Advanced clinical practitioners (ACPs) are practitioners who have been certified in MSc-level training in advanced clinical practice. They use their advanced clinical knowledge and expertise to enhance patient care and outcomes (Timmons et al, 2022), as well as demonstrated expert autonomy, examination, diagnostic and decision-making skills to maintain high standards of care (Health Education England (HEE), 2017; Simpson et al, 2022).
The healthcare industry has faced recent challenges such as financial constraints, the increase in co-morbidities, patients living longer and staff shortages. As a result, patient care and safety have declined (Maier, 2015; Cooper and Lister, 2021). ACPs have been brought into the workforce to help address the ongoing problems.
‘Advanced practice’ is a level of practice rather than a specific specialism (HEE, 2017). ACPs can exercise independent judgement in the delivery of care across the four pillars of advanced practice, which are: leadership and management; education; research and clinical practice (HEE, 2017).
This article will explore the four pillars with respect to the frailty specialty, taking both the perspectives of the author and a trainee ACP into account. The evaluation will also analyse the historical development of advanced clinical practice and the knowledge, skills and competencies (KSBs) expected at the advanced level.
Background
The global expansion of advanced practice began in the 1980s, and increased rapidly in the UK in the 1990s due to the demands placed on the NHS (Mortimore et al, 2022). The NHS Long-Term Plan (2019) and HEE's multi-professional framework (MPF) (2017) have been key drivers in pushing the advanced practice agenda forward (Hill and Fox, 2023).
The MPF defines the skills necessary of an ACP and sets a minimum standard for safe and effective requirements for clinicians working in expanded roles (Mortimore et al, 2022). ACPs are now recognised as being essential towards meeting the demands of the contemporary healthcare landscape, and their roles have extended to other professions such as nursing, midwifery, paramedicine, physiotherapy, occupational therapy, physician associates and pharmacist (Timmons et al, 2022; Hill and Fox, 2023).
The British Medical Association (2022), the European Working Time Directive (2004), the NHS long-term plan (2019) and HEE's (2017) MPF all assert that ACPs can help manage health care challenges such as the complex needs of patients, staff shortages and an ageing population. Conflict around the advanced practice role has resulted from the fact that the multi-disciplinary team (MDT) has not always shared this viewpoint (Wood, 2021). As a result, there is now an established ACP definition recognised across all specialties (HEE, 2017; Hill and Fox, 2023), which signifies that ‘advanced practice’ is a level of practice designed to transform and modernise care, and enable the safe and effective sharing of skills and competencies. This is designed to guarantee an understanding of advanced practice and the safety, quality and effectiveness of the role (Hill and Mitchell, 2021). Despite this, it can be argued that due to the differences in training and work-based competencies, the way trainees and ACPs utilise the four pillars of advanced practice continues to vary between specialties (Lawler et al, 2020). This could be a concern in terms of potential training inconsistencies and differing work-based experiences.
The multiplicity of the ACP role, which has been shown to improve service delivery and satisfy patients' holistic healthcare requirements, has also sparked debate (Evans et al, 2020). Some critiques of the role include the ACP being incorrectly perceived as a doctor's replacement, ACP-structures replacing existing medical models, ACP's being perceived as limiting colleagues professional development and (previously) the absence of a regulatory framework (Leary and MacLaine, 2019; Diamond-Fox and Stone, 2021). Peate (2019) and Mundy and Pow (2021) maintain that tensions within the MDT were created because of the wider team's limited understanding of what duties of the ACP are.
ACPs are able to assess, diagnose, prescribe, interpret diagnostic results and discharge patients (Lawler et al, 2020; Timmons et al, 2022). These features were coded into HEE's MPF advanced practice definition, which has helped provide clarity to colleagues, patients, universities, workplaces and professional bodies on what advance practice and the role of the ACP are. While ACPs have historically been used to fill in a workforce gap, advanced practice now holds value within its own professional right, as opposed to being seen a medical model substitute (Lawler et al, 2020).
Frailty
The British Geriatric Society (BGS) (2017) defines frailty as a long-term condition. With people living longer and presenting with complex conditions, the ACP within frailty is an essential role (BGS, 2017; NHS England, 2022). Part of the trainee ACP role within frailty is to become competent in completing comprehensive geriatric assessments (CGA), which require trainees to have skills in history taking, physical examination, clinical reasoning, prescribing, deprescribing and discharging safely (Diamond-Fox and Bone, 2021). However, it is a combined effort from all healthcare clinicians, leveraging other professions, to meet the holistic needs of older adults successfully and safely. Rockwood and Howlett (2018) and Won (2019) advocate that frailty is characterised by a decrease in the physiological reserves, which makes a person susceptible to outside stressors. Frailty syndromes are classified in adults aged 65 years and older, the symptoms of which include pharmaceutical side effects of medications, falls, immobility, delirium and incontinence (Jones et al, 2004).
