The questionnaire was on Survey Monkey for three weeks and accessed 643 times. The questionnaire received 528 full responses and 115 partial responses. The original request population for the modelling project was n = 50 giving a response rate of over ten times the estimated response. Fifteen interviews were carried out with ACPs from a variety of origin professions, from different regions of England. Nine interviewees were trainee ACPs and six were ACPs. Interviewees’ self-declared area of clinical practice are detailed in Table 1.
Table 1
The respondents areas of practice.
Speciality
|
Respondents
|
Acute Gerontology
|
10
|
Long Term Condition (e.g. cancer)
|
18
|
Acute Medical (Adult)
|
92
|
Acute Medical (Paediatric)
|
6
|
Acute Mental Health
|
8
|
Acute Paediatric
|
19
|
Acute Surgical/Theatres
|
23
|
CAMHS
|
4
|
Community Care
|
25
|
Community Long Term Condition (e.g Respiratory)
|
11
|
Community Mental Health
|
16
|
Community Paediatric
|
3
|
Emergency Department (Adult)
|
89
|
Emergency Department (Paediatrics)
|
9
|
Learning Disability
|
2
|
Midwifery
|
2
|
Other
|
19
|
Pre-hospital Care
|
10
|
Primary Care
|
104
|
Radiology
|
11
|
Critical Care
|
28
|
Neonatal
|
7
|
Radiotherapy
|
4
|
Emergency Department (Adults and Paediatrics)
|
7
|
A third of questionnaire respondents’ titles were Advanced Clinical Practitioner, a third were trainee Advanced Clinical Practitioner, and the remaining third selected “other”. The respondents’ demography are detailed in Figs. 1 and 2.
The largest groups of respondents were from Primary Care, Emergency Department (adult) and Acute Medical (adult). Respondent’s length of time as an advanced clinical practitioner is detailed in Fig. 3. The largest groups of respondent’s registered profession were Nurse (365), Paramedic (55), Physiotherapist (40) and Radiographer (diagnostic) (23).
In total, 35% of respondents were currently in education to become an ACP. This was the largest group of respondents followed by those who had been an ACP for 1–3 years (21%). The majority of respondents (82%) were employed on a permanent NHS contract. 26% were rostered on a medical rota, and 66% were not. The National Health Service in England has a nationally agreed pay structure of banding. This starts at Band one and goes to Band 9. The majority of respondents were on Pay Band 7 (40%) or Pay Band 8a (36%). 3% of respondents were on a non-NHS grade. The smallest group of respondents (less than 1%) were pay band 5 s, there were 4 respondents in this group. Of those rostered on a medical rota, 9% (54) were paid locum medical rates if they undertook locum medical shifts.
There was variation within each group. For example out of the total 97 Emergency Department respondents 33% (n = 32) were trainees. 28% (n = 27) had been registered for 1–3 years, and 2% (n = 2) had been registered for 16–20 years.
Data from the questionnaire are presented alongside the interview data to allow for comparison. Interview responses allow depth and further detail to some questionnaire responses. Questionnaire quotes are presented in italics and interview quotes in bold to provide further clarity between the data.
The key themes and findings from interviews and free-text questionnaire answers are summarised in Box 1.
Box 1: Key findings
1. Advanced Clinical Practice was considered by 52% of the questionnaire respondents and all interviewees their only viable clinical progression option.
2. There is a lack of clarity around the structure of the ACP role, and its future.
3. Balancing training for Advanced Clinical Practice with a full time role was challenging.
4. 52% of questionnaire respondents thought their employer encouraged them to work across all four of the advanced practice “pillars”, 29% did not.
|
Advanced Clinical Practitioner as a route for professional progression
Respondents suggested that there was a lack of opportunity available to progress clinically in their career apart from the ACP route. 52% of questionnaire respondents answered no, there were no other opportunities other than the ACP to progress clinically in their career, 32% responded yes, and 6% responded with not sure. Of those that answered no, 67% were nurses, 13% were paramedics, 11% were radiographers and 8% were physiotherapists. Of those that answered yes, 76% were nurses and 6% were paramedics.
Respondents indicated that alternative progression was only available in managerial roles with little if any patient contact, or that progressing clinically would result in having to drop a grade or not be promoted or paid for additional responsibilities.
“Management was the only other option and I wanted to remain in clinical practice.”
“I don't know how you progress clinically if you don't do ACP. You progress managerially.”
“I had progressed as far as I could within my career path without becoming purely managerial.”
Reasons for going into advanced clinical practice in the interviews ranged from a lack of other opportunities to progress, to advanced practice covering everything that they wanted. The majority responded that they wanted to remain in clinical work, that their current role was not recognised as advanced and other progressions would lead them away from patient-facing work.
“Because there was no progression where I was.” – ACP in emergency medicine
“When I looked into the role of the ACP, it just seemed to encompass the things that I wanted. So you were still very clinical, without all the managerial stuff to go with it.” – Trainee ACP (surgery)
Professional Uncertainty
Questionnaire respondents were asked about where they see their professional aspirations and expectations. The dominant theme centred on the uncertainty of whether their employer will offer them a job as an ACP once they qualify, or if they will have to go elsewhere.
“Not sure at present as our hospital do not have a clear pathway as to what is happening to us once we are qualified.”
“I cannot see any career progression within the ACP role locally. So either the status quo or a move to primary care. Banding would be unlikely to change. I feel stuck at this level now.”
Interviewees also felt that employers didn’t understand what an advanced clinical practitioner would be able to do once qualified, and as a result there was a general lack of understanding particularly from immediate/middle managers.
