Change, for better or worse, seems to be endemic in western societies, and in the past two decades advanced practice has not been exempt. Healthcare leaders and lecturers in the UK have adapted education programmes that are preparing for increasing numbers of health professionals to take on advanced clinical practice roles that meet policy and practice developments emerging from population need and government-influenced changes. Such change has included advanced practice policy from Health Education England (HEE) regarding funding for advanced level students, and the introduction of the advanced clinical practitioner (ACP) title.
This article focuses on advanced practice/ACP education.
Background
The advanced level practice role started within the nursing profession in the 1960s in the USA. In the UK, advanced practice has had a mixed history since the role was first defined in 1993 by the United Kingdom Central Council (UKCC) (1993), which has been superseded by the Nursing and Midwifery Council (NMC). International advanced practice comparisons tend to focus predominantly on nursing roles; however, in the UK the remit was deliberately broadened to include non-medical allied health professionals (AHPs), such as radiographers and physiotherapists (National Leadership and Innovation Agency for Healthcare (NLIAH), 2010; Gardner et al, 2016).
A UK structure for advanced level practice was proposed in 2008 following the publication of NHS Scotland's Advanced Practice Toolkit (Scottish Government, 2008) depicting a ‘four pillars’ role framework: clinical practice, research, leadership and education (Figure 1). The height of the pillars were considered flexible, depending on the current activity of the advanced practice, although the clinical pillar seems to have been prioritised ahead of the other three.
The simplicity of the framework proved resilient, despite it seeming reductionist compared with the complexity of emergent senior advanced practice roles in health care. With adaptations, the framework was adopted for nurses and AHPs in Wales by the NLIAH (2010) and informed a position statement for nurses in England (Department of Health, 2010).
This framework continues to be advocated by NHS Education for Scotland (2021) (Figure 1) and is cited by HEE in its multiprofessional framework for advanced clinical practice in England (HEE, 2017). Interesting to note is the slightly different terminology to head up each pillar, for example NHS Scotland uses the pillar term ‘facilitating learning’ while HEE applies the term ‘education’.
The four pillars
Clinical practice
ACPs will be working autonomously in a role that requires them to assess, diagnose and manage complexity, working in collaboration with the wider health team.
Facilitating learning or education
This pillar is important for supporting staff, patients and for advanced practitioners' self-awareness to assess and address their own learning needs.
Leadership
Effective leadership is required to influence and motivate others to work effectively and co-operatively with health and social care practitioners, senior and junior staff, and to meet the goals and objectives of the service and the wider organisation (Chadwick and Leigh, 2018). Understanding leadership styles is essential for leading staff of all disciplines and leading new services designs. Leadership also embraces communication skills, supporting patient groups and acting as a role model for less experienced staff (NHS Leadership Academy, 2014).
Research
ACPs need an understanding of all research methodologies to be able to evaluate research evidence relating to new methods of treatment and care (NLIAH, 2010). Students can feel daunted by research, but need sound knowledge to be able to communicate and debate issues related to evidence-based practice with patients and healthcare staff (Linsley et al, 2019).
Education
ACPs must meet professional standards and requirements, as mandated by regulatory bodies such as the NMC, Health and Care Professions Council or General Pharmaceutical Council. ACPs are accountable for their actions and must be able to justify their clinical decision-making with appropriate evidence. It is proposed that advanced level practice should reflect a set of responsibilities, competencies and capabilities on the career continuum and, as such, practitioners are always accountable to their regulatory body whatever the context of their practice and level (NLIAH, 2010).
The NMC admits how the lack of regulation for ACPs has resulted in a ‘patchwork’ of advanced practice education across the UK, with each country establishing its own standards and frameworks. Indeed, the NMC is currently exploring its role in regulating ACPs as part of a major evaluation into its post-registration standards, which is due for consultation in 2021.
Furthermore, there is growing debate about whether advanced practice requires regulation, mindful that approaches to advanced practice across the four countries of the UK are at different stages of maturity. Seen as a priority in its 2020-2025 strategy consultation on draft strategic themes, the NMC (2019) is exploring potential regulatory approaches to specialist and/or advanced practice, including whether there should be common approaches across a number of professions.
