A multidisciplinary learning approach: training, preparation and role transition

A generic narrative review was undertaken in the first part of this discussion (Hulse, 2022), exploring the global development of advanced practice. The review concluded that there are vast global differences in advanced practice definition and roles, with a lack of standardised curriculum structure and limited literature surrounding advanced clinical practitioner (ACP), including advanced nurse practitioner (ANP), training preparation and role transition. The review did, however, highlight the importance of interprofessional education and interprofessional collaboration through teaching and clinical mentorship during and after training. With advanced clinical practice firmly embedded across multiple disciplines in health care, promotion of ongoing multidisciplinary collaborative working partnerships is central to improving healthcare services and to meet ongoing complex healthcare demands worldwide (Interprofessional Education Collaborative (IPEC), 2016; Health Education England (HEE), 2017).

There are a number of well-established learning theories and educational frameworks that relate to practitioner development of knowledge and skill acquisition. Benner's (1984) widely used novice-to-expert theory describes a five-stage learning journey and is arguably the best description of role transition for emerging novice ACP/ANPs (Lyneham et al, 2008). Benner's model applies the Dreyfus (1984) model of skill acquisition, which differentiates between ‘experienced’ and ‘novice nurse’. The Dreyfus (1984) model describes a five-stage process of the learning journey:

• Novice, where beginners have no experience
• Advanced beginner, where the novice demonstrates acquisition of knowledge and skill and applying them in context
• Competent, characterised by feelings of mastery and ability to cope and manage situations
• Proficient, where the performer perceives situations as a whole and has the ability to modify plans in response to events
• Finally, expert, where a high level of experience is apparent.

Application of these models to the ACP/ANP learning journey sees trainees embark on a programme of study with pre-existing knowledge base. However, arguably they are ‘novice’ learners to the ‘advanced’ knowledge and skills required for the job role.

Evidence-based frameworks have been developed to provide guidance, structure and processes to support the future generation of exemplary advanced clinical practice. Using these, this article aims to add to the body of educational research in this field through exploration of paediatric and neonatal trainee and qualified ACP learning experiences.

The study aimed to answer the following questions:

• Does ACP training adequately prepare trainees for clinical practice and role transition?
• What are the key elements that assist in successful role preparation and transition?
• How effective is a multidisciplinary learning approach in ACP training and how does this promote future collaborative working partnerships?
• How does the ACP role implement the ‘Four Pillars of Advanced Practice’ and how does this conform to the NHS vision and values of a shared leadership approach?

The author was keen to examine current delivery of advanced practice education and curriculum to evaluate its effectiveness in the learning process and its impact on shaping future collaborative multidisciplinary working partnerships.

Methodology

A cross-section mixed-methods design survey was developed to explore learner experiences of ANP/ACP training and role transition. Evaluation research methodologies and their application were examined through exploration of three specific advanced practice frameworks:

• Multi-professional Framework of Advanced Practice (HEE, 2017)
• Cheshire and Merseyside Governance Framework for Advanced Clinical Practice: Paediatrics and Neonates (Barnes et al, 2019a; 2019b)
• ‘PEPPA’ framework: Participatory, Evidence-Based, Patient-Focused Process for Advanced Nursing Practice (Bryant-Lukosius and DiCenso, 2004; Bryant-Lukosius et al, 2016).

Also considered was Kirkpatrick's four-level training evaluation model, developed in 1976 (Kirkpatrick and Kirkpatrick, 2006; Morgan et al, 2012).

PEPPA framework

The PEPPA framework, ‘Participatory, Evidence-Informed, Patient-Centred Process for ANP role development’, designed by Bryant-Lukosius and DiCenso (2004), aimed to guide the successful development, implementation and evaluation of ANP roles. An adaptation of two existing frameworks by Dunn and Nicklin (1995) and Spitzer (1978), the ultimate goal was to design and deliver an accessible, effective and efficient patient-centred healthcare system that meets the needs of patients through delivery of coordinated care and collaborative relationships among healthcare providers and systems (Bryant-Lukosius and DiCenso, 2004). Conceptually, the framework encourages the design of patient-centred care models, promoting effective human resource planning and successful role implementation. It promotes ANP role clarity and engages stakeholders early (Bryant-Lukosius et al, 2016). Initially developed in 2004, the framework was updated in 2016 to a three-stage evaluation framework matrix, incorporating role development, introduction, implementation and long-term sustainability. Since its introduction it has been widely used internationally, in at least 16 countries (Bryant-Lukosius et al, 2016).

