Advanced clinical practice (ACP) programmes have evolved in the UK since the 1980s (Leary and MacLaine, 2019) and higher education institutions (HEIs) have adapted to ensure responsiveness to changing political and workforce needs. The introduction of the NHS multi-professional framework for practice (NHS England, 2017) aimed to define and map the capabilities required for clinicians to practice at an advanced level across the four pillars of practice. More recently, the NHS Long Term Workforce Plan (NHS England, 2023) highlighted gaps within the NHS workforce in advanced practice roles and shifted its focus to an apprenticeship model of educational healthcare delivery. This poses both an opportunity and a challenge for HEIs to successfully present traditional and apprenticeship models of delivery while maintaining the needs and experiences of past and present students. Equity of student experience is important for a standardised developmental journey and central to HEI quality assurance processes. It also endorses inclusive education by advocating the presence, participation and progression of all learners, which is known to improve healthcare outcomes (Beech et al, 2019; Medina-García et al, 2020). These processes are key to assuring that students are robustly prepared for the demands of the ACP roles and are equipped to achieve the required competencies regardless of pathway.
The advanced clinical practice landscape
The introduction of the ACP programme accreditation aims to maintain a level of consistency and quality assurance to uphold patient safety and clinical excellence (NHS England, 2021). Traditional ACP masters programmes are established across the UK and HEIs have observed a steady growth in admission numbers from self-funded and employer-funded learners. This is expected to continue at a steady pace, according to the projections set out in the NHS Long Term Workforce Plan (NHS England, 2023). It projected a 46% expansion target for advanced practice training by 2031–32, with 22% of all clinical training facilitated through apprenticeships by 2031–32. HEIs must prepare to maintain quality education while increasing capacity and apprenticeship routes for advanced practice, which may overtake the traditional masters programme route in terms of admission numbers.
The occupational standard for the ACP apprenticeship was first approved in 2018, informed by clinicians and experts and driven by ‘trailblazing groups’ (Institute for Apprenticeships and Technical Education, 2018). Although traditional masters routes to advanced practice have been influenced by workforce needs, apprenticeships require closer collaborations to ensure agreed off-the-job and on-the-job training opportunities (Department of Education, 2024). A mutual agreement between the employer and the HEI is required to demonstrate that apprentices have achieved the required knowledge, skills and behaviours (KSBs) to proceed to the end-point assessment (EPA). The Institute for Apprenticeships and Technical Education (IfATE), Office for Standards in Education (OFSTED) and the Education and Skills Funding Agency (ESFA), are all involved in the regulation and scrutiny of apprenticeship programmes. These governing groups seek to assure quality and standardisation of delivery. The prescriptive nature of the apprenticeship programme and the additional requirements can place an added administrative burden on apprentice learners, inhibiting engagement in comparison to traditional students (Fabian et al, 2022).
Programme delivery
Apprenticeship delivery requires significant resource investment from HEIs to ensure internal and external compliance. The EPA requires the employment of a number of independent assessors (IAs) who possess sufficient clinical and teaching experience. Tripartite progress reviews require both named clinical and academic based assessors. This resource intensive approach to supervision may also be considered a supportive mechanism and adopted for non-apprenticeship students. Regardless of entry route, the level of practice and competence of an ACP must be of a consistent standard, presenting a strong argument for alignment of programme curricula. Increased numbers of experienced clinical educators are needed to facilitate this. Educators must consider innovative teaching and assessment practices to maintain quality education when cohort sizes are growing. Pedagogical developments in learning and design practices can offer additional flexibility. They can incorporate blended learning approaches to foster collaborative learning and accommodate different learning styles to create meaningful learning applicable to real-world practices (Bayley, 2023). Successful co-delivery models such as the personalised learning (PL) model can be emulated for ACP. PL models advocate education for all and there are international efforts to adopt approaches which increase student diversity to become more inclusive in terms of student learning needs (Peterson, 2016). PL provides higher levels of learning, individually tailored to build upon the existing strengths of the students (Zhang et al, 2020). PL models complement the ethos of ACP programmes and take into account the fact that students are from multi-professional backgrounds with different experience levels when they enter the programme. Apprenticeship students are already required to analyse their baseline skillset in the form of a skills scan to establish funding eligibility. The programmes deliver a range of core and optional modules specific to student specialisms. There are workload implications for academic and support staff in HEIs, given the financial strain on the sector. Striking the balance between pooling resources across programmes for shared and personalised learning opportunities while recognising the individual learner's journey brings challenges as well as opportunities.
