At graduation, it is likely that the graduate's job title will reflect their core profession (e.g. nurse, physiotherapist, speech and language therapist, etc). These titles can be extended following career progression or the completion of additional clinical training; titles such as ‘highly specialist’ or ‘extended scope’ can be added to reflect increased professional understanding or practical capacity. Historically, as these senior clinical roles have not had clear clinical capability standards associated with them, clinical governance has relied on local processes rather than nationally agreed standards. To provide these standards and guidance, Health Education England (HEE) published the multi-professional framework for advanced clinical practice in England (HEE, 2017).
Advanced clinical practitioner (ACP) roles are defined by high-level clinical judgement and autonomy in situations of undifferentiated diagnosis and clinical uncertainty. As multidisciplinary teams have developed in primary and secondary care, and as patients have become more complex with long-term condition management, ACP roles have developed in many professions and clinical areas (Peate, 2021).
The overarching capabilities for ACP roles are defined by HEE's multi-professional framework (2017), which outlines four pillars of practice: management, research, education and clinical. A series of additional speciality-specific frameworks have been published off the back of the 2017 standard (HEE, 2020a; 2020b; 2020c; 2021; 2022a). This list is not exhaustive, as further clinical areas continue to be developed. The specific skills described by the first three pillars are broadly consistent across different clinical speciality areas; however, the clinical skills required by an ACP working in mental health will be vastly different from an ACP in an emergency department.
Clinicians in advanced practice roles are expected to demonstrate MSc-level training and competency in all four pillars of this framework. This can be either through the completion of a recognised MSc in advanced clinical practice or the HEE e-portfolio, during which the clinician can provide experiential evidence of their capability of working at at advanced practice level. Clinicians undertaking MSc-programmes may have received financial support from their employer, the level-7 apprenticeship fund or be self-funding. The HEE e-portfolio route is not expected to be an option indefinitely, as all future ACP clinicians are likely expected to pass through the MSc-route to accreditation.
The advanced practice landscape has evolved rapidly since 2017:
- Healthcare providers have been evaluating clinical role titles and job descriptions to understand which roles are appropriate to the now-called ACP roles
- Universities have been developing modules and programmes of study to fulfil the need for MSc courses
- Clinicians have had to consider how best to officially achieve ACP recognition, either through (further) MSc study or the supported e-portfolio route.
Informal discussions had taken place with a range of clinicians across the region who were interested in advanced practice, either as ‘qualified’ ACPs, ACPs in training (current MSc or e-portfolio route) or clinicians who were hoping to develop into ACP roles in the future (aspirant ACPs). It was clear that uncertainty existed with regard to the range of training opportunities that were available, as well as how professionals could best utilise such opportunities in their current roles for a future career. To explore these needs further, the authors planned a structured survey of clinicians along the continuum of aspirational to qualified ACPs. This survey had two aims:
- To understand what training/learning opportunities clinicians had found most useful in developing their current level of advanced practice capability, across the four pillars
- To understand what training/learning opportunities they needed further access to, to further develop and/or consolidate their advanced practice capability, across the four pillars.
Method
Survey design
The survey was designed using an online platform (www.smartsurvey.com). Section one gathered clinician demographics. Section two was divided into the four pillars of advanced practice; for each pillar, the respondent was asked to rate how useful a range of development opportunities had been in expanding their current level of capability in the respective pillar. They were then asked to prioritise which development opportunities would be most important to support their future skill and capability development. The prioritisation was achieved by re-ordering statements of possible skill development opportunities. These questions were asked for each pillar (clinical, management/leadership, research and education). Free text boxes were available at the end of each section for respondent comments (e.g. continuing professional development (CPD) routes omitted from the survey).
Data analysis
The respondent's demographic data and their rating for the usefulness of each development opportunity were presented as descriptive data. The importance of future development opportunities were assigned rank order scoring (highest score for most important); these were totalled for all responses. These data were presented in rank order.
Survey dissemination
A dissemination strategy was planned to distribute this survey to all relevant clinicians working in the integrated care system (ICS). The survey link was distributed to nursing and allied health leads in primary care (training hub), community health care providers, mental health and acute hospital trusts, and charity-sector hospices. It was distributed at regional, multi-professional ICS meetings such as the Allied Health Professions Council. The survey link was sent directly to all ACPs (trainee or qualified) working in any local organisations. The link could be forwarded to any other interested clinician.
