The ascent to advanced practice: challenges, support and opportunities

The advent of advanced practice

Advanced clinical practice has been primarily influenced and shaped by service need and has faced, and continues to face, several challenges during its development. To meet the growing demand for timely access to health care in the UK, the nursing profession has become a focus of attention for the development of advanced clinical practice, because it is one of the largest professional groups in the NHS (The King's Fund, 2020). Although the journey continues, there have been professional developments and studies that have helped to shape the progress of advanced nursing and continue to do so.

In 1987 Stilwell et al examined the impact of a specially trained nurse on patient consultations and outcomes. They suggested that nurses who were able to practise with greater autonomy could provide a wider clinical service to patients. However, despite such advantages, the evolution of advanced nursing practice remained a complex journey, fraught with misinterpretation, lacking clarity and challenged by those who believed that nursing could be undermined by the advent of advanced nurse practice (Barton and Allan, 2015).

The expansion of nursing skills and knowledge continued with the introduction of The Scope of Professional Practice by the then governing body of nursing, the United Kingdom Central Council (UKCC) (1992). It allowed nursing to develop skills seen as ‘advanced’, which were often aligned to those procedures traditionally performed by doctors. This enabled care to be delivered swiftly to an increasing number of patients with growing complex needs. The UKCC believed acknowledgement of the terms used to define enhanced skills needed recognition. This resulted in the production of the Standards for Specialist Education and Practice (UKCC, 1994), which outlined higher-level practice. However, this document clearly stipulated that the standards did not relate to advanced practice. Castledine (2002) was critical of this suggestion, pointing out that advanced practice was indeed higher-level practice and should be accepted as such.

Other noted influential developments included the European Working Time Directive, which restricted junior doctors' hours (Health and Safety Executive, 2003) and The NHS Plan (Department of Health (DH) (2000), both of which affected service provision and helped enhance the development of advanced clinical practice. The emergence of non-medical prescribing allowed independent prescribing via the Standards of Proficiency for Nurse and Midwife Prescribers (Nursing and Midwifery Council, 2006), which was an additional opportunity to move towards achieving greater autonomous practice.

Clarifying advanced practice and developing opportunities

The growing requirement for access to health care by the population and the subsequent growth in the number of ACPs to support service provision only heightened the debate on what ACPs could offer and who could call themselves ACPs. This led to misunderstanding and professional debate, both nationally and internationally, as to what knowledge and skills were needed by ACPs (Ormond-Walshe and Newman, 2001; Daly and Carnwell, 2003; Bryant-Lukosius et al, 2004; Sibbald et al, 2006).

In recent years, attempts have been made to improve the clarity and development that helps structure advanced practice. In 2010 the DH produced a position statement on advanced level nursing. The intention of this document was to help define advanced nursing practice by using 29 elements divided into four themes, otherwise known as the four pillars (DH, 2010):

In 2017 Health Education England (HEE) developed the Multi-professional Framework for Advanced Practice in England. This document identified the level and capabilities associated with advanced clinical practice and the preparation and education required for the development of the ACP. The four pillars remained, but were renamed as:

The definition provided by HEE (2017) outlined the level of complexity required for advanced clinical practice development and mirrored the Quality Assurance Agency (QAA) (2020) characteristics statement of a master's degree. Both of these documents define the key requirements of the trainee ACP, which include a deep understanding of their field of practice and awareness of the issues that dominate the subject matter, the ability to critically appraise, undertake and apply relevant research and adopt innovative solutions to complex problems, while using professional and ethical practice. Advanced clinical practice within nursing has also been supported by the Royal College of Nursing (RCN) which produced the RCN Standards for Advanced Level Nursing Practice (RCN, 2018). This offered a clinical and professional resource to guide nurses on the requirements for advanced clinical practice.

The four pillars of advanced clinical practice have also been incorporated within the Advanced Clinical Practice Apprenticeship Degree, which was first considered in 2017 and acknowledged in 2018, through the Institute for Apprenticeships and Technical Education (2018). More recently, the International Council of Nurses (ICN) created Guidelines on Advanced Practice Nursing (ICN, 2020), which help clarify issues surrounding advanced and specialist practice. The guidelines from the ICN define terms that have been associated with advanced nurse practice and identify what is meant by the titles and what can be expected of someone who holds such a title. This has helped to identify and clarify the terms, of which there are many, including: advanced nurse practitioner, emergency care practitioner, and nurse practitioner. Specialist capabilities related to specific advanced practice roles have also emerged. Competencies associated with emergency medicine have been produced by the Royal College of Emergency Medicine (2019). Competencies related to primary care have been produced by the Royal College of General Practitioners (2015). Nevertheless, challenges continue, not least those surrounding support for development and the transition to advanced practice.

