In recent years, the NHS has clearly experienced complex challenges to its ability to provide safe and efficient care to patients. For the NHS to overcome these, the workforce has been overhauled several times, and this has included the introduction of roles such as advanced clinical practitioner (ACP) and advanced nurse practitioner (ANP).
In 2017, Health Education England (HEE, 2017a) produced a multiprofessional framework for advanced clinical practice in England. This explains that advanced practice is a level rather than a type of practice.
ACPs are educated to master's level in clinical practice and have been assessed as competent in practice, using their expert clinical knowledge and skills to practise at an advanced level. They have the freedom and authority to act, making autonomous decisions in the assessment, diagnosis and treatment of patients. ANPs are nurses who are working in an advanced practice capacity and, while this title is still widely used nationally, ANPs are in effect part of the wider multiprofessional term ACP.
Although the HEE (2017a) framework gives the most widely accepted definition of advanced practice, there are still issues that require further development. There is currently no mandatory regulation of advanced or specialist roles in the UK, nor protection of titles. As a result, any individual could call themselves an ACP. The regulation of advanced roles is widely discussed internationally (Heale and Rieck Buckley, 2015) and, while this is a complicated issue, there are growing calls for this to be implemented to protect professional standards, ensure patient safety and identify where boundaries between professions cross over (King et al, 2017).
The HEE framework (2017a) suggests that ACPs need to develop a portfolio of evidence showing they are clinically competent to complete their role safely; however, it does not identify tailored, specialty learning outcomes for ACPs to work towards. This is in part because of the wide variety of specialities that ACPs work within, which explains why early curricula/frameworks such as those of the Royal College of Emergency Medicine (RCEM, 2017) and the Faculty of Intensive Care Medicine (FICM, 2015) were limited in their transferability to ACPs not working in emergency medicine or intensive care.
In recent years, a significant amount of work has been performed in this area and various curricula and frameworks are now available for ACPs to work towards, and a larger volume of credentials are in development (HEE, 2021).
Aims
This study aimed to explore ACPs' perceptions of the term competency and how they evidence competency in their practice.
Design
A qualitative study design was used for this research to explore the perceptions of the participants in depth.
Sampling
All ACPs studying on the advanced clinical practice master's of science (MSc) programme at a local university were invited via the learning platform to participate in this study. This included trainee ACPs and some ACPs employed in a qualified capacity who were still working towards completion of their MSc. The sampling used was convenience sampling and six participants were recruited into the study.
Data collection
Between February 2019 and May 2019, semi-structured, in-depth individual interviews were conducted. These allowed the researcher to generate a rich understanding of participants' perception. Each interview was recorded and transcribed verbatim. Telephone interviews were also used within this study for researcher and participant convenience.
Data analysis
An inductive, manifest content analysis approach was used to analyse the raw data. This involved organising and analysing textual data from each interview transcript into codes and themes.
Ensuring reliability
Reflexivity was used to ensure reliability in the study especially because, at the time of conducting the study, the researcher was a trainee ACP studying the same MSc programme and therefore an insider researcher. Although this could augment the research, it could also cause bias.
Ethical issues
All aspects of the study followed the relevant laws and institutional guidelines and the study was given ethical approval in accordance with the university processes.
Findings
Value of trainee ACP status
From the participant interviews it is apparent that there is variation between clinical areas regarding what defines a trainee or qualified ACP and the training plan for becoming a qualified ACP. Only two participants mentioned being supernumerary throughout their training.
All of the participants referred to academic qualifications when asked what differentiated a trainee from a qualified ACP in their workplace. The number of master's modules required to become a qualified ACP depended upon the clinical area within which the student was practising, with some areas requiring a full MSc degree and others a postgraduate certificate plus an imaging module. Some clinical areas did not require a full MSc:
‘It's probably not a formal definition. The essential bits you have to have in terms of qualifications to deliver the service [are] a prescribing module and an imaging module.’
‘It's just experience and a master's degree.’
One colleague who had almost completed their studies noted their significant experience as both a nurse and an ACP, which meant they had likely been practising in a qualified ACP role for a long time:
‘I think I am working within a trained ANP role … I've been doing the job for a long time and being qualified a long time … There was no formal requirement to do the master's when I took on this role.’
Skills, training and knowledge
All the participants had completed a history taking, physical assessment and consultation module at master's level. Some participants had already completed a non-medical prescribing module; some were undertaking this. One participant had been given in-house training to extend their skill set because of the clinical area they worked in.
Skills practised
All ACPs interviewed noted they had similar core skill sets to each other. Common skills were taking a history, performing an examination, requesting investigations, formulating a management plan, prescribing and referring to other specialities.
One participant noted that they could discharge patients autonomously because they were working in a qualified role. Another reported that, because they were a trainee working in the emergency department, all their patients had to either be discussed with, or reviewed, by a senior colleague before discharge.
Meaning of competency
The definition of competency is complex and widely debated, and the subthemes identified in this section involved the complexity of defining the term and comparison to medical staff:
‘It [competency] means different things to people—it's subjective.’