Framework strengths include being health-oriented, patient-centred, comprehensive and addressing complexity of ANP roles. On a practical level, it offers an evidence-based valuable guide for the development and implementation of ANP roles in healthcare systems (Bryant-Lukosius and DiCenso, 2004; Bryant-Lukosius et al, 2016). However, challenges exist regarding its application, including lack of resources, lack of physician support, inability to assess data to determine ANP need, lack of evaluation expertise and frequent turnover of ANPs (Bryant-Lukosius and DiCenso, 2004).

Frameworks built around the ‘four pillars’ of advanced practice

As ACP roles emerged across the UK, a structured curriculum pathway and role identity was required. This led to the development of the HEE (2017) framework, which sets out clear capabilities of advanced clinical practice in England encompassing the ‘four pillars’ that underpin advanced practice:

• Clinical practice
• Leadership and management
• Education
• Research.

It aligns curriculum, role, expectations and responsibilities, enabling standardisation in advanced clinical practice in England and is echoed in subsequent advanced practice policy across the UK (HEE, 2017). Building on this, Barnes et al (2019a; 2019b) introduced the ‘Cheshire and Merseyside Governance Framework for Advanced Clinical Practice: Paediatrics and Neonates’. Incorporating minor additions to the original HEE (2017) framework capabilities, it reflects the unique developmental components and family-centred focus that are fundamental to advanced practice care of neonates, infants, children, young people and their families/carers (Barnes et al, 2019a; 2019b).

Clinical

Within the clinical pillar, ACPs are expected to comply with their relevant code of professional conduct providing evidence of their underpinning knowledge, competence, capabilities, skills and behaviours relevant to their role setting and scope (HEE, 2017; Barnes et al, 2019a; 2019b). Working in collaboration with other healthcare disciplines, ANPs/ACPs are responsible and accountable for their decisions, acts and omissions and must demonstrate a critical understanding of their level of responsibility and autonomy while working within their limits of competence (Royal College of Nursing (RCN), 2018).

Leadership and management

As clinical leaders in health care, ANPs/ACPs must engage in team leadership, lead new practice and service redesign, and work across boundaries to continually develop practice in response to changing health needs (HEE, 2017; Barnes et al, 2019a; 2019b). They must act as role models promoting organisational and NHS values, inspiring a vision and leading change to improve services and enhance quality and safety.

Education

The education and leadership pillars of advanced practice interlink. The ACP frameworks outline that in order to lead and develop care and services, ANPs/ACPs must engage in self-directed learning and critical reflection to maximise clinical skills and knowledge. They must work collaboratively with others to support health literacy and empower individuals to make decisions regarding care. They must advocate and contribute to a culture of organisational learning, inspiring others in learning, supporting the NHS vision and values (NHS Leadership Academy, 2011; Storey and Holti, 2013). They must facilitate work-based and interprofessional learning, and act as role models, educators, supervisors, coaches and mentors, seeking to support and develop others (HEE, 2017; Barnes et al, 2019a; 2019b).

Research

ANPs/ACPs are key to contributing to and developing an evidence base for clinical interventions, which drive quality improvement and contribute to the research and leadership pillars. A sound research knowledge base and understanding of how to contribute to the corpus of research in health care is essential.

Kirkpatrick's training evaluation model

Based on his earlier work stemming from 1959, Kirkpatrick's, model, developed in 1976, is one of the most popular models for analysing and evaluating education programmes used by organisations (Bates, 2004; Kirkpatrick and Kirkpatrick, 2006). Its overwhelming popularity relates to its simplicity, flexibility and its systematic approach to evaluation with attainment of effective results (Wang, 2011). This model was chosen over other popular training models such as that by Kolb (1984) as it identifies the setting of clear training outcomes and objectives, with emphasis placed on a multi-evaluation approach to assess and evaluate the effectiveness of learning. As opposed to Kolb's (1984) four-stage ‘experiential learning cycle’ where the basis of the model is reflection of learner experience, which is then reviewed, analysed and evaluated systematically in stages, the Kirkpatrick Training Evaluation Model (Kirkpatrick and Kirkpatrick, 2006) places emphasis on both evaluation of learning and subsequent transfer of this learning. It consists of four outcome levels:

• Level 1. Reaction: the extent to which participants react favourably to the learning event
• Level 2. Learning: the extent to which participants acquire the knowledge, skills and attitudes based on their participation in a learning event(s)
• Level 3. Behaviour: the extent to which participants apply what they learn during training when they are back in practice
• Level 4. Results: an assessment of the extent to which a targeted outcome occurs, following the learning event(s) and subsequent reinforcement.

