Semi-structured interviews were designed to explore stakeholder perspectives on the ACP role. In total 63 key stakeholders participated in a one-to-one interview during January-December 2020 with two postdoctoral research fellows (CM, CO). Due to restrictions on movements, and pressures on the NHS, all interviews were conducted remotely by telephone or online platform e.g. Microsoft Teams and lasted between 30 and 60 minutes.
A purposive snowball sampling technique was used to identify key participants meeting the inclusion criteria. The main inclusion criteria were for participants to be actively working in a role relating to ACP or ACP education in England. Participants were invited to contact the team if willing to be interviewed and all volunteer participants were provided with an information sheet explaining the study and were asked to provide consent to participate. Throughout the study the sampling approach was revisited to ensure a reasonable spread of representation across professions and roles. For example, we recognised that no dieticians or speech and language therapists had been involved in the first 50 interviews and therefore we targeted these professions to include them before data collection ceased. The following table outlines this sampling spread.
The following tables at Fig. 1 outline this sampling spread.
Although roles are categorised as discrete above, there is significant overlap, for example most employers are also practitioners, and many are also clinical supervisors.
Since the research was focused on stakeholder groups across a range of roles, the research team developed two separate semi-structured interview schedules. Two variable interview schedules were utilised focusing on the areas of specialism – for example, prompt questions for HEIs and employers focused on their experience of achieving accreditation and managing ACP implementation. For the trainee ACP interviews the questions focused on their experiences of learning and undertaking the ACP role. A range of common questions and the semi-structured nature of the interviews ensured that all participants had the opportunity to fully reflect on the ACP role and contribute to the evaluation.
All interviews were digitally recorded and transcribed verbatim, anonymised and thematically analysed. The thematic analysis utilised inductive and deductive coding and was undertaken separately by two researchers (CM, CO) using NVivo 12 software comparisons for inter-coder reliability19. Team based discussions with the wider team (CE, CM, ST, RP, KHS) facilitated iterative development of the themes presented in this paper.
The study gained ethical approval from the University (NUBS REC/2019, number 201819034)
The key findings are reported in three broad themes – (1) The role of ACPs, (2) Barriers and facilitators of the ACP role and (3) The contribution of ACPs to health services in England. The first theme explores the ACP role in England and is informed largely by the initial research question related to scoping the current ACP role. The second theme focuses on the key facilitators to implementation of the role and finally, the third theme reports the stakeholder view of the impact that the ACP role has on the NHS, in relation to workforce development and patient outcomes.
Theme 1 - The role of ACPs
Data from the study confirmed that the ACP role was wide-ranging and is undertaken in community and hospital settings, care homes and community settings as well as other locations such as secure care (for example, children’s homes, young offender institutions and mental health hospitals). All ACP participants, with one exception were working in direct contact with patients (the exception was a radiographer). The 63 participants in our study came from a wide range of professional backgrounds (see Fig. 1). We identified three sub-themes relating to the role of ACPs – the scope of the role, and the dichotomies of general or specialist and role or level of practice.
Sub-theme: Scope of the role
The ACP roles of the participants in our study were very wide-ranging and there was some concern from multiple participants that the ACP role is not clearly defined. ACP it is not a protected title and there was evidence of its overuse and misuse in numerous NHS Trusts and in different clinical settings. There was some tension and confusion between nursing roles, such as the Specialist Nurse Practitioner (SNP), Advanced Nurse Practitioner (ANP) and Advanced Clinical Practitioner (ACP) job titles and roles:
And currently with the models in the UK anyone can call themselves an advanced practitioner. And we’ve done research at this university into the misuse of the Advanced Practitioner title, which is widely misused by people who’ve had no education or any training at all.
Assistant Professor, HEI (Nursing) P08
One participant described an internal study at their organisation that revealed 50 clinical posts that have ACP in their job title but none of these roles are held by clinicians who have undertaken a Masters program aligned to the HEE ACP framework. This was a source of frustration to those working in the field who suggested the ACP title needs to be protected in order to protect the reputation and validate those who are undertaking the masters level ACP programmes. A further participant demonstrated awareness of best practice from other countries (such as Australia) where the ACP role is a protected title.
Sub-theme: Generalist or Specialist
The study participants identified advanced practice as being a combination of both general and specialist skills delivered with confidence and autonomy:
The Advanced Practitioner will have that more holistic approach to the patient and should be capable of dealing with a broader set of issues, instead of being single system focused.
Trainee ACP (Nursing, Paramedic) P28
Those experienced in delivering ACP services suggested it is a balance between advanced skills and professional background:
It’s not forgetting where you’ve come from because you’re got those very specialist skills. And you’ll always utilise those skills and I suppose in the areas where you’re not so sure, so I don’t know if I get a completely random condition in clinic, I do all the basic history-taking, the basic assessments and then because it’s diet, it’s nutrition and treated, I fall back on taking my dietary assessments while I’m thinking about what else do I need to do. And it’s my comfort blanket I suppose .. (laughs) And I think it’s an ACP is bigger than that and sometimes it’s letting go of your comfort blanket.
