Advanced clinical practice is a defined level of expertise within health and care professions such as nursing, pharmacy, paramedics and occupational therapy. Practice at this level is designed to transform and modernise pathways of care, enabling the safe and effective sharing of skills across traditional professional boundaries (Health Education England (HEE), 2017). Advanced clinical practitioners (ACPs) are equipped with the skills and knowledge to allow them to expand their scope of practice to better meet the needs of the people they care for.
Advanced level practitioners are deployed across all healthcare settings and work at a level of clinical practice that pulls together the four pillars of clinical practice, leadership and management, education and research (HEE, 2017) (Figure 1). According to HEE (2017) ACPs are educated to master's level or equivalent, although not all advanced level practitioners in England hold a master's; they have achieved this level of practice through experience and expertise. The need for master's level education is advised, but it is not set by law, nor is ‘ACP’ a qualification that can be registered with a professional body; it has yet to be made a legally protected title that requires professional registration.
The increasing demand on health services and continued financial constraints mean that it has never been more important to have educated and competent staff delivering the best care possible. It has therefore been recognised that the changing landscapes of both the NHS and the private sector require an advancing level of practice extending beyond initial registration (Royal College of Nursing (RCN), 2018).
Advanced practice
According to HEE (2017), advanced clinical practice is delivered by experienced, registered health and care practitioners. HEE (2017) defines it as ‘a level of practice characterised by a high degree of autonomy and complex decision making’, and includes the analysis and synthesis of complex problems across a range of settings, enabling innovative solutions to enhance people's experience and improve outcomes. In addition, advanced clinical practice embodies the ability to manage clinical care in partnership with individuals, families and carers. The benefits of advanced practice are illustrated in Box 1.
This definition of advanced clinical practice has been developed to provide clarity for service users, employers, service leads, education providers and health professionals, as well as potential ACPs already practising at an advanced level. This is the first time that there has been a common multiprofessional definition that can be applied across professional boundaries and clinical settings. The definition serves to support a consistent title and recognises the increasing use of such roles across the UK.
HEE (2017), in partnership with NHS Improvement and NHS England, developed a multiprofessional framework for advanced clinical practice, which includes a national definition and standards to underpin the multiprofessional advanced level of practice.
The RCN's (2018) definition of advanced clinical practice is in line with that of HEE, in that it acknowledges ‘advanced practice is a level of practice, rather than a type of practice’.
Multiprofessional framework for ACPs in England
HEE's (2017) multiprofessional ACP framework, which built on a preceding NHS England document outlining an advanced practice model (NHS England, 2010), set out a new, bold vision in developing this critical workforce role in a consistent way to ensure safety, quality, and effectiveness. It has been developed for use across all settings, including primary care, community care, acute, mental health and learning disabilities.
The framework recognises that, as the health and care system rapidly evolves to deliver new models of care, health and care professionals have adapted to meet the increasing health needs of individuals, families and communities. For the first time in England, the HEE (2017) framework sets out an agreed definition for advanced clinical practice for all health and care professionals and articulates what it means for individual practitioners to practise at a higher level from that achieved on initial registration.
The multiprofessional framework offers opportunities for mid-career development of new skills, such as prevention, shared decision-making and self-care. It aims to ensure a common understanding of advanced clinical practice and supports individuals, employers, commissioners, planners and educators in the transformation of services to improve the patient experience and outcomes.
Eligibility to become an ACP
All registered health professionals are eligible to become ACPs. An MSc in advanced level practice in England requires the completion of 180 credits and may consist of modules that include pathophysiology, clinical examination, project management, non-medical prescribing, clinical reasoning, practitioner competence, research, and education modules.
The variety of modules demonstrate the knowledge and skills required within the four pillars of advanced practice (HEE, 2017). (Figure 1).
The requirements for advanced clinical practice in Wales, Scotland and Northern Ireland are in line with HEE criteria in England (Scottish Government, 2008; National Leadership and Innovation Agency for Healthcare (NLIAH), 2010; Northern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC), 2016).
Early advanced practice frameworks
There have previously been advanced practice frameworks in the UK, but they were applied within the field of nursing only. Scotland was the first country in the UK to produce a structured toolkit specifically for nurses, giving advanced clinical practitioners an identity through a defined role (Scottish Government, 2008; Hill, 2017); Scotland was followed by Wales, which introduced its own framework (NLIAH, 2010).
Northern Ireland recognised the need for advanced practitioners in 2013, putting forward the ‘development of an advanced nursing practice framework’ and advanced nursing practice framework supporting advanced nursing practice in health and social care trusts. Again, the focus was on nursing and not an inclusive multidisciplinary level of practice or set of roles (NIPEC, 2016).
In November 2010, the Department of Health (DH) released a position statement on advanced level nursing in England, providing a benchmark for enhancing patient safety and delivering high-quality care by supporting local governance, assisting in good employment practices and encouraging consistency in the development of roles (DH, 2010; Hill, 2017).