Ethical approval
NHS ethical approval was not required, but guidance was sought from Bath and North East Somerset, Swindon and Wiltshire Together integrated care system education leads.
Results
The survey received 36 completed responses. There were five incomplete responses with data for the development of clinical and management competencies, but not research or education competencies, which were included in the data set. Other incomplete responses with no data for any development opportunities were discarded.
Respondent demographics
The survey had 38 full responses; 75% were either trainee or qualified ACPs. The respondents were mostly physiotherapists (45%) or nurses (39%); the majority were in the UK agenda for change (AFC) pay bands 7 or 8a. Nearly all (90%) of respondents had some level of MSc education (Table 1).
Table 1. Respondent Demographics
| Question | Variable | % (n) |
|---|---|---|
| Do you consider your role as… | Fully qualified advance care practitioner (ACP) (MSc-level in 4 pillars) | 34 (13) |
| ACP in development (MSc-level in clinical pillar) | 39 (15) | |
| Aspirant ACP (ACP as desired career pathway) | 26 (10) | |
| Your main employer is… | NHS acute trust | 32 (12) |
| NHS-funded community services | 45 (17) | |
| Primary care services | 19 (7) | |
| Charity supported services | 5 (2) | |
| Highest academic qualifications… | MSc-level: either awarded or in progress (MRes/PGCert/Dip) | 83 (32) |
| Apprentice route to MSc | 8 (3) | |
| BSc under-graduate | 8 (3) | |
| Primary registered profession… | Physiotherapist | 45 (17) |
| Nurse | 39 (15) | |
| Paramedic | 11 (4) | |
| Speech and Language therapist | 5 (2) | |
| Agenda for change banding (or nearest equivalent)… | Band 5 | 5 (2) |
| Band 6 | 3 (1) | |
| Band 7 | 53 (20) | |
| Band 8a | 32 (12) | |
| Band 8b | 8 (3) |
The survey asked for responses within the four pillars of advanced practice; the study results will be presented in the same format. Respondents selected from a range of statements indicating how useful they had found a variety of development methods. There were very few free text responses. Importantly, the comments made did not include any further CPD options which had been omitted from those asked in the survey. The free text responses did detail respondents' personal experience of learning, but were insufficient to provide qualitative insight to the survey response data. These responses are not reported further in this article.
Clinical
Respondents reported having used national guideline documents and research literature to develop their clinical competency. The evaluation of these guidelines has likely been improved by enrolment in MSc modules and courses, and, consequently, the development of professionals' critical appraisal skills. The results also described the importance of training opportunities from local clinical teams and mentorship from within the clinical speciality.
The development opportunities available through the primary care training hub were least accessed. Most respondents (55%) were employed by acute sector or community providers and had not accessed the training hub. There were seven respondents who worked in primary care (either as a provider or direct GP), three who accessed training hubs (which were rated as useful) and four who never utilised training hub training.
Future priorities
Respondents would prioritise access to mentorship, MSc study, conferences and peer feedback to further develop their clinical skills. Weekend courses, the usual stalwart of CPD, were not prioritised; neither were social media options such as podcasts, even though these have proliferated in recent years and access is most often free.
Management and leadership
Respondents have developed leadership and management competency through MSc-level study and delegated responsibility at work. Regional and local service manager forums have not been prioritised. There were many active contributors on social media who are leaders in health service-related leadership, service transformation and management; however, most respondents had not accessed these resources, though those who had reported them as useful.
Future priorities
Future development in management competencies appears to require the use of local processes for mentorship in specific, locally-relevant management projects to support the learning from conferences and MSc-modules.
Education
The most useful opportunities have been practical experience of education, including patients and peers, with peer-reflection and support. These opportunities would appear to be supported by exposure to academic learning and knowledge though MSc modules. Despite these, respondents did not describe themselves as having had an education role, either in local or regional clinical forums or in multi-disciplinary teams.
Future priorities
Respondents want to be able to access specific MSc-modules to support their ability to deliver education, as well as gain access to local mentorship and training for developing educational skills.
