DCAF) Scheme: a 3-year award that covers salary, PhD tuition fees, research costs and a bespoke clinical and academic training programme
- HEE/NIHR Advanced Clinical and Practitioner Academic Fellowship (ACAF) Scheme: a post-doctoral award for 2 to 5 years that covers salary, research costs, and further academic and professional development costs.
These awards are highly competitive but offer an ideal opportunity to ACPs who want to fully embrace the research element of advanced practice. Similar schemes are available through the Clinical Research Time Award (Health and Care Research Wales, 2022) and the NHS Research Scotland (NRS) Career Researcher Fellowships (NHS Scotland Chief Scientist Office, 2022). However, there is no formal NMAHP clinical academic career structure in Northern Ireland (Council of Deans of Health, 2018).
Many NHS organisations have yet to embrace the value of clinical academic career pathways for ACPs; those who successfully achieve an NIHR Fellowship may find it difficult to secure a post that enables them to use their hard-won research skills (Iles-Smith and Ersser, 2019; Avery et al, 2022). Currently, the clinical academic workforce in the NHS is under threat, particularly in relation to those in doctoral or post-doctoral positions due to increased pressure on the NHS. The UK Government is currently considering what can be done from the perspectives of funders and the NHS to improve the situation (UK Parliament Science and Technology Committee (Lords) 2022).
The value of clinical academic roles is clear and likely to expand in the future. Iles-Smith and Ersser (2019) present a useful toolkit to support NHS organisations in developing career pathways for post-doctoral clinical academics. The toolkit presents details examples of successful partnerships between NHS organisations and HEIs in Leeds and Southampton, as cases of how partnerships can build research capacity, develop and retain post-doctoral NMAHPs, and support joint positions up to professorial level. Similar collaborative partnerships have developed in Oxford and the northeast of Scotland (Strickland, 2017), at St Bartholomew's Hospital in London (Woolfe-Loftus et al, 2022) and in Nottingham. ACPs can use these successful collaborations to influence their organisations to embrace clinical academic career pathways for ACPs.
Conclusion
The need for ACPs to develop their capabilities within the research pillar is vital to the provision of quality patient care. ACPs are ideally placed to drive change and lead research in the clinical arena. There are challenges to attaining the knowledge and skills required to be the research leaders of the future, but clinical academic roles offer a solution to overcoming the barriers and making a real difference to the provision of evidence-based health care.
KEY POINTS
- Advanced clinical practice is developing in the UK and internationally
- Research capabilities are a key pillar of advanced practice and drive improvements in patient-centred care
- Clinical academic roles support advance care practitioners in developing and maintaining clinical competence, while also developing the knowledge and skills to lead on research in the clinical arena.
CPD / Reflective Questions
- How do ensure that you meet the requirements of the research pillar of advanced clinical practice?
- How do you evidence that you are competent in the research pillar?
- Have you considered how you can develop your research capabilities?
- How do you critically appraise and apply research in practice?