As previously discussed in this series of articles on advanced practice, advanced clinical practitioners (ACPs) originate from a variety of health professional backgrounds. They may be nurses, paramedics or physiotherapists, to name a few, with many holding senior positions before becoming trainee ACPs (NHS Improvement and the Royal College of Emergency Medicine, 2018; Reynolds and Mortimore, 2021). According to Health Education England (HEE):
‘Health professionals working at the level of advanced clinical practice will exercise autonomy and decision making in a context of complexity, uncertainty and varying risk, holding accountability for decisions made.’
Therefore, having professional experience at senior level and being able to address the four pillars of advanced practice: clinical practice, leadership and management, education, and research (HEE, 2017) are prerequisites to becoming an ACP.
In 1984, Pat Benner devised a theoretical framework, based on the Dreyfus and Dreyfus (1980) model of stages of expertise, that assesses nursing competence and professional growth from novice, beginner, competent and proficient, through to expert status. Nearly 40 years on, Benner's From Novice to Expert model is still widely cited and utilised in current healthcare systems worldwide. It is commonly referred to during mentorship and leadership programmes and additionally employed as a teaching aid to student and registered nurses (Titzer et al, 2014; Davis and Maisano, 2016; Murphy and Mortimore, 2020). Incorporating the novice to expert model in health professionals' development, as recommended by Davis and Maisano (2016), allows:
‘… healthcare systems to build confident, capable leaders who increase staff retention and contribute to quality, safe patient care.’
In the early 1980s, it would have been difficult to predict the future transformation of nursing and healthcare systems when Benner published From Novice to Expert (1984). Therefore, in the authors' view, new roles that previously did not exist, such as ACPs and nurse consultants, have not only clearly reached ‘expert’ status, but transcend beyond this point.
This article reflects on Benner's novice to expert theory and propose that her model, when discussing the attributes of the ‘expert’, should be amended to reflect the advanced levels of clinical expertise in a 21st century NHS (Figure 1).
Figure 1. The Derby model: 7 levels of practice advancement
Increased scope of practice
Since the conception of the NHS in 1948, the following decades witnessed the health needs of the nation becoming progressively complex, owing to an increasingly ageing population. In relation to this, it has been suggested that health professionals may require greater development in generalist skills, because many adult patients present with two or more comorbidities (Barnett et al, 2012; Department of Health (DH), 2012; NHS England and NHS Improvement, 2019). Doctors, nurses and professionals allied to medicine, both in primary and secondary care, have been required to adapt to meet these needs. These challenges were outlined in NHS England's Five Year Forward View (2014) and NHS England's Next Steps on the Five Year Forward View (2017).
Since the 1980s, when Benner wrote From Novice to Expert, nurses and other health professionals have been able to develop their level of practice through the extension of clinical skills and competencies, previously the domain of doctors (Castledine, 1995). Consequently, the scope of practice was extended for nurses and health professionals allied to medicine to encompass these changes (United Kingdom Central Council (UKCC), 1992; Health and Care Professions Council (HCPC), 2013; HCPC, 2014; College of Paramedics, 2015). In 1994, the UKCC defined higher level practice for nurses (UKCC, 1994), which interestingly was criticised by Castledine (2002), who recognised that advanced practice should already be acknowledged as higher level practice, and which more recently was expanded to encompass professionals allied to medicine (HEE, 2017).
Over the past 40 years, the NHS has witnessed the advent of new roles such as nurse specialists, nurse practitioners and ACPs, and the development of nurse consultant posts, the latter two requiring the additional academic attainment of a master's degree (HEE, 2017). This academic attainment is further supported by the International Council of Nurses (ICN), which in 2020 released guidelines on advanced practice nursing and recommended, in addition to a master's level of study, that a nurse ACP must have an expert knowledge base with complex decision-making skills and competencies (ICN, 2020). For example, ACPs review their own patient caseload, organise diagnostic tests and investigations, interpret the findings and, based on these findings, diagnose. Furthermore, they can undertake minor surgical procedures: suture, take blood, insert intravenous cannulas, intubate, extubate and prescribe medications.