The Kirkpatrick model offers an in-depth multi-method evaluative process illustrating a truly effective evaluative approach. The distinction between levels 2 and 3 in particular (learning and behaviour) highlights the importance of the learning transfer process, illustrating the true effectiveness of learning.

The model highlights the process of evaluation in effective learning and the importance of transfer of learning into practice (Kirkpatrick and Kirkpatrick, 2006). Application of levels 1, 2 and 3 are demonstrated in the literature review and the mixed method data set. Kirkpatrick and Kirkpatrick (2006) highlighted level 4 as probably the most valuable level, contributing to organisational success, often determined by financial measurement (Bates, 2004). Applying this to ANP/ACP implementation, the cost of role implementation has significant financial impact; however, this is weighed against the documented benefits of streamlined patient care, reduced hospital stay and admissions, improved patient care, patient experience and overall improvement in healthcare systems (Woo et al, 2017). Furthermore, global development and implementation of ANP/ACP roles illustrate their necessity in growing complex healthcare systems.

Despite its widespread popularity, model analysis in the literature highlights limitations. Bates (2004) identified three main limitations: incompleteness of the model, assumption of causality, and simplification of the tool, ie not considering individual or contextual influences and organisational factors such as conducive environment, training tools and resources. Despite these limitations, it offers an in-depth multi-method evaluative process illustrating a truly effective evaluative approach. The distinction between levels two and three in particular (learning and behaviour) highlight the importance of the learning transfer process illustrating the true effectiveness of learning.

Sampling

Data were sought from trainee and qualified advanced paediatric nurse practitioners (APNPs), advanced neonatal nurse practitioners (ANNP) and paediatric ACPs/ANPs.

Convenience sampling was used to invite participants from two groups:

• Group 1: Final year paediatric APNP/ANNP/ACP/ANPs trainees at a local university; total number of students (n=29)
• Group 2: Trainee and qualified APNPs/ANNPs/paediatric ACPs/ANPs in a closed social network group providing support/education for paediatric ANPs/ACPs; total number of participants (n=435).

The total sample size was 465 possible participants: group 1 (n=29) and group 2 (n=435).

Inclusion and exclusion criteria

Paediatric ACPs/ANPs were included in the study and adult ACPs/ANPs were excluded.

Method

The frameworks enabled content validity and reference to be established. They were chosen due to their relevance to advanced practice, popularity and effectiveness in evaluation of education and training. Furthermore, each framework yields valuable evaluative evidence that is complementary to the others.

The rationale for the data collection method chosen was its relevance to this study in order to reach the desired target population and ease of distribution across a national network. Further benefits include low cost, convenience, design flexibility and distribution time; however, major potential weaknesses include, perception of junk mail, impersonal and low response rate (Evans and Mathur, 2005).

Due to the limited studies of similar nature, there were no existing survey tools that could be applied. Therefore, the author designed the survey to accommodate the specifics of this study. The survey was designed using an online survey tool (Jisc Online Surveys Tool), with a mixture of closed and open-ended questions with additional areas for further comments. Closed-ended questions were scored on a Likert scale allowing production of numerical data. An open survey approach was applied to obtain qualitative data of participant learning experiences.

A pre-test pilot undertaken by two qualified ANPs checked validity prior to distribution, allowing removal of any questions that did not yield relevant data, provided opportunity for clarification, indicated completion time and enabled feedback on presentation, layout and user ease. This process is recommended in research literature to add rigour to the data collection method (Bell and Waters, 2014; Korstjens and Moser, 2018).

The survey has 15 questions with 30 sub-questions. There were six main categories: demographics, previous training experience, training content, assessment and preparation, clinical support, supervision and mentorship, collaborative multidisciplinary learning and role preparation and transition.

The survey was distributed electronically: first, via email sent by the course tutor to the trainee cohort group (group 1) and, second, via a post on a closed ANP/ACP social network support group (group 2). This ensured complete anonymity, confidentiality and voluntary participation, leading to reliability and thus, quality in the data collection method. The cross-sectional design produces a ‘snap-shot’ of the population at one point in time and offers a representative sample of this particular population (Cohen et al, 2011). However, findings may not be reproducible with another similar sample as findings are based on individual experience. Moreover, the convenience sampling does not represent any group apart from itself and therefore findings are not generalisable for the wider population (Cohen et al, 2011).