Research
As with other pillars, respondents have gained most from a mix of MSc study and local experience, which has allowed them to put audit and service evaluation skills into practice. This cohort of respondents had minimal exposure to research-active workplaces, whether secondary, community or primary care providers; for example, the Council for Allied Health Professions Research (CAHPR) have offered minimal access to training and respondents have rarely taken any completed audits or quality improvement projects to peer-review publications, beyond local dissemination.
Future priorities
Respondents mainly identify MSc modules as the key approach to develop research competency, but also identify the need for local training from employers, training hubs and exposure to research active departments.
Discussion
This survey was conducted in an integrated care system in the southwest of the UK. The respondents were aspirant, trainee or qualified ACPs from organisations representing acute-sector NHS organisations, community providers, primary care and the charity sector.
This survey demonstrates that respondents recognise their skills have been developed through a blended approach of academic development in MSc-modules, then embedded in real-world experience. Their real-world experiences have been supported by peers and mentors within their clinical environment.
This survey particularly aimed to explore how clinicians viewed their future training needs for developing and maintaining competency across all four pillars of advanced practice. The summary presented in Table 2 is a summary of the 10 most prioritised development opportunities. It has been coded into the type of development identified.
Table 2. Summary of the 10 Most Prioritised Development Opportunities
| Research | Education | Management | Clinical |
|---|---|---|---|
| Experience of designing and implementing service evaluation and/or auditc | Selected modules within full MSc course e.g. self-funded, employer-funded or apprentice route | Selected management and leadership themes at professional conferencesd | Identification of, and time with, a clinical mentore |
| Selected modules as part of MSc study e.g. self-funded or employer-fundeda | Selected modules as part of MSc study e.g. self-funded or employer funded | Selected modules as part of MSc study e.g. self-funded or employer-funded | Modular approach to MSc study e.g. self-funded or employer-funded |
| Selected modules within full MSc course e.g. self-funded, employer-funded or apprentice route | Experience of educational roles and responsibilities: students, new graduates, clinical placement coordinatorc | Training and support provided by local line managersb | Speciality-specific conferencesd |
| Select research themes at professional conferencesd | Located appropriate mentor, either within or outside employer organisatione | Locate an appropriate mentor, either within or outside employer organisatione | Peer observation (observing or being observed, with critical discussion afterwards)f |
| Experience of quality improvement cycles (PDSA, QI, SPC approaches)c | Training and support provided by local line managers and colleaguesb | Training provided by employerb | Training provided by local clinical teamb |
| Research training provided by employerb | Select education themes sessions at professional conferencesd | Training provided by regional training hubsb | Full MSc course e.g. self-funded, employer-funded or apprentice route |
| Experience of working in a research-active department (data collection for grant funded studies and submission to peer-review)c | Training provided by regional training hubsb | Selected modules within full MSc course e.g. self-funded, employer-funded or apprentice route | Training provided by regional training hubsb |
| Research training provided by regional training hubsb | Training provided by employerb | Experience of delegated management roles and responsibilitiesc | Access to, and critical appraisal of, research papers |
| Research training via CAHPR, Nursing Research Council or equivalent | Peer observation: patient education (observing or being observed, with critical discussion afterwards)f | Peer observation (observing or being observed, with critical discussion afterwards)f | Training provided by employerb |
| Research training and support provided by local line managers and colleaguesb | Peer observation: clinician education (observing or being observed, with critical discussion afterwards)f | Time for reflection (e.g. writing critical event analysis)g | Time for reflection (e.g. writing critical event analysis)g |
MSc courses;
blocal training through employer or TH;
cexperiential, on the job, learning;
dattending conferences;
ementorship;
fpeer observation;
greflection
CAHPR, Council of allied health professions research; PDSA, Plan Do Study Act; QI, Quality Improvement; SPC, statistical process control
Accessing and funding MSc programmes
Advanced practice roles require MSc-level training, yet roles advertised with ‘advanced’ in the title continue to use person-specifications that do not require MSc-level training as ‘essential’. A key aim for developing the multi-professional framework for advanced practice and specific clinical credentials (HEE, 2020b; 2021) was to ensure consistent level of capability and expertise across roles in different providers and different clinical settings.