Practitioner (Dietician) P54
Some data suggested that the ACP role is more generalist than specialist:
It’s not a bad thing being a generalist is it? If you can put your hand to a lot of things, that's actually a good thing for the patient. Because you could pick up on different things. While you're might be dealing with one specific issue, but you might pick up on other things.
Deputy Workforce Lead (Non-clinical Employer) P48
Sub-theme: Role or level of practice
A dichotomy identified by participants is whether ACP defines a role or a level of practice, despite HEE being clear that the ACP framework3 relates to an advanced level of practice:
You know, they’ve got ACPs doing different roles in their organisation, but they don’t know where to put me because they don’t assume that … because they see it as different roles rather than a level of practice.
Programme Lead, HEI (Nursing) P35
A function of the ACP role is the ability to function autonomously. For example, doctors in our study suggested that mastery of a task was achieved when a clinical presentation had been experienced multiple times and became comfortably embedded within the clinician’s scope of practice:
If you’re a master of a particular task you know, it’s something that you … not just necessarily a task but you know, a particular clinical presentation, something that you’ve seen many times before. You’ve seen its variants you know, you’ve not just seen the kind of standard presentation and it’s something that you feel comfortable with. I suppose the definition of mastery is that you’re almost not having to think too hard about it you know, it’s something that is very clearly within your scope of practice and you feel very comfortable with it.
Clinical Supervisor (Doctor in secondary care) P62
Within the field of nursing autonomous decision-making was linked to the ability to make decisions for example, as an independent prescriber:
So, mastery is around making those clinical decisions and acknowledging that there are multiple ways to tackle problems. But to be able to rationalise which option you have chosen and for what reasons because it would be very different from one patient to another as to what approach you choose potentially.
Clinical Lead/Supervisor (Nursing) P63
This was supported by views of a physiotherapist supervisor who suggested:
When they get to that point of being able to work with undifferentiated and undiagnosed clients and to be able to recognise that, that’s when they’re gaining the mastery in advanced practice.
Clinical Lead/Supervisor, (Physiotherapy) P59
This research was undertaken during the Covid-19 pandemic. There was evidence that during this time ACP roles were working in a range of flexible and responsive ways to react to the pandemic.
This section has outlined high levels of variability and ambiguity of understanding and deployment of the ACP role in England.
Theme 2 - Facilitators of the ACP role implementation
This theme explores the factors acting as facilitators to implementation of the ACP role.. We identified three sub-themes relating to this, training and education, clinical supervision and organisational support.
Sub-theme: Training and Education
The training pathway is a university approved masters ACP programme aligned to the HEE framework. The pathway comprises regular modular classroom teaching and assessments, supported by an in-practice portfolio of clinical skills developed through on-the-job learning and supervision.
Due to the range of clinical professionals undertaking the ACP role there were high levels of variation in participants’ previous clinical experiences and learning needs. Different professional backgrounds had variances in the amount of direct patient contact in both the pre- and post-registration training and it was suggested that a therapeutic background, for example in nursing, gave clinicians a head start on the ACP requirements compared to other AHPs, for example pharmacists and paramedics:
Students from a paramedic background, from a nursing background, from a physio background, would be very much hands-on and very much used to speaking with patients and they will have different skills in terms of the interprofessional … or the interrelation skills to talk to patients and get their confidence. I think the pharmacists maybe struggle a little bit more with that aspect because they don’t have as much hands-on with patients that in their pre-reg training
ACP Lecturer, HEI (Nursing) P22
The multi-professional ACP cohorts added value to the learning experience of the group. Many participants described benefits from learning in a multidisciplinary cohort:
What they bring in terms of learning within the classroom is phenomenal because the OTs and the dieticians will bring some really valuable discussion that the nurses haven’t considered, likewise physiotherapists or paramedics. So, they learn from each other so much, which is just so rich.
Programme Lead, HEI (Nursing) P36
One ACP course invited a trainee ACP with expertise in mental health to co-produce and co-deliver relevant parts of the course.
English universities have the opportunity to be accredited with the Centre for Advancing Practice, through HEE. Participants suggested the accreditation process was vital to reduce variety in courses:
It will reduce the variability in students’ experience and delivery. I think you know there is a sort of perception that some courses are better than others and some students are more supported than others.
Assistant Professor, HEI (Nursing) P08
Both employers and trainee ACP participants suggested that the standards were a useful measure ensuring quality in employing ACPs and facilitating their easy movement within the NHS as a transferable skill:
As an employer I would view that we need to have a level of standardisation on regulation of some form because otherwise how do we know what we’re getting when we have more and more, hundreds more ACPs in the country, then how do we standardise that across organisations?