Ethical considerations

The study was approved by the university's Research Ethics Committee and is aligned with the British Educational Research Association (2018) Ethical Guidelines for Educational Research Framework. Data were collected from health professionals only with NHS ethical approval not required. Participant confidentiality was maintained. Data protection principles were followed in accordance with the Data Protection Act 2018 and the General Data Protection Regulation (GDPR). Completed surveys were contained within the online Jisc survey tool platform and stored on a university password-protected computer.

Informed consent was obtained for voluntary participation with right to withdraw not possible after survey submission as responses remain anonymous, leading to inability to retrieve data. Anonymity and confidentiality were maintained throughout the data collection process. Care was also taken to remove researcher bias, aiming to improve reliability and validity of the study. Reflexivity is demonstrated in the researcher being aware of their own role in the research process (Korstjens and Moser, 2018). The author was part of the trainee cohort group. Hanson (2013) and Moore (2012) both described this pre-existing relationship as ‘insider research’, where the research is conducted within communities of which the researcher is a member. In this instance the author did not complete the survey and careful consideration was made not to lead participants during the questioning.

Data analysis

The survey incorporated a mixed-methods data set, with quantitative descriptive data presented using numbers and percentages and narrative, qualitative data thematically analysed. Thematic analysis was deemed appropriate for the data collection method due to its flexibility with analysis guided by the Braun and Clarke (2006) step-by-step guide to thematic analysis.

Findings and discussion

A response rate of 73% (21/29) in group 1 highlighted a representative sample of trainee ANPs/ACPs. However, the group 2 (ACP social network group) response rate was extremely poor (4%, n=18/435), with an overall combined low response rate of 8% (39/465 completed surveys). It could be argued this low response rate was related to the timing of survey distribution coinciding with a global pandemic, leading to increased workload for the target population. However, the data illustrate experiences of both trainee and qualified participants across differing paediatric and neonatal healthcare advanced practice roles.

Section 1: Demographics and relevance of training / Identified need for role

A total of 39 completed surveys were submitted:

• Group 1: 21 trainee ANP/ACPs: 4 ANNPs, 17 APNPs, including 1 paramedic (final-year training on MSc advanced neonatal and paediatric clinical practice)
• Group 2: 18 qualified ANPs/ACPs with post-qualification (MSc in advanced paediatric clinical practice) experience ranging from <1 year to >10 years, majority split between <1 year (7) and 5-10 years (6).

Respondent clinical areas included: neonatal care, nurse-led hospice, day-case unit, critical care, general paediatric wards.

Aligned to the PEPPA framework (Bryant-Lukosius et al, 2016) and Kirkpatrick and Kirkpatrick (2006) level 1, findings highlighted that 79% (n=31) identified a need for the ANP/ACP role, with the remaining 21% (n=8) feeling that their role was not clearly defined.

Section 2: Previous training and experience

The majority of study participants had over 5 years' qualified health professional experience (5-15 years). Of these, a total of 84% (n=33) had a previous academic learning at Level 6 or Level 7, indicating that most trainees had a significant underlying knowledge base before acceptance on ACP training, supporting the literature (Parker and Hill, 2017).

Section 3: Training content, assessment and preparation

Section 3 aligned to the three advanced practice frameworks and level 2 (Learning) in Kirkpatrick's evaluation framework (Kirkpatrick and Kirkpatrick, 2006; Bryant-Lukosius et al, 2016; HEE, 2017).

Clinical

Respondents were asked to use a 5-point Likert scale (1=not covered to 5=extensively covered) to indicate how well covered each of the following clinical elements were within the MSc programme (Table 1). Due to a study design fault that was not raised during the pre-test pilot phase, there is some over-representation and under-representation, with an overall response rate of 85%. This became evident when analysing the findings, with inconsistency revealed in response numbers. In some cases the responses are out of 39 and in others out of 40: the discrepancies are indicated in Table 1.

Overall, of the 20 identified learning topics, there was a generally positive consensus of adequate coverage in ACP training. In particular, ‘adequate’ to ‘extensive’ coverage in comprehensive history taking, paediatric clinical examination, paediatric diagnostics, management of neonatal and paediatric emergencies, management of acute illness, differential diagnosis, safety netting advice, pharmacology and multidisciplinary team (MDT) collaboration. Literature highlights 60-80% of diagnosis is derived from comprehensive history taking and that differential diagnosis plays a vital role in guiding patient assessment to consider a number of possible aetiologies of symptoms and disease management. With the addition of detailed, systematic clinical examination, a holistic approach to patient assessment and care can be initiated (Keifenheim et al, 2015; Jain, 2017). Furthermore, safety netting forms an important element of the consultation process and must be given to patients/parents/guardians after patient consultation and before discharge from hospital (Bertheloot et al, 2016). These essential elements together form the safe assessment, implementation and delivery of appropriate individualised care and safe discharge from hospital.