Although such capabilities require advanced skills and knowledge, Benner (1984) acknowledged that as nurses gain experience they would progress through the levels of her theoretical framework, but not all would reach expert status. This is further supported within the literature by Ericsson et al (2007) and Christensen and Hewitt-Taylor (2006), who noted that not all experienced nurses were experts. Bobay (2004) postulated that an important element of nursing expertise was complex reflexive thinking, also known as critical thinking, and clinical decision-making (HEE, 2017) and that not everyone can ascend to the level of expertise recognised by Benner (1984). Moreover, as argued by Brykczynski (2010), expertise is situational, suggesting that not all nurses are experts in every situation and that experience in similar clinical situations is what separates the levels of skill acquisition.
Benner (1982) suggested that repeated, numerous and practical experiences, which accrue over time, help develop knowledge. The additional application of theory offers a guide that helps enhance questioning, via which practice can be adapted, but Benner insisted that clinical practice will always be the reality and is frequently more complex than theory could ever hope to be (Benner, 1982). However, with the need for the ACP to demonstrate the ability to practise autonomous decision-making in complex and unpredictable situations (HEE, 2017), a mixture of supervised advanced clinical practice and master's-level study should help address the points made by Benner (1982) and support development beyond the level of expert.
As the NHS evolved, with the development of advanced roles, so too have the experts. According to Benner:
‘The expert performer no longer relies on analytic principle (rule, guideline, maxim) to connect her or his understanding of the situation to an appropriate action. The expert … now has an intuitive grasp of each situation and zeroes in on the accurate region of the problem without wasteful consideration of a large range of unfruitful, alternate diagnoses and solutions.’
Senior ACPs have clearly attained Benner's expert level but, in many instances, their knowledge and skills have surpassed this. ACPs are now involved in every aspect of the NHS from preconception to death, and are role models for the wider health team. Therefore, it is not entirely surprising that the number of advanced nurse practitioners (ANPs) within primary care rose by 8% between September 2017 and September 2018, to 3305 (full time equivalent) (Buchan et al, 2019:20).
However, despite the growth of advanced clinical practice, it could be argued that some senior ACPs have reached expert status in several, but not all, of the four pillars of advanced practice (HEE, 2017). The varying levels of attainment in each pillar is dependent on the ACP's previous background profession, scope of practice and their current role within the workplace (HEE, 2017). Therefore, not necessarily reaching expert status in all four pillars, for example the research pillar, does not interfere with their expert clinical ability. However, some ACPs can attain expert status in all four pillars, and the authors would further argue that some surpass this expert level by not only having an intuitive grasp of the situation, but by also being able to see gaps in knowledge and/or care.
Many ACPs undertake audit to address shortfalls in care, helping to improve service provision and therefore the standard of care offered to patients. Indeed, Glendinning and Walker (2019) referred to the consistency provided to patient care through the provision of teamwork, leadership, and assistance with workload, concluding that the ACP was a great asset and helped support healthcare transformation.
Although it appears that there is scope for the development and progression of the ACP, some of the four pillars of advanced practice remain underdeveloped. It is true that there are opportunities for the ACP to contribute to research and innovation within clinical practice and patient care. This is possible because the ACP is often engaged in the real world and, through observation of current practice, can act as a catalyst for identifying research questions that emerge from phenomena (Lambert and Housden, 2017). However, there are challenges to such ambition, because research does not feature strongly in ANPs' daily working practice.
According to Ryder et al (2019), audit is often the closest an ACP can achieve to participation in the analysis of particular occurrences.
The authors suggest that audit provides results quickly, which is of value to organisations and, although this is not insignificant, encouraging and providing support to engage in primary research is less apparent. Ryder et al (2019) proposed that nurses within academia could play a valuable part in providing ACPs with the skills and encouragement to lead and publish research. If such collaboration between clinical practice and academia could be cultivated, then it is possible that we could see greater development of advanced clinical practitioners as indicated in the Derby model (Figure 1); however, this topic area requires further exploration. ACPs are not alone in championing transformation opportunities within healthcare practice. Indeed, a further example of a health professional who has surpassed expert status is the nurse consultant.
