Investigating the retention and attrition of emergency care advanced clinical practitioners in the UK

Stage 1: identifying the research question

The first stage of a scoping review, according to Arksey and O'Malley (2005), is to identify the research question. This includes a review of Patient/Population, Intervention, Comparison, Outcomes (PICO) criteria (Aslam and Emmanuel, 2010). The two questions to be answered by this review were:

Stage 2: identifying relevant studies

The second stage of the scoping review includes identifying relevant studies (Arksey and O'Malley, 2005). Initially, the search consisted of a very basic library search, using terms such as ‘Advanced Practitioner’, ‘Retention’ and ‘Emergency Department’. This enabled the development of more specific search terms, to identify more relevant and focused results (Bramer et al, 2018). Table 2 details the final search terms used. Advanced search strategies were then used to identify English language papers only, published between 2010–2022. Boolean operators, such as ‘AND’, ‘OR, were used to widen the search. Five databases (the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the British Nursing Index (BNI), MEDLINE, PsycINFO and the Cochrane Library) were investigated using the search terms related to retention and attrition of ACPs in EC. These databases have robust, peer-reviewed literature available, so were able to provide high-quality papers to consider for the review. CINAHL was used for its significant nursing and allied health professional emphasis, as well as the potential grey literature it includes. The BNI was also used because of its potential inclusion of specific nursing text from the UK. A total of 892 articles were identified from all five databases.

Stage 3: study selection

The third stage of a scoping review is study selection (Arksey and O'Malley, 2005). The criteria for inclusion were developed using the Joanna Briggs Institute's (JBI) Manual for Evidence Synthesis guidance, due to its transparency and unambiguous approach (Aromataris and Munn, 2020), and were linked back to the review question. The inclusion criteria considered the types of participants, the core concept of the scoping review, the context of the review and the types of evidence sources (Trico et al, 2018). Table 3 details the inclusion and exclusion criteria.

Initially, articles that did not focus on ACPs were going to be excluded; however, due to a lack of evidence relating specifically to ACPs, a decision was made to include medical staff, nurse practitioners and senior nurses, to identify any evidence available for comparison. There was a three-stage approach adopted to enable the selection of papers reviewed, as recommended by the PRISMA-ScR framework (Trico et al, 2018):

Stage 4: charting the data

The next stage of the scoping review protocol comprises the charting of the data (Arksey and O'Malley, 2005), which included reading the final seven articles in full again, followed by analysis, using data charting to identify key areas for further discussion (Aromataris and Munn, 2020). The final seven articles encompass a range of countries within the UK, including England (Lawler et al, 2020; Fothergill et al, 2022), Wales (James and Gerrard, 2017) and Northern Ireland (Pflipsen and Kennedy, 2015), with three articles just listing the UK as a whole (Dawood and Garmston, 2019; Darbyshire et al, 2021; Evans et al, 2021) as the place of study. The final studies are a mixture of study types, with three qualitative studies (James and Gerrard, 2017; Dawood and Gamston, 2019; Lawler et al, 2020); two scoping reviews (Darbyshire et al, 2021; Evans et al, 2021); one quantitative study (Pflipsen and Kennedy, 2015); and one mixed-method study (Fothergill et al, 2022).

Each of the seven articles were critically analysed for robustness and rigour and to identify themes. A Critical Appraisal Skills Programme (CASP) (2018) tool was used to critically analyse the research, to ensure consistency was maintained when reviewing the studies. This also ensured that a systematic approach was being undertaken during consideration of all factors within each study. The CASP (2018) tools addresses three issues:

All the studies reviewed were of a high quality, but there are still discussion points detailed in the themes during critical appraisal. As stated previously, due to the paucity of evidence available, none of the studies reviewed answered the two research questions. There was no research identified that specifically examined the reasons for ACPs leaving EC; however, there was research conducted on nurses, emergency nurse practitioners (ENPs) and doctors in EC that could be drawn upon.

Stage 5: collating, summarising and reporting the results

The final stage of the scoping review protocol is to collate, summarise and report the results (Arksey and O'Malley, 2005). Thematic analysis was undertaken as part of the scoping review (Braun and Clarke, 2022). Key themes emerged: a clear career progression pathway was integral; a structured training programme and education reduced attrition rates; and working conditions in EC were a concern.

To identify these themes, the final seven papers were read numerous times, with notes written on topics covered. Firstly, the papers were read in detail with no notes taken, so as to ensure minimal disruption and enable comprehension and assessment of the full paper against an appropriate CASP tool.

The second phase of the analysis was to read the papers again at different times of the day, to ensure fatigue later in the afternoon or at night was not contributing to missed elements. During this second phase, notes were taken and stuck to the printed documents, and important details were highlighted. The papers were also read in different locations to ensure distractions were minimised. For example, if the papers were read at work, disruptions often occurred; therefore, the papers were re-read in coffee shops where interruptions were minimal, and again at home. Braun and Clarke (2022) suggest that familiarisation with the dataset is imperative to be able to generate initial candidate themes and recognise important patterns. Often, different concepts were detected, dependent on the surroundings, so a change in scenery played an important part in the thematic analysis of the papers. Reading the papers electronically and in printed format also assisted in the identification of different thoughts in different forms.