The emergence of advanced practice education programmes
Education programmes preparing ACPs for the role began to emerge in UK universities in the 1990s, with programme content initially replicating Hamric et al's North American advanced nursing practice broad conceptual model (Hamric et al, 2009). Reflecting the complexity of the role, programme content included key topic areas such as collaboration, ethical decision-making, consultation, research, expert guidance and coaching, and leadership.
The amount and level of study required of ACPs has continued to cause controversy both in the UK and internationally. The International Council of Nurses has long argued that advanced practice should require a full master's degree, and there is evidence that doctoral-level programmes are being offered in the USA and Canada. However, HEE (2017) only requires ‘a master's level award’ for advanced clinical practice, thus implying that practitioners can use the ‘advanced’ title without completing a full master's degree. In reality, what has emerged are organisations that support ACPs to complete a postgraduate certificate or postgraduate diploma and not the full master's programme.
The UK Quality Assurance Agency (QAA) (2020:4) is clear that ‘all master's degree graduates will have in-depth and advanced knowledge and understanding of their subject and/or profession, informed by current practice, scholarship and research. This will include a critical awareness of current issues and developments in the subject and/or profession; critical skills; knowledge of professional responsibility, integrity and ethics; and the ability to reflect on their own progress as a learner.’
One could argue that ACPs who have not completed the full master's programme are unlikely to have studied the breadth or depth of subjects represented by the four pillars now synonymous with advanced level practice requirements.
In the UK, the current situation for advanced practice/ACP preparation is fluid. For example, there is now the advanced clinical practitioner (integrated degree): this is an apprenticeship route for ACP role development that is at master's level (Skills for Health, 2017). Programme accreditation has also been introduced by HEE together with a number of credentialing frameworks; however, the Royal College of Emergency Medicine (2020), Royal College of Nursing (2020), and the Faculty of Intensive Care Medicine (2015) have been accrediting advanced practitioners since 2016.
Multiprofessional framework for advanced practice in England
Useful to consider is the HEE multiprofessional framework for advanced clinical practice in England (HEE, 2017) to demonstrate educational development for ACPs.
The framework's definition of advanced level practice sets the scene and tone for the programme and level of education required: ‘Advanced clinical practice is delivered by experienced, registered health and care practitioners. It is a level of practice characterised by a high degree of autonomy and complex decision making. This is underpinned by a master's level award or equivalent that encompasses the four pillars of clinical practice, leadership and management, education and research, with demonstration of core capabilities and area specific clinical competence’ (HEE, 2017: 8).
The language used to describe the capabilities in the framework is deliberately mapped to level 7 (master's) taxonomy to support and make clear the expectation that health and care professionals working at this level are required to operate at master's level; they should have developed and can evidence the competencies underpinning their specialty or subject area, ie they have the knowledge, skills and behaviours relevant to their setting and job role.
Master's level requires an ability to make sound judgements in the absence of full information and to manage varying levels of risk when there is complex, competing or ambiguous information or uncertainty.
Taken from the HEE multiprofessional framework, Table 1 provides examples of the knowledge, skills and behaviours relevant to each health and care professional's setting and job role, spanning the four pillars that are then applied to specialist competencies.
| Knowledge and skills | Behaviours |
|---|---|
| Clinical practice | |
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| Leadership and management | |
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| Education | |
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| Research | |
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For further information about the multiprofessional framework and access to a toolkit, which looks at the practical implementation of this approach, see the HEE's advanced practice web page (https://www.hee.nhs.uk/our-work/advanced-clinical-practice).
Useful in the multiprofessional framework is the flowchart that provides guidance on possible ways to evidence the capabilities within the four pillars of ACP and, indeed, HEE has set up the Centre for Advancing Practice, which ensures a more standardised approach to ACP accreditation. The centre enables practitioners to become accredited with no formal education through an independent portfolio route, and will also oversee educational institutions that deliver ACP education by requiring them to accredit programmes in accordance with national standards for education and training.
Practice-based learning and assessment
Practice-based learning is normally supported in parallel through university-taught clinical modules. Indeed, HEE promotes continued assessment against, and progression through, the capabilities identified in the framework (HEE, 2017: 11). It therefore forms a vital component for the integration of theoretical and clinical learning at each stage of the education programme.