Challenges to transition

Despite attempts to define advanced clinical practice it appears that challenges relating to the question of what it is to be an ACP remain. The evolution required to reach an advanced level of practice was discussed by McKee and Eraut (2012) who described situations that may exacerbate the role transition. They argued that in some smaller organisations where the individual is known to their colleagues, transition is potentially complicated by not only a modification of themselves to the role of advanced practitioner, but by fellow colleagues understanding and respecting this change in role and level of practice.

Many practitioners who choose to become advanced practitioners do so because of their desire to remain clinical and serve their patients and their patients' families. They are confident in their ability to provide high standards of care and are often very experienced, but the transition to advanced practice can question their confidence, leading to uncertainty and apprehension (Murphy and Mortimore, 2020). Arguably, when developing advanced practice knowledge and skills, the acquisition of new information may challenge the student's understanding and create emotional instability in terms of confidence to practise.

Benner (1984) explored the various levels of competence, identifying the novice, who has little if any experience, through to the advanced beginner, competent, proficient, and finally expert practitioner. Interestingly, Benner (1984) refers to experience as not necessarily resulting from longevity of service, but from the accumulation of numerous practical experiences that provide knowledge. Therefore, this transitional phase is shaped by the clinical environment and experiences of the novice advanced practitioner, which if adequately supported, will encourage a structured transition. However, MacLellan et al (2015) suggested that experienced practitioners embarking on a new position often suffer from a sense of inadequacy, the expert to novice phenomenon, which can leave them feeling powerless. This emotional turmoil can lead to feelings of imposter syndrome, the idea of being unworthy of the status bestowed upon them. This can be exacerbated by the academic and clinical expectations required for advanced practice, which can stifle progression and create emotional instability as the trainee journeys between expert and novice (Morgan et al, 2012). As a new trainee ACP, comparing oneself to senior ACPs can be daunting and create feelings of anxiety (Harris, 2014).

Sharu (2012) identified factors that may also hamper transition. These include the skills to recognise the immediacy of care required by sick patients and the ability to confidently diagnose these cases and others effectively. However, trying to meet these expectations in a timely and effective manner, while carrying out continued professional development and learning, is challenging to the process of transition. These hurdles were recognised by Sharu (2012) as being problematic to a successful transition, but, with support, the evolution to advanced practice may prove meaningful and more effortless.

Support

The need to support the development of advanced practitioners appears obvious, but how can support be truly effective? Perhaps using a ‘community of practice’ may help address the need for assistance. Essentially, a community of practice enhances members who have a commonality and can share resources and experience from which they can develop and learn (Wenger, 2006). Therefore, if higher education institutions (HEIs) and health organisations who employ advanced practitioners can collaborate, then advanced practice-focused communities of practice may thrive and cultivate opportunities where capability and transition can be nurtured. This collaboration would help provide a structure for the support and supervision of those developing knowledge and skills and transitioning into ACPs, whatever their professional background.

Mentorship and supervision

Mentorship is beneficial in the first year of transition, when the challenges can be most evident (Burke, 2015). It is suggested that mentorship can support role transition by offering a positive outcome through encouragement and understanding. However, mentoring is a relationship through which the student is helped to learn (Scott and Spouse, 2013), which, although very useful, is not the same as supervision. Those identified as providing clinical supervision are often senior and highly experienced clinical practitioners who help manage the student's development (Scott and Spouse, 2013). Providing the trainee ACP with someone skilled who can oversee their development and expansion of knowledge and skill within the clinical environment must be advantageous. This is supported by McKimm and Swanwick (2010), who identified that learning to do a job is supported by doing the job and identifying what might be experienced and learned from that experience. Therefore, clinical supervision needs to be of a high quality that will help support the ACP to become self-assured and confident. Supporting development of advanced practice within the clinical environment is an important factor. In its publication Workplace Supervision for Advanced Clinical Practice, HEE outlines the need for high-quality clinical supervision, the education required to develop the clinical supervisor and the guidance required for workplace supervision (HEE, 2020).

Providing a high standard of clinical supervision helps to provide ACPs with the required support for the clinical choices they make, which forms the process of clinical reasoning. Cooper and Frain (2017) suggest that clinical reasoning can be modified into an educational activity, which is best delivered at the point of the clinical encounter, therefore helping to keep the learning in context. This process allows the ACP to experience, dispute, apply judgement and share opinions that can then be negotiated within these communities of practice, encouraging transformation. However, this will require greater involvement of the clinical provider in both organisational structure and participation in the educational curricular design. HEI staff must seek such a collaboration, using their knowledge of adult education and the national standards for master-level academic work (HEE, 2017; QAA, 2020), so that advanced practice is sustained, thrives and is central to the provision of today's health service.

Conclusion

The journey to a level of clinical practice that is advanced is certainly challenging. There are obstacles, but there is also work being carried out to support such hurdles and develop ACPs capable of excellence in the 21st century NHS. Support is key and effective clinical supervision is essential to success, placing significant importance on the role of the clinical environment in the education and transition to advanced clinical practice. Greater collaboration between HEIs and clinical providers is required, with provision for clinical supervision that is supported, monitored and constant.