Challenges
There are a number of standard academic conventions within HEIs that can pose challenges when considering apprenticeship programme delivery. One such challenge is recognising previous learning that corresponds to a programme completed at the same level of education at a different institution. The acknowledgment of equitable learning and the associated credit and time can have a significant impact on the apprentice student's learning journey. Gaps in individualised student plans can emerge within programmes and enforce amendments to the standard programme journey. These bespoke programmes are resource intensive and can often result in a disjointed programme. It can also impact the management of a student's progression, the learner's journey and their overall experience. Other issues such as designing programmes that run beyond the standard academic calendar have countless implications. They can impact resource management over the summer months when universities are traditionally quiet with reduced personnel and support systems. These programmes require careful consideration to ensure that equitable, inclusive experiences and opportunities are provided to apprentice learners (O'Leary et al, 2019).
When developing a full 52-week year programme, challenges can also present with pre-set assessment points and quality assurance mechanisms. Set dates for academic and progression points may not align with the traditional learners' expectations to complete the programmes by the end of the standard academic calendar year (usually July). Additional provision must be put in place to ensure that apprentice learners are not disadvantaged because of these traditional institutional and organisational barriers (Lester, 2020).
The apprenticeship option for students represents an opportunity for debt-free learning. Not only does this increase access to such programmes, it also provides opportunities for inclusivity (Dawson and Osborne, 2020). However, it does not come without a cost. There are increased requirements to complete additional tasks and assessments that are presented as evidence for off-the-job learning regulatory requirements. The students also go through frequent and repeated monitoring through tripartite and skills scans to evidence the KSBs required to meet IfATE standards associated with the programme. This can create a challenge for the apprentice learners who are already juggling work, education and social burdens. For those on a non-apprenticeship ACP programme or self-funding, the issues are not dissimilar though stresses may occur at different points. Consistent workplace and employer support, which is not tied into an apprenticeship contract, may prove a frustration. If students are burdened with service responsibilities and not adequately and consistently supported, they may be forced to choose between work and study.
The cost of self-funded study and financial burdens can often derail students progress owing to factors that may be outside of their control. This may be alleviated in the future by further implementation of standards through accreditation and more stringent requirements within regulation from professional bodies such as NHS England and the Nursing and Midwifery Council. This comes with additional requirements for the education provider and concerns over the potentially divisive impact of different professions. Diverse professional regulatory bodies means that ambiguity and inconsistency might emerge as a consequence. Maintaining a balance within a co-delivered programme to ensure equity of access and experience is impacted by all of these factors. It is a challenge to ensure that both apprentice learners and traditional students are offered the best opportunity to succeed.
Opportunities
Co-delivery of programmes offers the opportunity to share best practice. This can be illustrated by the apprenticeship EPA process. The EPA signifies a readiness of the student to move through the end-point gateway. It also indicates a preparedness for students to move towards completion through a robust assessment that is independently assessed and must be achieved to complete the award. The EPA comprises a meaningful presentation of practice-based changes, assessments of clinical acumen and complex decision making by students using authentic, individualised case studies. It provides a final opportunity to demonstrate the ACP apprenticeship KSBs while underpinning the multi-professional framework for advanced practice to support clinical competence (NHS England, 2017; IfATE, 2018). MacArthur (2023) identified that the ACP EPA was gathering recognition as a symbolic achievement at the end of the ACP apprenticeship programme. The author observed that it afforded learners and employers confidence in their ability to successfully transition into advanced practice roles. Programmes embracing joint delivery could adopt the concept of high-quality EPA assessment as the final credit-bearing module, regardless of the funding route. It could be argued that this final assessment at the end of the programme provides the student, employer and educational institution with reassurance that the universal standards are achieved regardless of the programme model. The adoption of EPA as a robust final assessment for all programmes may prove fundamental to equitable experiences. It could also support the notion of uniformity in teaching by programme and module teams, to guarantee content quality and comparability in assessment and achievement.