Another important proposal for new roles and responsibilities was published by the Council for Healthcare Regulatory Excellence (2009). However, it seems that the national government strategies to support advanced practice roles were not publicised or applied throughout the four UK health services (Hill, 2017). According to the RCN (2012), the role was implemented successfully in Scotland and Wales, giving Scottish and Welsh ACPs a recognised professional identity, but in England implementation was, until 2017, less effective, which was when HEE published its multiprofessional framework for advanced clinical practice (HEE, 2017).
The four pillars of advanced clinical practice
The term advanced clinical practice has been recognised within health care for the past few years. However, there continue to be wide variations in practice and some professions are now starting to address the needs of advanced practice and what it looks like in terms of patient care (Pearce and Breen, 2018). ACPs can demonstrate expertise and professional judgement to achieve advanced skills in areas such as diagnostics and therapeutics, enhanced skills in consultation, critical thinking and clinical decision-making, and leadership within their teams.
These skills can be demonstrated in different ways and will depend on the setting or role in which the ACP is practising, meaning that there is flexibility for employers to determine how ACPs apply their extended expertise, based on the type of service, the patient population, and team and organisational needs. Ultimately, health professionals working at an advanced level of practice are holistic and ‘accountable practitioners, working at the boundaries of their profession’ (RCN, 2018).
Leadership and management
Advanced clinical practice requires strong leadership and management of practitioners. This includes identifying the need for change and innovation within clinical practice, developing the case for change, creating a strategic vision and building a coalition of effective individuals to effect any change (Kotter, 2012).
Managing change and service improvement is essential in advanced practice, alongside team development, negotiation and influencing others. Advanced nurse practitioners are expected to initiate, evaluate and modify a range of interventions, which may include prescribing medicines, therapies, providing lifestyle advice and delivering care (HEE, 2017).
Examples of advanced practice management and leadership skills include:
Facilitating education and learning
Education is the cornerstone to improving practice within both the clinical and education sectors. Within advanced clinical practice, it is necessary for practitioners to apply the principles of teaching and learning across their role with patients, carers and staff alike, promoting an inclusive and creative learning environment (RCN, 2018). Developing service user/carer education materials, as well as teaching, mentoring and coaching staff, are essential for continuing to improve standards and the quality of care.
Practitioners must be aware of the evidence underpinning subject-specific competencies, ie they must have the knowledge, skills and behaviours relevant to their role and scope of practice, and how to apply these, acting as a role model for other team members (HEE, 2017). Advanced level practitioners must be equipped with effective communication skills in order to support colleagues in making decisions, planning care or seeking alternatives as part of the process of making positive changes.
Examples of advanced education and learning skills include:
Research and development
Research and evidence-based practice are essential for the advancement of clinical practice. This includes not only practitioners' ability to access research and use the information, but also their involvement in research, in order to bring about improvements and change in practice.
Advanced clinical practice requires practitioners to be involved in audit and service evaluation, and to have the ability to critically appraise and interpret data, in addition to implementing findings and development policies, protocols and guidelines (RCN, 2018).
Practitioners are required to act as clinical role models/advocates, developing and delivering care that is responsive to population needs, changing requirements and demand for services (HEE, 2017). They are able to assess individuals, families and populations holistically using a wide range of approaches to complete advanced needs assessment (RCN, 2018). They should also be willing to disseminate findings through presentations and publications to continue to meet the needs of patients and to improve population health.
Advanced clinical practice requires the integration of services to provide high-quality, equitable and individually tailored health care. Practitioners need to be adept at managing complex conditions and in applying critical thinking, clinical judgement and problem-solving skills to ensure that risk is appropriately assessed and managed both for individuals and from an organisational perspective. Practitioners at this level of practice must work within their respective code of professional conduct and within their scope of practice, and be responsible and accountable for their decisions, actions and omissions (Nursing and Midwifery Council, 2018).
Advanced level practitioners need to demonstrate a critical understanding of their broadened level of responsibility and act in accordance with professional clinical judgment, demonstrating self-awareness, reflection both ‘in’ and ‘on’ action (Schön, 1991), emotional intelligence and open to change.
Advanced research skills include:
Clinical proficiency
Advanced clinical practitioners must demonstrate clinical proficiency, which embodies the ability to manage clinical tasks holistically, using clinical decision-making and clinical reasoning skills. They must apply analytical skills when treating people with complex problems and use evidence-based knowledge and skills; they must practise with competence and maintain ethical conduct, in order to enhance people's experience and improve patient outcomes (HEE, 2017; RCN, 2018; NHS Employers, 2020).
Conclusion
It is evident that advanced level practice is becoming increasingly necessary within an intensifying NHS, with the need for suitable expert, registered health professionals who are able to expand their scope of practice and expertise within autonomous roles.
Multiprofessional frameworks are now in place supporting higher education institutions to provide standardised master's level programmes of study to regulate the education and training of ACPs. It is also important that the role is accredited by professional bodies to maintain the advanced skill sets of practitioners—practitioners who will have the necessary level and scope of advanced practice and who will able to work autonomously.
ACPs enhance the healthcare workforce and, most importantly, strive to improve patient experience and outcomes; it is also within their competencies to develop their expertise in leadership and management, education and learning, and research and development to equip them with advanced level expertise, enabling them to work as autonomous practitioners.