Clinical examination/assessment is most often assessed in a university setting by Objective Structured Clinical Examination (OSCE). OSCE assessments in universities are artificially staged, normally with actors or volunteers playing the patient role. University-based OSCEs are probably more valid and reliable than those performed in practice due to the ability to standardise them by replicating scenarios for all students in a cohort at each simulated clinical station and for them to be assessed by the same lecturer practitioner team.
Practice-based supervisors and managers
Practice-based learning has been viewed as essential, so it is often a requirement for entry to all education programmes, with organisational support required to complete most programmes.
Practice-based supervisors are often identified as medical staff, consultants and general practitioners (GPs), with the more recent addition of qualified ACPs. Most education programmes require a manager's and supervisor's signature to confirm a student's clinical learning. Hours of supervised support and protected learning time in practice are not specified by professional bodies and, anecdotally, there is enormous variation and inconsistency for protected learning time in practice and in university, with the potential to lead to unsafe practice for some of those with fewer hours, placing patients and advanced practitioners at risk.
Maintaining effective advance level practice
For public and student safety, practice learning and assessments are needed, but reassessment is also required at regular intervals to ensure the ACP is maintaining the safe level of knowledge and skills previously acquired. Without mandatory regulation, this may not occur as a requirement for all practitioners, and so safety could be compromised. HEE, in its multiprofessional framework, is clear that ongoing professional development is a requirement of the ACP role.
Conclusion
Advanced clinical practice embodies the ability to manage clinical care in partnership with individuals, families and carers. It includes the analysis and synthesis of complex problems across a range of settings, enabling innovative solutions to enhance people's experience and improve outcomes (HEE, 2017: 8).
ACP programmes at master's level are generally acknowledged across the higher education sector as requirements for assessing critical analytical thinking skills, scrutiny and challenging existing published evidence and knowledge. This thinking is synonymous with the QAA requirement of the master's graduate who has in-depth and advanced knowledge and understanding of his or her subject and/or profession, informed by current practice, scholarship and research (QAA, 2020)
Standing the test of time is the four-pillar framework for defining and understanding the ACP role. The height of the pillars is often considered flexible and will depend on the current activity of an individual ACP. The danger is the prioritisation of the ‘clinical’ pillar, making the others invisible. Effective advanced level practice requires equal prioritisation of the four pillars. Although there is consensus that a master's level education (or equivalent) is required for an ACP, this does not extend to practitioners working in advanced practice roles. If an advanced level practice title can be used by practitioners whose education programme falls short of the full master's degree (or equivalent), this lack of clarity and expectation of the role will persist.
The Association of Advanced Practice Educators continues to petition for improved standards and regulation for master's degree graduates. This group represents an influential collaborative network of higher education institutions across the UK, which are providers of advanced clinical practice programmes of education for interprofessional groups.
HEE's Centre for Advancing Practice is exciting and timely, ensuring a more standardised approach to ACP accreditation. Its role with advanced practice and the accreditation of programmes could also promote the consistency that is currently missing with the educational preparation for the ACP role.
Finally, the NMC (2019) is reviewing the regulation of advanced practice. Regulation would assist in safeguarding the public—the current situation allows any individual, without any qualifications whatsoever, to call themselves an advanced practitioner. Indeed, Leary et al, in 2017, found over 300 titles being used for advanced practice, with some of these individuals not even being qualified nurses. A total of 323 postholders were recorded as holding titles such as advanced nurse practitioner or specialist nurse who were not registered with the NMC.
Optimistically, opening advanced practice to all AHPs and pharmacists, in addition to nurses and midwives, could lead to a strong AHP professional group achieving regulation and other professions following due to requirements for equity and equality.
Recommended is a longitudinal study to evaluate the current impact of the four-pillars framework on ACP/advanced practice education programmes. Research could also be undertaken to understand and evaluate the learning needs and support required to develop these high-functioning, safe advanced practitioners. Crucially, all education programme teams should be encouraged to maintain a culture that debates what advanced practice is and is not throughout their programmes.