Internationally, prescribing forms a core component of advanced practice curriculum and is a fundamental part of the ANP/ACP role (HEE, 2017; Parker and Hill, 2017; Barnes et al, 2019a; 2019b). Findings were positive with a 78% consensus (n=31) that adequate (28%, n=11) or extensive (51%, n=20) content of pharmacology and prescribing is included within the programme.

Finally, multiprofessional collaboration is key to patient care and outcomes, to successful learning and to the building of multiprofessional partnerships and is emphasised as a key value in the NHS vision and values (NHS Leadership Academy, 2011; Storey and Holti, 2013). There was a consensus of 87% ‘moderate’ to ‘extensive’ coverage of MDT collaboration.

Despite these overall positive findings, there were some suggestions for areas where the curriculum requires strengthening. In particular, neonatal examination and diagnostics, mental health, nutrition and growth, chronic disease management and diagnostics including laboratory investigations and imaging. Perhaps the most notable area for improvement was that of diagnostics, interpretation and imaging. A large component of autonomous practice is the ability to appropriately order and interpret laboratory diagnostic tests, blood gas analysis and imaging as these play a vital role in the diagnosis and treatment management.

Overall, findings illustrate that all elements including laboratory diagnostics, arterial blood gas analysis, imaging (including X-ray, CT, MRI interpretation) infectious disease and microscopy were included within most advanced practice curricula, however, findings indicate moderate to adequate coverage of each element with greater need for more content reflected, particularly relating to laboratory diagnostics (n=5–16) and imaging (n=9–10). With an overall general consensus in all of these elements ranging from 54% to 61% ranking ‘none’ to ‘moderate’ content included (Table 1), these findings suggest a gap in practitioner knowledge and need for further curriculum content, which resonates with findings from the literature (Hart and Macnee, 2007).

Traditionally the ordering and interpreting of laboratory diagnostics and imaging would predominantly be part of the medical role. This is often a new skill and new knowledge that ANPs/ACPs need to acquire to deliver advanced healthcare practice (HEE, 2017; RCN, 2018; Barnes et al, 2019a; 2019b). It is therefore imperative that these become core elements of advanced practice curriculum. Ionising Radiation Medical Exposure Regulations (IRMER) e-learning, in partnership with the Institute of Physics and Engineering in Medicine and HEE should be completed by health professionals who work with patients undergoing ionising radiation medical exposure. In-house training may also be provided in some hospital trusts.

Clinical skills content included vascular access, intubation and resuscitation. Overall, responses were divided with an overall 50% consensus, and 13% (n=5) indicating more content was required. Depending on field of practice, clinical skill requirements will vary. With this in mind it is difficult to align skills training to individual needs, however, these findings suggest improvements could be made on the scope of clinical skills learning within ACP programmes. Furthermore, adequate learning opportunities and clinical supervision are essential for clinical skills acquisition. As illustrated by Illingworth et al (2013) a lack of practice teachers and mentors to support acquisition of advanced practice knowledge and skills leads to concerns regarding structure and organisation of advanced practice programmes.

Participants were asked to explain their learning experiences further. Using thematic analysis, responses were coded and grouped into themes. Four themes were identified: academic learning delivery, learning experience, clinical learning and more learning required. Excerpts from the data included: ‘very interesting course but very fast paced’, ‘the content in class was exceptional at times, but depended on the teacher’,‘excellent learning experience’, ‘more content [needed] regarding X-ray, CT and MRI as a base understanding’, ‘more content for practical skills’, ‘more on bloods and gases’.

Participant comments indicate a comprehensive programme with alignment to paediatric and neonatal advanced practice. However, the overall consensus is that the programme is fast-paced with vast learning content covered in a limited time frame. Similar findings were in the literature, with advanced practice programmes described as ‘overwhelming’ and a ‘rollercoaster’ of learning (Illingworth et al, 2013). Arguably, this makes consolidation of learning challenging. Furthermore, the diverse healthcare backgrounds and differing learning needs of ACP trainees makes adherence to these needs challenging.

Leadership and management

Study participants were asked to indicate using the 5-point Likert scale (1=not covered-5=extensively covered) content coverage in preparation for a leadership and management role within clinical and non-clinical capacity. Overall, there was a mixed response. The general consensus was that training provides an overarching approach to leadership and management, however, this is mainly directed to expectations within a clinical capacity with leadership and management elements evolving after qualification, with experience. This suggests a need for more training regarding expectations of leadership and management in a non-clinical capacity.