Clinical Lead/Employer (Nursing) P63
Alternate pathways to accredit existing ACPs exist through an evidence portfolio and personalised training plan. Our participants indicated that an equivalence route is a strong facilitator to enable practitioners delivering at the ACP level to accredit their expertise and provide recognition:
There’s also a mass of advanced practitioners potentially who are out there you know, who have not done a course or have part done a course, yet who are functioning and really need to be drawn in.
Programme Director, HEI (Nursing) P07
As evidenced above, multiple HEIs pointed out that it would be disheartening for ACPs to be required to undertake Master’s training if they could evidence working at the level required for an ACP in other meaningful ways. Indeed, some participants suggested they would pursue an equivalence route of accreditation if it was comparable.
This theme highlights that a standardised education pathway can be a facilitator to the scheme. However, the lack of protection for the role and some variances in experience could be a barrier to the scheme. Overall, through the training and education provision, HEE and the Centre for Advancing Practice play a significant role in facilitating the development of ACPs in England.
Sub-theme: Clinical supervision
Mentoring and supervision were identified as a vital component of the ACP role development and facilitator of scheme implementation and role development. The role of the clinical supervisor was twofold – supporting learning and assessing development. One participant informed us that in primary care both clinical supervision and pastoral mentoring are both offered. Some local programmes offer peer support mechanisms to underpin clinical supervision along with a pastoral support network. In two clinical settings associate supervisors were offered to underpin learning in the pillars beyond clinical – for example a research mentor appointed from the University:
We are looking at the associate supervisor … across the other pillars who’s best-placed to supervise that ACP around those other pillars during training when they’ve got set goals they have to meet within the academic programme but also once qualified.
ACP Clinical Lead/Supervisor (Nursing) P58
All participants alluded to the fact that learning was not knowledge alone but the application of theory into practice. It was suggested that ACP learning was best facilitated in the workplace when learners had the opportunity to link theory and practice:
It should all be about applying things in real-life work settings and having that you know, vocational approach rather than a hugely academic sitting in a classroom and learning lots of theory.
Head of Assessment and Credentialing (Pharmacy) P61
Several participants who were supervisors pointed to the importance of shared context, in order to facilitate learning opportunistically. One supervisor suggested that direct clinical supervision of new skills and experience was essential for patient safety. A nurse supervisor suggested that the clinical supervisor needed a knowledge base of the likely issues that a learner might experience. Through revisiting particular presentations, the supervisors scaffolded complexity. One medical supervisor suggested that the best feedback for learning was when a supervisor witnessed a learner complete a clinical task repeatedly, offering reinforcement of learning with hints for improvement. Participants agreed that supervisors must strategically reduce the scaffolding to support autonomous decision making:
Everything has to be grounded in that individual scope of practice, otherwise the risk is that the advanced practice attributes are abstract and free-floating and not actually of patient care and clinical value or necessarily supporting safe care.
Director of Education (Optometry) P60
Clinical supervision was an important facilitator of the role but implemented inconsistently and there was evidence of a huge variance in experiences. Some work environments, in particular non-hospital settings, struggled to release time to provide mentoring opportunities for their ACPs:
So, if I'm working in a ward for example, the consultant will only be on there for 10 minutes and you won't see them for the rest of the day.
Trainee ACP (ODP) P48
There was variance clinical supervision across masters programmes – one university provider mandated participants to spend one day per week with a clinical supervisor in contrast to another who had no specific supervision time for their ACP learners. Participants suggested that experienced ACPs could be utilised to provide effective supervision as the critical mass of ACPs develops.
Clinical supervision is a crucial facilitator to ACP development. Good quality supervision in shared contexts scaffolds learners to achieve their potential and the scaffolding can be reduced as the learner achieves autonomy. There were variances according to the support and commitment afforded to clinical supervisors by their organisation.
Sub-theme: Organisational support
Previous sub-themes outlined the importance of support for individuals, which was facilitated by support at organisational and strategic levels. Time release varied for the participants in our study, for example, one NHS Trust provided ACPs with a minimum of 6 hours per week for Continuing Professional Development (CPD). Another Trust was increasing release time for ACPs up to 10–15% of an individual’s contracted hours.,
Key individuals played a key role in facilitating the role in organisations, especially at the highest level in NHS Trusts:
There needs to be really within an organisation a very clear sense of, we want ACPs and this is what we want them to do.
ACP Clinical Lead/Supervisor (Nursing) P58
ACP development was reliant on the support of management at all levels and buy-in at organisational level was essential to progress the role. There was evidence of success when there was joined-up working between the HEI provider, the local trust and ACP trainees:
You know their Medical Director is on board with the ACP, he’s involved with the assessments of ACP. They have real buy-in from the medical school, they have a real joined-up way of thinking around it. And we are the entire polar opposite here.