Nurse consultants, consultant practitioners and ACP progression
Nurse consultants were introduced to the NHS in 1998, offering a career pathway for experienced and expert nurses who wished to remain in clinical practice. The expectation was that nurse consultant roles would focus on autonomy with strong leadership skills, provide expert practice and care to patients, contribute to education and training and form links with education providers (Kennedy et al, 2012).
In 2014, Welsh guidance was published for higher education institutions (HEIs) and NHS organisations regarding consultant practitioner posts that encompassed paramedics, nurses, midwives occupational therapists and physiotherapists, to name a few, stating that such roles would assist in improving health care and service outcomes for patients, whether in primary or secondary care (NHS Wales, 2014). Within the guidance there was an expectation that such roles would offer an expert level of knowledge, skill, clinical practice, and the ability to think strategically.
Nurse consultants were to contribute to audit and research (DH, 1999). However, in contrast, a later report published in 2014 acknowledged that, due to changing political priorities, NHS staff shortages and increased targets, undertaking research was problematic for consultant practitioners (Dyson et al, 2014). These are the types of challenges that face all advanced level practitioners; to be afforded the time, support and opportunity to undertake research and audit to attain the additional advanced expert and international influencer advancement levels as indicated within the Derby Model (Figure 1).
The Derby Model: 7 levels of practice advancement
The Derby Model: 7 Levels of Practice Advancement (Figure 1) is the result of work undertaken as part of a PhD by one of the authors of this article. In relation to this model, which is based on Benner's From Novice to Expert theoretical framework, (1984), there are seven levels instead of Benner's five. The latter two levels of achievement, ‘advanced expert’ and ‘international influencer’ would have been difficult for Benner to predict for nurses in the early 1980s, which is why it is suggested by the authors that the Derby Model, focusing on the expert stage and beyond, should be modified to encompass these changes.
The Derby Model clearly maps out two additional levels of expert, reflecting how ACP- and consultant-level practice can contribute to evidence-based medicine and care, and create an opportunity to rapidly transcend the level of ‘expert’. This progression to an ‘advanced expert’ creates the potential to not only intuitively comprehend and solve complex situations, but to also see gaps in knowledge and care, influence policy and inspire national and international change to address such shortfalls.
It is anticipated that the Derby Model, which suggests what is achievable, will motivate ACPs, consultant-level practitioners, nurses and allied health professionals to attain levels of advancement that several decades ago were inaccessible for many, especially within the UK. The purpose of this model is to identify how the ACP can progress further than the expert they clearly are and what this progression means. This may help address the point made by Lawler et al (2020) that career advancement for ACPs needs to be communicated and its possibilities made transparent, acknowledging not only the significance of clinical knowledge and skill development, but also the value of research, education and leadership. This requires a collaborative relationship with HEIs, ACPs and their employers.
Conclusion
The Derby Model offers just such scope for attaining the abilities discussed in this article and visualises the possibilities for some ACPs and nurse consultants. By identifying these opportunities, the research, education and leadership pillars associated with advanced clinical practice (HEE, 2017) are realised. In addition, the requirements for ACPs and consultant-level practitioners to meet their original remit to support the expansion of research and education through their advanced expert leadership (Kennedy et al, 2012) will serve to improve patient care and services for all.
KEY POINTS
- The nursing profession has developed since Benner's From Novice to Expert theory (1984), with roles including advanced clinical practitioners (ACPs) and nurse consultants
- This article discusses Benner's theory and applies it to ACPs practising in 21st century healthcare environments
- This article introduces the Derby Model of Practice Advancement
CPD reflective questions
- Is there an area within your clinical practice or service delivery that you could improve? If so, how?
- Which part of the Derby Model of Practice Advancement reflects your current level of practice and where on the ladder do you think you will be in 3 years', 7 years' and 10 years' time?
- What can you do to advance on the Derby model ladder?
- What are the challenges that may affect your ability to advance?