Research

Evidence-based practice is widely recognised as key to improving healthcare quality and patient outcomes (Chien, 2019). ANPs/ACPs must work collaboratively to identify gaps in research to promote change and innovation (HEE, 2017; Barnes et al, 2019a; 2019b). Participants were asked to illustrate their learning experience of how the programme has developed their knowledge and skills in the research process and helped prepare them for undertaking research in the future.

There was a general consensus of 87-89% adequate preparation during training in relation to understanding the research process. However, a need for further educational input regarding critical appraisal, dissemination of findings, ability to evaluate and audit one's own and others' research was indicated by 25% of the study population.

Education

For the final pillar, education, the aim was to gather participant learning experiences regarding ACP training and how this has helped prepare them for future learning and learning facilitation for others (Table 2).

There was an overwhelming positive response to the 6 statements (92-97%), emphasising the importance of managing one's own learning needs, highlighting the importance of ongoing self-directed learning and the facilitation of learning for others. As fundamental within the four pillars and linking closely with leadership, this preparation is essential for ANP/ACP roles (NHS Leadership Academy, 2011; Storey and Holti, 2013; HEE, 2017; Barnes et al, 2019a; 2019b).

Positively, a further question addressing a shared learning approach focusing on facilitation of learning for others illustrated that 36% (n=35) respondents participate in work-based teaching within the clinical environment, 32% (n=31) participate in the delivery of in-house teaching, 12% (n=12) deliver academic teaching, 14% (n=14) engage in public speaking, 3% (n=3) have published their own or collaborative research.

Assessment of learning was also addressed. A multimodal approach to assessment is used within the paediatric and neonatal advanced practice programme through academia and clinical practice. This approach proposes a fair assessment process, provides assessment of competence and adheres to multiple learning styles and needs (van der Vleuten and Schuwirth, 2005). With huge global variation evident in the literature, the introduction of advanced practice frameworks with clear role definition, curriculum guidance and robust assessment strategies are fundamental for academic achievement and fitness to practice (HEE, 2017; Barnes et al, 2019a; 2019b).

Overall, participant responses positively (95%, n=37/39) welcomed this multimodal approach. Despite these findings however, it was felt overall that curriculum standardisation across academic settings needs to prevail, with further guidance post qualification encompassing a standardised approach to ongoing learning and development. Moreover, following academic achievement further evidencing of clinical competence and continuous professional development is required (HEE, 2017; Barnes et al, 2019a; 2019b). This is arguably imperative given the current lack of registration and regulation of advanced clinical practice roles within the UK (King et al, 2017; Nadaf, 2018).

Section 4: Clinical supervision and mentorship

Section 4 was aligned to the HEE (2017) and Barnes et al (2019a; 2019b) advanced practice frameworks and level 2 (learning) of Kirkpatrick's evaluation of training framework.

As highlighted in the previous article (Hulse, 2022), clinical mentorship is crucial to ANP/ACP learning in order to link theory with practice, acquire relevant clinical knowledge and skills, and develop confidence and competence in order to reach the ultimate goal of becoming an independent, autonomous health professional (Morgan et al, 2012; HEE, 2017; Barnes et al, 2019a; 2019b). Programme requirements indicate that trainees must undertake 500 supervised clinical learning hours. Aligned with medical training, a wide breadth of clinical/specialist areas must be included (HEE, 2017; Barnes et al, 2019a; 2019b).

Overall, the findings identified mentorship from both ANP/ACP and medical supervisors (100% response rate, n=39/39), with 82-85% identifying that they had either an ANP mentor or both an ANP and medical mentors.

When asked to describe their experiences, responses indicated clinical mentorship as invaluable in the learning process. Key themes included guidance and supervision, support, relationship, feedback and learning experience.

Excerpts included: ‘very beneficial to have support of both ANP and medical mentor’, ‘peer support with other APNPs is very valuable’, ‘I had an excellent relationship with my mentor and gained a lot of experience’ and ‘learning from others within the role and medical staff is invaluable’.

Evident in the findings is the positive impact of having mentorship from both an ANP/ACP and medical practitioner. Both provide different types of mentorship and support relevant to the ANP/ACP role. The literature highlights advanced practice as upskilling existing nursing/clinical staff to undertake numerous ‘traditional’ medical roles (Gray, 2016; RCN, 2018). Therefore, medical mentorship is invaluable to the ANP/ACP learning process.