The third part of the analysis included use of a visual mapping technique, which was completed by hand. This was used to support the development of themes and potential sub-themes, enabling the recognition of layers within the analysis of the final papers. Thematic maps support connection recognition between the papers and the relationships and any differences between the different data collected (Byrne, 2022).

Theme 1: career pathway

A lack of a clear career pathway was detailed in four of the seven papers reviewed (Dawood and Gamston 2019; Lawler et al, 2020; Evans et al, 2021; Fothergill et al, 2022) as a reason for either attrition from EC or frustration from staff. The papers recognise that a defined pathway for career progression for ACPs is required to maximise retention and improve job satisfaction, with an assurance of ongoing development ensuring continued motivation and, ultimately, the retention of ACPs. The same was recognised for EC nurses and is important in the retention of the most experienced staff (Dawood and Gamston, 2019). Although a defined career pathway was highlighted as important to EC staff, it is likely an aspect of development required in all fields of advanced practice, where role sustainability would be enhanced by the development of a structured career pathway (HEE, 2022). It was recognised that a lack of lucidity surrounding the structure of the ACP role and the future of the position was described as a source of frustration and concern for staff. While all four papers (Dawood and Gamston 2019; Lawler et al, 2020; Evans et al, 2021; Fothergill et al, 2022) were clear on the requirements of a career pathway, the scoping review (Evans et al, 2021) identified a baseline of evidence on ACP roles and outcomes: successful ACP implementation programmes had good role preparation and a clear local career progression pathway. Agreement was found across all four papers on the necessity of a clear professional pathway, as poorly structured career progression can cause anxiety, uncertainty and apprehension in staff, thereby impacting their ability to perform and potentially contributing to attrition rates.

Differences recognised in the four papers are the level of practice across respondents. Fothergill et al (2022) conducted a large-scale evaluation (n=4365) across England on the ACP role in the form of a cross-sectional survey; the ACPs in this study were from a variety of specialisms, not solely from an EC role. In total, there were 125 different job titles described in this evaluation; interestingly, one of the roles that received three responses was that of a lead chaplain, which is likely due to inappropriate dissemination of the survey (Fothergill et al, 2022). The paper did not describe which responses were from which clinicians or areas of practice, and did not detail the questions asked in the survey; however, the researchers did summarise the objectives: to better understand governance, education, clinical practice and accreditation in the ACP role (Fothergill et al, 2022).

This is in contrast to Dawood and Gamston (2019), who focused on EC, but whose participants fulfilled the ENP role, as opposed to ACP; however, this paper did reiterate that, at whatever level of practice, a form of career progression and structure is desired by ACP staff. In comparison to the other papers, Dawood and Gamston (2019) conducted a small-scale investigation, encompassing only 12 responses; as the authors worked in the same unit in which their study was conducted and information gathered, there is a potential for response bias (Althubaiti, 2016).

Lawler et al (2020) conducted a large-scale survey (n=528) of ACPs across the UK, with 35% of respondents being trainee ACPs, in contrast to the other papers. Trainee ACPs will potentially give different responses than more experienced practitioners regarding career pathway needs. What was interesting is that this paper provided the survey and interview questions as an appendix. The survey's questionnaire tool comprised five pre-determined questions that, in summary, investigated the reasons behind participants becoming an ACP and their training experiences, alongside which challenges they have encountered and what has worked well in the role. As this research was not targeted specifically at EC ACPs, there are no questions regarding attrition or satisfaction related to EC as a career choice (Lawler et al, 2020). One of the researchers' key findings was that 52% of the 528 respondents stated that they felt advanced clinical practice was the only viable route to progress clinically without going into managerial roles (Lawler et al, 2020). Although there are many routes to progression within the NHS, most roles become less patient-facing as they become more senior, such as research positions, senior nursing management, educational posts and secondments to university. As a large proportion of ACPs that have progressed into advanced practice see it as the only feasible route to develop a clinical career, this may be suggestive of one of the potential reasons for attrition rates from advanced practice. If ACPs are entering this career path without a thorough and in-depth understanding of the role and its responsibilities and demands, this could then potentially cause a lack of longevity in the position.

Theme 2: structured training programmes

Two of the seven papers (Evans et al, 2021; Fothergill et al, 2022) highlighted the importance of a structured training programme. There was agreement across both papers that a structured approach to training ACPs was required, to ensure consistency and quality in the academic components of their continued professional development. This consistency was needed not only in the MSc in advanced practice, but also in the funding available further professional courses for ACPs, which was found to be very inconsistent across the UK (Evans et al, 2021; Fothergill et al, 2022). The other feature recognised by both papers included the need for systems that provide ACPs with ongoing clinical supervision and mentorship in clinical practice within a structured training programme to be established (Evans et al, 2021; Fothergill et al, 2022). Although the educational components of an MSc course provide education on examination skills and diagnostic interpretation, this needs to be supported in clinical practice to further enhance ACPs' development. The university qualification for advanced practice is only one component of training for an ACP, and clinical supervision and mentorship is imperative in developing the necessary skills to work effectively as an ACP.