Important recommendations to support older adults living with frailty were included in the NHS Long-Term Plan (2019). The BGS (2017) recommends that healthcare providers should consider the completion of a CGA for those at risk of frailty, who present with a frailty syndrome or have a clinical frailty score of five or more. To meet the needs of older adults, the BGS (2017) recommends that holistic care should be provided by healthcare professionals, with trainee ACPs being trained to undertake a CGA. This care is a holistic approach and should include a physical examination, mobility assessment, social care, medication and mental health assessment, which aims to improve older adults' quality of life, and help them maintain their independence and health for as long as possible (BGA, 2017; NHS, 2019; Lee et al, 2020). As a result, training ACP within frailty remains essential to provide joint, holistic and high-quality care.
Clinical and research pillars
The author of this article is employed within frailty, working as a trainee ACP. While the role allows for trainees to meet the clinical practice pillar and advanced practice related-clinical KSBs, it is harder to conduct active research (Mortimore et al, 2021); thus, trainees are often left with difficulties in meeting the requirements of the research pillar of advanced practice. However, as a trainee and qualified ACP, by maintaining our skills and knowledge, maintaining high quality care by using evidenced-based practice, backed by policies, it can be argued, working within elements of the research pillar are maintained. Furthermore, wishing to become an ACP, provides strength in being able to work on the other pillars of practice and when possible, using off the job learning and study days, to work or shadow the research team, undertake audits and commence individual QIs. This must not be underestimated in the journey of advanced practice and the positive influence it has on patient care and individual development.
Education and leadership and management pillars
As mentioned in Evans et al (2020) and Wood (2021), the terms and requirements of the advanced-practice related education pillar can be difficult to fulfil. Trainees can take part in teaching and leadership opportunities—such giving lectures, teaching staff clinical skills, educating patients, developing relationships, working as role models and developing responses to changing population needs—which ensures they develop skills in relation to the education and leadership and management pillars (HEE, 2017; Skills for Health, 2018). The author's current managers within frailty ensure trainee ACPs carry out co-ordinating duties and staff appraisals, which helps them gain exposure and meet the frailty and leadership and management competences mapped out within the KSBs (Skills for Health, 2018). Exploring existing literature that relates to advanced clinical practice, seeking learning opportunities around personal needs and pillars of practice, and using off-the-job learning and supervision, remains vital (Evans et al, 2020).
Personal experience
Throughout my time on frailty, I learnt how to complete a CGA and conduct history taking, physical examinations and memory screenings. All these skills improved my capacity to care for patients and their families, as I was able to:
From a personal perspective, I found that being able to provide a thorough assessment of a patient's physical health and their emotional and social wellbeing had several benefits. While it primarily improved their quality of life, it also developed my communication skills, deepened their trust in their healthcare providers, and reclarified the importance of maintaining therapeutic relationships.
Recommendations
It is recommended that other trainee ACPs, across the frailty field and beyond, seek supervision and maintain a portfolio of their work. By doing this, developing ACPs can track their progress, identify their strengths and weaknesses, and support others if appropriate.
In my Trust, the lead ACP encouraged supervision and networking. I found this approach beneficial, as it gave me a support network within my working environment and ensured my wellbeing as a healthcare professional. Portfolios can be used to record evidence and growing skillset, and help ensure trainees have met work-based competencies, knowledge and skills. While the use of supervisors and portfolios have not been standardised into practice in a way similar to HEE's MPF and the four pillars of advancing practice, their inclusion may prove to be beneficial, as they can help to ensure that the coded pre-requisites of the ACP role are met and developed to a high standard.
Further research into the use of both measures would be recommended before they could be fully incorporated into standardised advanced clinical practice.
Conclusion
Working as a trainee ACP allows practitioners to learn how to provide safe care and enhance patient care and experiences. Throughout my journey on frailty, I have been able to provide person-centred care, holistic complex care and appropriate support to those that need it.
Additional off-the-job learning has provided me with the opportunity to work with colleagues in the Trust and explore the research KSBs, teach and start a QI project. I have been able to complete such tasks and actions due to the support I have received through supervision, which allowed me to proactively work on my strengths and weaknesses, and refine my skills, confidence and clinical abilities in preparation for qualification.