Clinical Lead/Supervisor (Nursing) P63
There was also evidence that where support or buy-in to the ACP scheme was sparse, at either individual or organisation level, this acted as a barrier to the role being implemented and benefits of the role realised:
I think if an employer is very much involved with ACPs then they probably are aware of it. But I haven’t heard anything other than you know a vague sort of interest in it.
Senior Lecturer, HEI (Nursing) P09
Theme 3 -The contribution of ACPs to health services in England
This theme relates to the contribution of ACPs and the work of the NHS in two key sub-themes – the impact of individual ACPs on patient outcomes, and the impact of the role on workforce development.
Sub-theme: Patient outcomes
We interviewed across a wide range of health professions and so were able to see the reach of the ACP role and impact of this role on patient outcomes. Participants talked about their own experiences of providing improved care for specific conditions such as Parkinson’s and with stroke survivors as well as across secondary care and in community settings. In addition, participants working in other settings such as outpatient services, mental health provision and general practice (GP) shared similar stories and experiences.
There were multiple examples where the ACP made a significant impact on patient care, utilising their professional background with their new advanced clinical skills. Specific examples included a speech and language therapist who set up a triage system for patients referred into hospital at risk of laryngeal cancer to ensure they were seen within two weeks. Several pharmacists had set up schemes to support and manage specific patient groups, such as those with multimorbidities, long-term conditions or risk of falls in primary care. An occupational therapist (OT), alongside other cardiology ACPs, set up and ran a one-stop shop of follow up for heart failure patients. A dietician set up telephone consultations to start treatments for patients at home that reduced attendance at emergency care by 20%. There was significant evidence from our data that showed the way in which the ACP role had a positive impact on service provision across a wide range of clinical contexts. One employer gave an example of the ACP reducing the average length of stay in hospital from 9.7 days to 2.3 days, and pointed to the financial tariffs which meant his team benefitted from £500,000 additional saving.
Sub-theme: Workforce development
In this sub-theme we report on the impact of the ACP role on workforce development. Many of our ACP participants were in roles designed strategically by the employer to fill a need and therefore fulfilling a specific workforce gap. There was also evidence that AHPs were undertaking roles which would historically have been assigned to a nurse or junior doctor, and therefore highlighting the changing roles of traditional roles and duties. In some cases, ACPs had filled a gap that was not able to be filled in any other way, clearly meeting workforce needs. Participants in all professions reported that that whilst the ACP role ‘filled a gap’ it did so in a way that also added value, by utilising the specific expertise of professionals, providing holistic care and freeing up doctors to focus on the specific tasks which required their attention:
We know that there are like globally a shortage of doctors, shortage of nurses, shortage of other … but I do think that the ACPs do bring something else to the table. They do bring that holistic approach to patient care. They’re not just looking at a diagnosis, a treatment and then sending the patient on their way, they are looking at the whole picture. I do think that you know they are very much keen and enthusiastic to give that extra to patients, they feel that they can do the whole journey with the patient that includes the socioeconomic kind of care as well as the sort of practical care. And I think they get to think about the impact of the condition and the disease on a patient rather than just this is your diagnosis you know, you go on and do … now they think more broadly really around how that will impact on the patient.
Senior Lecturer, HEI (Nursing) P02
Employers and clinicians in the study gave examples of the ability to diversify the delivery of healthcare services by deploying ACPs in their clinical settings. There were several specific examples of how the role of ACP contributed to changing workforce development in departmental contexts. These include several examples from mental health services and from secondary and community care provision:
Having that baseline knowledge and understanding really enhances then their ability to, in fact, also do their mental health assessment, to really enhance their ability to prescribe. Because you suddenly have much more awareness of some of the interactions and issues and all of that. So, I think they were the first ones who really start to think, wow, this could be fantastic, and this could see us really operating in a different way, doing different things than traditional mental health nurses have done. And gradually I think other people started to get that as well
Deputy Workforce Lead (Non-clinical Employer) P48
One employer discussed that orthopaedic ACPs were able to go in to ED to assess and deliver interventions which could avoid a patient admission or reduce time required for an acute bed. There was some evidence of regional variances in workforce development in England. It is suggested that areas in the North and Midlands were leading developments which the South are slightly later to develop. There was also an indication of workforce development variances in primary and secondary care provision. There was some suggestion that there was a focus on secondary over primary care in the UK. It was suggested that ACPs can contribute to new ways of working in primary care, that will require some level of system change.
It is clear from our interview data that the ACP role can contribute to workforce development. In particular, practitioners and employers drew attention to the scope of the post to be a co-ordinating force that can focus on individualised care and responsibility for ensuring the delivery of fully integrated and meaningful care going forwards.