Section 5: Collaborative multidisciplinary learning

Section 5 explored participant learning experiences in relation to a collaborative multidisciplinary learning approach and how this approach has impacted learning and development. Study findings illustrate that almost all (97%, n=38) had a curriculum delivered by both academics and health professionals in multiple fields. The remaining one participant highlighted faculty delivery only. In addition, 90% (n=35) indicated that they worked clinically with other specialities during their training. These findings highlight a positive approach to advanced practice learning, with interprofessional education and interprofessional collaboration widely supported in the literature (World Health Organization, 2010; Green and Johnson, 2015; IPEC, 2016; Goldsberry, 2018). With a broad scope of knowledge and skills acquisition required, working across multiple disciplines during training is fundamental to the learning process, with 95% (n=37/39) highlighting a multidisciplinary learning approach has helped integrate the ACP role into healthcare practice.

Five key themes were identified: knowledge and skill development, supportive learning from others, relationship building/networking, understanding other MDT roles and experience. The themes knowledge and skill development (28%, n=9) and understanding other MDT roles (56% n=18) yielded the most responses, arguably illustrating the most beneficial factor in MDT learning experience.

Excerpts from the data include: ‘shared knowledge and skills, shared perspective’, ‘learn from others who may think in a different way’, ‘understanding roles, importance of collaborative working as a team’ and ‘gives a balanced learning experience’.

These findings illustrate the value of collaborative learning and working partnerships and support the foundations of healthcare leadership (NHS Leadership Academy, 2011; Storey and Holti, 2013). With emphasis on a shared learning approach, the development of advanced knowledge and skills promotes best evidence-based practice, enhances patient experience and assists in the streamlining of patient care provision, thus supporting the value and need for ANP/ACP role implementation as outlined in the literature (Bryant-Lukosius and DiCenso, 2004; HEE, 2017; Barnes et al, 2019a; 2019b; NHS England/NHS Improvement, 2019). Furthermore, it embeds the ANP/ACP role firmly within a modernised and complex healthcare system, with understanding of the role and acceptance fundamental to its success through the building of collaborative relationships and networking. For effective collaboration to be achieved, teamwork needs to be emphasised (IPEC, 2016). Working together, sharing knowledge, skills and expertise, ensures a comprehensive evidence-based approach to patient care in order to achieve the most effective treatment plan and best possible outcome.

Section 6: Role preparation and transition

Section 6 aimed to seek individual experiences of how training has prepared participants for practice, aligned to the advanced practice frameworks (Bryant-Lukosius et al, 2016; HEE, 2017; Barnes et al, 2019a; 2019b) and level 4 of Kirkpatrick's model (Kirkpatrick and Kirkpatrick, 2006) (Table 3).

Overall, findings highlight a positive general consensus of role preparation for transfer into clinical practice across all elements with the vast majority of participants agreeing (64-74%, n=25-29) or strongly agreeing (13-28%, n=5-11) to the statements (82-95% overall consensus). Further descriptions of how training prepared participants for role transition include, ‘made me a skilled practitioner and gave me clinical credibility’ and ‘more confident’. In contrast to Hart and Macnee (2007), these findings illustrate the importance of careful curriculum design in order to meet both academic and clinical requirements. This structured approach together with addressing learner needs helps to ensure adequate ANP/ACP role preparation and transition as supported in the HEE (2017) and Barnes et al (2019a; 2019b) ACP frameworks.

However, a small proportion of participants indicated ‘disagree’ (3–5%, n=1–2) in the elements of role transition and independence and autonomy and a further 5–13% (n=2-5) indicated a neutral response across all elements, suggesting need for improvements. Further descriptions include, ‘difficult to transition into a role where there is no ANP’ and ‘I will face continual challenge in transition as my trust has no specific plan for me’.

Participants were also asked to explain any challenges faced during or after ACP training. Of 18 responses, five key themes were identified: allocated ANP/ACP training time, role clarity, curriculum content/workload, role acceptance and self-vision.

Excerpts from the data included: ‘challenge of getting adequate study time from my trust’, ‘confusion re. role from colleagues’, ‘Intense workload in first year’, ‘staff opposing my role and development which delayed progression’ and ‘main challenge is imposter syndrome’.

These findings support the literature with the need for stakeholder and organisational involvement early to identify role necessity, role responsibilities and expectations (Illingworth et al, 2013; Robeano et al, 2019). This active participation helps to ensure support at an organisational level with regard to education provision and resources (Bryant-Lukosius et al, 2016). Moreover, it also resonates with global literature regarding role clarity and identity (Stasa et al, 2014; Casey et al, 2017).