A significant benefit for ACPs working within EC is the potential to credential with the RCEM. The credentialing portfolio was developed by the RCEM and HEE, with endorsement from the Royal College of Nursing (RCN), as a standardised curriculum that provided consistency for ACPs in EC (RCEM, 2022). All ACPs that complete credentialing are signed off by their workplace supervisors as working at a level of at least a specialist trainee year 3 junior doctor. This provides future employers with an understanding as to the rigorous work undertaken and the capabilities that come with being a credentialed ACP (RCEM, 2022). There are now over 120 ACPs credentialed with the RCEM since its pilot launch in 2017, with two credentialing windows scheduled within the year; this number is predicted to continue to grow (RCEM, 2022). The credentialing portfolio is now a standard part of the RCEM's work, and there is also an acknowledgement that a fulfilling career in emergency medicine (EM) is necessary for all EC staff, to ensure a sustainable workforce for the future (RCEM, 2021). There are other colleges that are integrating a credentialing portfolio pathway as a way of creating a structure for ACPs in clinical practice that goes beyond the university MSc. The Faculty of Intensive Care Medicine (FICM) (2023) developed their first portfolio credentialing plan in 2015 and continue to support credentialing, and the Royal College of Paediatric and Child Health (RCPCH) (2023) have more recently received approval for their portfolio by NHS England, with the hope to release in the coming months.

Theme 3: working conditions in emergency care

Three of the reviewed studies (Pflipsen and Kennedy, 2015; James and Gerrard, 2017; Darbyshire et al, 2021) investigated the retention and attrition of doctors in EC. Although each respective paper investigated different aspects of doctors' experiences in EC, all three reported poor working conditions as a significant concern, alongside low levels of staffing (Pflipsen and Kennedy, 2015; James and Gerrard, 2017; Darbyshire et al, 2021).

Pflipsen and Kennedy (2015) specifically investigated why EC trainees in Northern Ireland were leaving EC, as opposed to James and Gerrard (2017), who reported on why EC consultants stay. Pflipsen and Kennedy (2015) identified that trainees felt that the workload and intensity, alongside poor work–life balance and high stress levels, were significant contributing factors to their departure from EC.

James and Gerrard (2017) conducted focused interviews with ten consultants across seven hospitals in Wales; these were all medical, not ACP, consultants. The interviewers' questions focused on the motivation to work and stay in EC, and discussion on the reasons behind attrition; these were not predetermined, but instead were part of a fluid discussion (James and Gerrard, 2017). Predetermined questions give the benefit of being standardised, so that all participants are asked the same questions; they also require fewer interviewing skills. However, considering interview bias is important, as the interviewers' expectations may influence the answers provided by the participants (Brinkmann and Kvalem, 2015). Overall, the responses were very positive, with the numerous reasons given for the participants' choice of career in EC including a positive work–life balance and clinical satisfaction. This contrasts with the findings of Pflipsen and Kennedy (2015), who received negative responses on poor work–life balance, working conditions and training programmes. However, James and Gerrard (2017) recognise that work–life balance while training was a contributing factor to attrition from EC. Furthermore, the researchers acknowledge that overcrowding, due to limited bed capacity in the hospital and inadequate staffing levels, was also a factor that contributed to attrition (James and Gerrard, 2017).

Indeed, this was echoed across all three papers (Pflipsen and Kennedy, 2015; James and Gerrard, 2017; Darbyshire et al, 2021). ‘It's not the job that gets you down, It's the inability to do your job,’ (James and Gerrard, 2017) reported a consultant in relation to reasons for attrition from EC surrounding exit-blocking and bed capacity in the hospital (James and Gerrard, 2017). Generally, the consultants in James and Gerrard's (2017) paper were still positive about their choice of career into EC; however, there are certain limitations to be considered in regard to this paper. Firstly, it is a small-scale study of only ten consultants. Although a wide range of departments were chosen, most sites selected only had one participant, so were therefore not representative of a larger sample size. Secondly, the location of the participating hospitals varied significantly: some were rural, others inner city and others coastal. There is likely a difference in patient presentations to EC in these varying EDs, which may contribute to incongruities in work–life balance, job satisfaction, stress levels and economic factors. This was not an area discussed in James and Gerrard's (2017) paper. Although there are certainly comparisons to be made between ACPs and doctors, there are certainly differences that may play a role in professional attrition and retention, such as shift pattern working and rate of pay. Consultant doctors will certainly have a higher rate of pay than ACPs and, at consultant-level, often have fewer night-shift work commitments and less out-of-hour obligations than ACPs potentially do, which may have contributed to the overall positive responses given in this study (James and Gerrard, 2017).