“Our trust doesn’t know what it wants its ACPs to do” – Trainee ACP
“Potentially all three of us could be sitting there with an ACP qualification, nobody really knowing what to do with us.” – Community Matron (Adult Mental Health) ACP Trainee
Other questionnaire responses saw their career progression as aiming for a consultant role, moving more into research and a small number wanted to move completely out of healthcare.
“Nothing to do with ACP as probably burnt out from pushing this boulder uphill”
Many wanted to stay in the ACP role but with more acknowledgement and clarification around the role structure. 6% of respondents wanted to be involved in work to improve the ACP training experience for future ACPs.
“Same but with a better set up. Perhaps helping others coming through to improve their experience over mine.”
Interviewees also noted the lack of structure and plans set in place for when they started the role. Expectations of what they would be able to do added pressure to the ACPs to prove their worth and ensure that as pioneers of the role, they proved it was a success. The ACP role is seen as something novel despite advanced practice being established in UK healthcare for many years.
“The executive boards didn’t know that we existed, there was no governance in place, nothing like that, so it was a bit of a challenge when we started.” – ACP team leader
A recurring issue interviewees reported that although having no set plan in place when they began meant that they could contribute to shaping their future role, it was detracting from their current job and adding unnecessary stress and pressure.
“It made me feel quite empowered that there was two of us shaping the future a little bit and how we were perceived and we were able to modify things like that so that was quite nice. But it made me feel like it detracted from what I was meant to be doing” – ACP trauma and orthopaedics
“I felt like there was a lot of added pressure to us because we were the first: we were trying to prove a point and make the role a success.” – ACP trauma and orthopaedics
Others also noted that they thought they would be further in their career financially and clinically had they taken a different route, and the promises of what the ACP education would give them had not been fulfilled.
“In terms of clinically…financially, I’m again going to have to be very honest with you, I feel I may have actually been further in my career if I had stayed in [specialism].” – Trainee ACP
Unpaid work
In the survey 34% (179) of the total respondents did not work unpaid overtime. For trainees this this was 44% (78). Interviewees commented on the fact that clinical hours towards Advanced Clinical Practice training had to be made up in their own time. Many were continuing with their origin profession while undertaking the education, and what respondents termed ACP hours had to be outside of these regular hours.
“I have remained as my day to day hours as a Band Five and my day to day responsibilities are what you would expect of a Band Five and then I go in, in my own time, to do hours of practice for my course.” – Emergency Department Trainee ACP
“I still do my job as a [specialism] specialist nurse two days a week and that’s been my biggest stumbling block through my training really.” – Trainee ACP
The expectation that they would have to continue their normal employment contract whilst completing the ACP course was in some cases not clear to respondents, and they found this a shock and an unexpected challenge.
“What I didn’t realise was the expectation was that I would carry on doing the job that I was doing while I was doing my training.” – Trainee ACP
This was described by multiple interviewees as the biggest challenge of their ACP experience. In one case an interviewee was undertaking ACP education in a clinical speciality completely different to their origin profession as this was the only area there was progression available, and they had to balance the work of two very different areas simultaneously, one of which was a new area of practice.
“The demands of the course and, also, the clinical demands of having two jobs: that’s been really difficult” – Trainee ACP (Surgery) (origin profession Diabetes nursing)
Working across all four pillars
Interview respondents were asked whether they were encouraged or supported to work across all four pillars of advanced practice. Answers varied from some never having heard of the four pillars, to others covering all four pillars, and some saying there was a disproportionately large focus on the clinical pillar.
“I don't know, to be honest no one really mentions the four pillars.” – Trainee ACP (paramedic)
“No one has ever brought up the four pillars.” – Trainee ACP (paramedic)
“There’s nothing in my contract to say it’s 70/30 clinical to non-clinical or 60/40 or 80/20: there’s nothing written down” – ACP in Emergency Medicine
29% (151) of questionnaire respondents responded that they didn’t think their employer encourages them to work across all four pillars, 10% (52) were not sure, and 52% (275) thought they did (Fig. 4).
Advantages of the role
Respondents were asked about the best parts of their experience as an ACP. Many answers were on their ability to provide improved and more holistic patient care and to improve their knowledge and skills.
“The best part is making a difference to the patients’ journey so it’s using the extended skills that I’ve learnt” – Senior ACP (Emergency)
“Understanding that the issues we have, we’re not isolated, everybody else is having similar struggles about how to apply Advanced Clinical Practice in the different allied health professions.” – Trainee ACP
“There is a lot of opportunity for us to demonstrate our aptitude and demonstrate the abilities of our role and shape it that way, from the inside.” – Trainee ACP (A&E)
Issues and challenges
Interviewees were about their biggest challenges in their experiences of advanced clinical practice. Interview respondents all perceived that patients didn’t fully understand what being an Advanced Clinical Practitioner meant. Using the word ‘trainee’ when introducing themselves was also a source of contention, and sometimes caused resistance from patients.
“I found it was quite a barrier to patients just saying the word ‘trainee’…I had one patient say I’m not having a trainee coming near me.” – Trainee ACP
All interviewees also commented that they were required to explain their role to other colleagues, who they believed didn’t understand their role. This restricted them, and some felt that they weren’t being able to carry out work to their full ability as a consequence.
“The biggest challenge was making the workforce understand the role of Advanced Clinical Practice” – Trainee ACP
“It’s also been extremely frustrating because I think we’re so restricted, it’s hard for people to get their head round it” - Surgical Care Practitioner
Questionnaire respondents were asked whether they thought the “ACP” title accurately described their role. Of the 528 who answered, 54% (287) thought that ACP was the right job title for them. 19% (98) of respondents wanted their origin registered profession to be included in their title, and 3% (6) wanted their title to include their level of seniority as an ACP.