Role acceptance of one's self and ability are essential in the transition process. ‘Imposter syndrome’, described here, is a psychological pattern where someone experiences self-doubt in their ability and fails to internalise their accomplishments, leading to the belief that they are not deserving of the position that they have achieved (Lake, 2015). These feelings mirror those of ‘transition shock’, described as ‘disorientating, confusing and doubt-ridden chaos’, often experienced in the early transition phase (Fitzpatrick and Gripshover, 2016:e419). In agreement with the literature, these findings highlight the importance of ongoing support and mentorship post qualification, particularly in the early phases of role transition (Robeano et al, 2019). Moreover, acceptance by others within the organisation also plays a crucial role in practitioner support and development (Hart and Macnee, 2007; Hill and Sawatzky, 2011; Robeano et al, 2019). Without acceptance across multiple disciplines, challenges are faced by trainees in relation to practitioner development and progression. This ignorance leads to trainees being disadvantaged in the learning journey and a negative learning experience, which may lead to negative feelings of accomplishment and poor staff retainment post qualification (Hill and Sawatzky, 2011; Illingworth et al, 2013; Parker and Hill, 2017).

Consolidation and transfer

Preceptorship period post qualification is identified in the literature as beneficial (Hart and Macnee, 2007; Robeano et al, 2019). This period may vary dependent on individual learning needs, competence and local requirements. Overall, findings illustrate trainees would find a preceptorship period post qualification beneficial with 93% consensus, supporting Hart and Macnee's (2007) idea of a fellowship post qualification.

Limitations

A major limitation of this study is the unfortunate timing in relation to the global pandemic, which led to a very low overall response rate. Convenience sampling could also be seen as a limitation, however, a dual view of both trainees and qualified ANPs/ACPs was sought and therefore is justifiable in recruitment selection. A representative sample from each group is presented. A further limitation is the cross-sectional study design and the inability to guarantee wide population representation (Cohen et al, 2011).

Conclusion and recommendations

Overall, the findings illustrate positive learning experiences of advanced practice training, concluding that current and previous training in the UK does adequately prepare trainees for practice.

The role of collaborative multidisciplinary teaching, learning and mentorship were identified as key elements in the learning process and role transition, and are consistent with the literature (Benner, 1984; Dreyfus, 2004; IPEC, 2016; HEE, 2017). This illustrates the benefits of collaborative learning partnerships and need for multidisciplinary teaching in advanced practice programmes, promoting educational leadership within healthcare settings and conforming to the NHS vision and values (NHS Leadership Academy, 2011; Storey and Holti, 2013). This multidisciplinary learning and interaction builds the foundation of future multidisciplinary relationships, promoting innovative change in traditional healthcare delivery to meet ongoing demands and enhance the quality and safety of healthcare services.

The introduction of the ‘four pillars of advanced practice’ in accredited programmes ensures the achievement of appropriate level of advanced practice through capabilities aligned to training and credentialing processes. Ongoing monitoring and evaluation of advanced practice roles is fundamental to demonstrating its impact on service function and effectiveness to enhance quality, outcomes, experience and safety of healthcare delivery (HEE, 2017; Barnes et al, 2019a; 2019b).

Overall, findings highlight extensive coverage of curriculum content in the field of advanced practice. However, this study highlights gaps in curriculum content, particularly image interpretation, laboratory diagnostics, clinical skills and mental health and recommends strengthening in these areas. The monitoring of multidisciplinary advanced practice roles across healthcare organisations to evaluate and assess its impact both locally and nationally on enhancement of efficiency and safety of healthcare services is also recommended.

KEY POINTS

• ACP roles enhance capacity and capability within healthcare services and healthcare delivery
• With ACP/ANP roles now embedded into healthcare services, appropriate education, supervision and mentorship are fundamental in assisting the preparation of trainees for clinical practice
• A collaborative multidisciplinary learning approach is invaluable to advance practice learning and role transition, with interprofessional education and collaboration widely supported in the literature
• Standardisation of ACP education and training, encompassing the four pillars of advanced practice, ensures fitness to practise, with the governance of advanced clinical practice roles vital to success

CPD reflective questions

• How widely accepted are ACP roles within your organisation and how is training for the roles supported in your clinical area?
• In your workplace, has the implementation of ACP roles promoted collaborative multidisciplinary working partnerships and how has this affected patient care?
• Consider whether has the implementation of ACP roles has helped to improve healthcare services within your organisation