The value of MSc-learning is clearly valued and rated by respondents. There is variation in how clinicians can access such academic training. The most structured route would be an MSc in advanced practice completed as part of a level-7 apprenticeship, which is accessible to many employing organisations (HEE, 2022b). This route requires strategic planning to:
- Demonstrate how services will evolve with the provision of ACP roles
- Ensure salary funding to promoted trainee ACPs (often paid at AfC band 7) to qualified ACP graduates (paid at AfC band 8a)
- Capacity within the service to release trainee ACP apprentices away from clinical role for protected learning time.
Other options, such as providers funding MSc-modules from CPD budgets, or clinicians self-funding modules as their career develops, are less structured; clinicians risk selecting modules that do not contribute to MSc advanced practice programmes. It is crucial that universities give constructive advice regarding the requirements for their ACP MSc programmes to reduce this risk.
The ACP MSc landscape is developing as new modules and MSc programmes are ratified by HEE; it would be beneficial to clinicians and service managers for integrated care system apprenticeship leads to maintain flowcharts and guides to MSc courses. Employer leads for education strategy need to market the funded apprenticeship routes and provide support to service managers who are considering the process for application, as well as help to establish these roles.
Local training remains critical
Respondents continue to identify local training—local team, employer-provided and primary care training hubs—as critical to development across all four ACP pillars. Who provides this local training will depend on the clinical context of the respondent. An ACP physiotherapist is likely to have peer-support within the team of other physiotherapists, an ACP nurse in A&E may have access to support from allied health professionals (AHPs) and medical colleagues up to consultant level, while an ACP Paramedic in primary care may have support from GPs and the wider primary care multi-disciplinary team. How well trained are these colleagues at delivering education, clinical training and mentorship? Some of the clinicians listed above will have had training in training (accredited GP trainer for example), though such training is not universal. As advanced practice roles develop, there is an expectation that these ACPs will become the mentors of future trainee-ACPs (HEE, 2020d).
While respondents had developed their educational skills mainly though experience in roles with students and new graduates, they were prioritising more academic options for furthering their skills. Clinical undergraduate courses (nursing, midwifery and AHP professions) do not routinely include training in how to teach—this skill is perhaps assumed to be absorbed through experience. University support for undergraduate student mentoring will focus on supporting the students who are excelling or struggling, but not the principles of education themselves. Skills in education delivery are important for both the senior clinicians who mentor ACPs (as noted earlier), as well as for the ACP clinicians who are in the position of educating those who aspire to ACP roles in the future and new graduate clinicians. Accredited MSc advanced practice programme curricula are designed to support clinicians in developing these educational skills.
Primary care training hub training events are primarily advertised to clinicians in primary care and are clinically focussed, with occasional management and leadership short courses available. The training hub resource is not targeted at clinicians in community or acute sector organisations, though access might be possible with local negotiation. As primary care increases the use of ACP roles through the Additional Role Reimbursement Scheme (ARRS) in the next few years, it will be important to monitor how training hubs are able to support these clinicians.
In the context of the ACP research pillar, ‘research’ includes audit, service evaluation or quality improvement projects. Outside from Acute NHS Hospital Trusts, employer-provided training in research skills is sparse.
While the Council for AHP Research (CAHPR) has hosted free research training events, a review of CAHPR activities by Cooke et al (2021) highlighted that much of their work is not visible to the wider clinical workforce and suggested a communication strategy to improve this. Due to its immediacy and accessibility, social media communication, such as Twitter, has often overtaken traditional routes such as professional journals.
Organisations such as CAHPR are present on Twitter (https://twitter.com/CAHPRsouthwest), as are many other national and international clinicians, researchers and academics who would be relevant to advanced practitioners. Respondents did not rate social media platforms as particularly useful for competency development. This may reflect clinician uncertainty of how to curate social media feeds to ensure quality information, as well as how to present themselves professionally on social media (Hughes, 2020).
Experiential learning opportunities
While training courses are vital, respondents clearly valued the opportunity to put theory into practice. The selection of service evaluation and quality improvement experience in the research pillar reflects that nearly 50% of respondents are from community providers, where active research projects are less common than in the acute sector or primary care (depending on the primary care network).
Having non-clinical projects delegated as part of a yearly professional development review process is common practice. These results highlight this is good practice, which needs to be joined up alongside appropriate training in non-clinical aspects (see previous section) and also appropriately supported for success.