Equity across programmes remains a priority, with equality, diversity and inclusivity (EDI) acknowledged as a cross-cutting theme. The Higher Education Workforce Report (Universities and Colleges Employers Association, 2019) identified that only 11.7% of the apprenticeship professional service staff were from ethnic minority backgrounds. These figures are concerning for both HEIs and employers at a time when closing the attainment gap is so important (Beech et al, 2019). Recent policies have identified opportunities for NHS progression. The implementation of healthcare apprenticeship models may provide a vehicle to cultivate EDI within the ACP workforce (Beech et al, 2019; NHS England, 2023). While offering a choice of funding and programme routes can encourage diversity, there are other strategies that may be valuable in providing equity in student experience.
Students must have their voice promoted via student representative systems, collaborative forums and extracurricular societies. The consultation of students from both pathways is necessary during programme development through university ACP forums to ensure equity. It promotes the integration of authentic assessment processes and supports the desire for continued Observed Structured Clinical Examinations (OSCEs) and further simulation-based education. These strategies unite to maintain clinical currency for students. The evolving advancement of technological and digital health systems also gives way to co-development opportunities with practice partner organisations and innovative cross-faculty team collaborations.
Formal feedback sought from Continuous Monitoring and Enhancement (CME) quality assurance processes and the Postgraduate Taught Experience Survey (PTES) are also vital. Leman (2023) identified that not all postgraduate students experienced a sense of belonging or felt part of a learning community bases on the results of the PTES. Programmes strive to create a sense of community by promoting peer support in the form of student events and standardisation of the Virtual Learning Environment (VLE). The VLE is a key point of contact for students and is thought to act as a social interaction platform to scaffold learner engagement and provide group cohesiveness (Lazareva, 2018). It can actively support discussions and student cohort engagement across both programmes.
Feedback facilitates HEIs to support strategic decisions and recognise challenges or barriers that learners may experience, specific to delivery (Leman, 2023). Accessibility to academic and digital resources are a necessity for ACPs, who are often balancing academics with unsociable working hours. Regardless of programme route, students with neurodivergent needs are required to share the individualised student learning plans with their clinical supervisors to support the crossover between academic and practice-based learning activities (HEE, 2022). Therefore, enhanced communication strategies between HEIs and practice providers are invaluable to safeguard learner success and implement support. These strategies are integral to the long-term sustainability of ACP programmes. They are central to educating the growing ACP workforce, to advance multiprofessional ACP provision and anticipate the provision of ACP specialist competencies for role longevity (Council of Deans of Health, 2018; NHS England, 2023).
Future research directions
Moving forward, there is considerable scope for research on ACP educational delivery and student outcomes. Areas for consideration are the experiences of the learner during their journey and comparable route-specific outcomes. Insight into supervisory experiences and readiness of supervisors who support ACP students could enhance student supervision and assessment strategies. The preparedness of apprenticeship students for the EPA and their subsequent transition from trainee to qualification holders could offer insight into future role development. The implementation of such research studies would contribute to the ongoing discourse on ACP education.
Conclusions
The sustainability of ACP programmes is vital as part of workforce planning and role longevity. While co-delivery is essential to promote equitable student experiences, each pathway must support student learning and offer parallel opportunities. Recommendations for practice are for continuous evaluation and appraisal of both models of education, to identify gaps in knowledge base for curricular development. No learning journey is without its difficulties and a clear focus is required to ensure that regardless of the pathway, the desired outcome is a learner who is ready to practice at an advanced level.