Peer support and mentoring
While the survey did not define the difference between peer-support and mentoring, respondents would appear to have made a distinction.
The authors would define peer-support as informal and ad-hoc, which may include discussing a clinical case with a team colleague, a debrief following a clinical incident or situation, or giving feedback on a piece of academic work.
In contrast, mentorship is a planned and established relationship, where a mentor is more likely to be trained in providing constructive critical feedback (trusted criticism) and probing for self-evaluation and realisation, than a peer (Burgess et al, 2018).
The HEE workplace supervision for advanced clinical practice (HEE, 2020d) describes the supervision requirements for ACP roles, which can be used for both peer-review and mentorship roles.
The report describes the need for ACPs to access both cross-professional and cross-organisational support, as these roles are working at the limit and scope of professional practice. It may be that the ACP development need (in research skills for example) cannot be met within their team or their organisation, but that mentorship could be provided from another organisation in the ICS.
In practice, this could be primary care GPs providing mentorship to ACP paramedics and physiotherapists to ensure serious pathology or non-musculoskeletal causes are considered. Conversely, this could also include ACP physiotherapists providing mentorship back to GPs to upskill their assessment and management of musculoskeletal conditions.
There are local situations where a lack of mentorship has been detrimental to staff wellbeing and retention. A local service staffed by experienced ACPs, based in the acute sector had good team peer-support, with informal support to each other through shifts and with WhatsApp groups, but did not have established mentorship process to support these ACP roles. This contributed to lack of staff retention and satisfaction with the roles, such that the service could no longer be supported.
Mentorship arrangements appear to be a crucial consideration when planning to develop services and use ACP roles. Local acute providers who are developing ACP roles in haematology and neo-natal intensive care teams have considered the necessary mentorship arrangements at the earliest stages of planning the business cases.
These services are taking a long-term (more than 5 years) view of staffing developments to scale up the number of qualified ACPs, who can then mentor future trainee-ACPs through their capability development.
Job planning is crucial
This survey has shown a range of opportunities are necessary to develop, and then maintain, capability as an ACP. MSc-modules, local training hub courses, mentorship meetings, clinical debriefs, local service audit or evaluations all take time; it is critical that ACP job plans reflect these needs. This need is all highlighted by guidance on ACP roles from the Royal College of Nursing (Royal College of Nursing, 2018), the Charted Society of Physiotherapy (Chartered Society of Physiotherapy, 2023) and Health Education England's Centre for Advancing Practice (HEE, 2020d).
Limitations
The respondents were primarily nurses and physiotherapists in acute and community providers, so these results may not translate directly to primary care roles.
The respondents all work in England and so potentially work within policies and procedures unique to England; this factor may limit the transferability of the results to other UK countries, or internationally. The survey respondents ranged from clinicians who are career-planning towards advanced practice, to those who are qualified. This included range will reduce the specificity of results for developmental needs of clinicians at specific career points along this continuum, but the authors feel this survey does incorporate the needs of the current and future ACP workforce as a whole.
Conclusions
Clinicians who aspire to ACP roles, ACPs in training and qualified ACPs, require a range of ongoing development opportunities across the four pillars of advanced practice. MSc-courses and modules are most prioritised and will be the only route to ACP qualification in the future, so it is critical that strategic use is made of financial support available for clinicians to access these programmes. Other development opportunities require consistent job planning for ACP roles to allow the clinicians access. Robust mentorship and opportunities for experiential learning, particularly in educational and research activity, must be supported.
KEY POINTS
- Aspirant to qualified advanced clinical practitioners (ACPs) have used a variety of resources to develop their capabilities in the four pillars of advanced practice
- Support for MSc routes were highly valued
- ACPs required support for developing research and education capabilities
- Mentorship was deemed critical across all pillars; this aspect needs considering at the earliest stages of business cases for developing advanced practice roles in teams.
CPD / Reflective Questions
- If you are an advanced clinical practitioner (ACP), how do you develop/maintain your capabilities, particularly outside of the clinical pillar?
- If you are a service manager/lead, how do you support your ACPs to develop capability across research and education pillar?
- Do you have cross-organisational networks when required?
- Do you support job plans to reflect development needs?