Complexity of term ‘advanced clinical practitioner’
Participants' opinions differed when it came to defining the term competency in advanced practice. Some agreed that the definition is variable, while others made the definition in terms of the things that they did within their role, such as technical tasks and responsibilities.
Two participants had contrasting views of their competency as an ACP in comparison to that of a junior doctor, with one participant feeling the two could not be compared as their primary training was different while the other stated competency to them was when they could deliver care to the level of an foundation year 1 (FY1) doctor:
‘Safely deliver care to the level of an FY1 doctor.’
‘There is comparison between the competency of junior doctors and ANPs. I do not feel they are comparable in any way … the whole basis of their training is different.’
Experience of assessment
As part of competency, it became clear that ACPs need to prove they can perform the job that they do in the form of collating evidence of competency.
All the ACPs acknowledged how they felt a curriculum or detailed portfolio that they had to work towards would help evidence their competency in practice. They felt that, although this would be time consuming, they understood how it would augment their practice and provide evidence of their competency:
‘Having a standardised general training as an ACP would be very beneficial because I have a very narrow background and I wouldn't have to be filling in the gaps now.’
Subtheme: self-directed portfolios
There was disparity between the participants' perceptions of the importance of a detailed portfolio and whether they actually completed one. One participant did collate a detailed portfolio, another was discouraged from doing this by their supervisor until they had completed the master's programme and two participants infrequently added entries to theirs:
‘So I have put a couple of reflections and a couple of observed clinical procedures.’
‘Really, I should be putting in all the standard things such as venepuncture and arterial blood gases.’
‘Currently, I do not … my clinical supervisor feels I should complete my MSc before commencing an RCEM portfolio in which I will evidence competency.’
Subtheme: work-based assessments
Work-based assessments (WBAs) include several assessment tools found in medical training programmes. Only two participants completed WBAs and one did not feel they were needed at present in their practice. This participant also stated the competency booklet provided by the department was entirely self-certification, requiring no supervisor sign-off.
‘It doesn't seem as essential or important at the moment although I know in the future that will change.’
‘Yes, actually, not very often but interesting ones I do—definitely I do’
‘I anonymise my clinical clerkings and document and reflect upon these as evidence of my ability to assess patients, take a history and make a clinical plan based upon findings from the history, examination and investigations.’
Discussion
There is disparity in the definitions of a trainee ACP and qualified ACP depending upon the clinical area and organisation.
As mentioned previously, the HEE (2017a) definition of advanced clinical practice refers to master's level study. However, as this does not explicitly state a full master's programme of study has to be completed, the number of master's level credits needed may be open to interpretation. The Royal College of Nursing (RCN, 2018) credentialing process does require ANPs to have completed a full master's programme; however, having a full master's degree does not automatically grant ACP status (HEE, 2017a). One participant briefly stated that experience of doing the role played a part in differentiating between trainee and qualified ACPs and this is an important consideration. Clinicians practising in an advanced practice role need to have the appropriate experience and be able to demonstrate core competence alongside speciality-specific competence (HEE, 2017a).
Being able to work in a supernumerary capacity while training is also an important consideration for ACP training programmes. In a study comparing two cohorts of trainee ANPs (on supernumerary versus non-supernumerary training programmes), McDonnell et al (2015) found that the supernumerary cohort felt more confident and had higher levels of knowledge, skills and competence at the end of their training. According to the FICM (2015), trainee ACPs should be supernumerary throughout their training programme; however, other credentialing councils such as the RCEM (2017) make no mention of supernumerary time. HEE (2017b) states that supernumerary status during training should be ‘dependent on level of experience of the trainee’, which is somewhat ambiguous.
Skills, training and experience
Confusion remains over the scope of practice of advanced practitioners (Stanford, 2016) given the degree of variation in individual competence and scope of practice (Williams, 2017). Standardised competency frameworks and curricula have been suggested as solutions to define advanced practice roles, quantify varied scopes of practice and potentially make transferring from one employee to another easier (Stanford, 2016; Williams, 2017).
Nazarko (2016) suggests common themes that are likely to be part of the ACP role in contemporary practice; these were compared against the participants of this study, and findings were similar (Table 1).
Table 1. Activities that are likely to be part of the advanced clinical practitioner role in the present and a previous study
| Present study | Study by Nazarko (2016) |
|---|---|
| Performing an examination | Physically examine patient |
| Prescribing | Prescribe |
| Taking a history | Take a clinical history |
| Referring to other specialties | Determine when onward referral is required |
| Formulating a management plan | Decision-making and accountability |
| Determine diagnosis | |
| Practise autonomously | |
| Admit and discharge patients | |
| Collaborate with patients to manage conditions | |
| Requesting appropriate investigations | Educate and promote health |
| Extended skills: removal of sutures, suturing, insertion of peripherally inserted central catheter lines, refilling baclofen pumps |
Understanding of the term ‘competency’
There are differences in opinion with regards to the participants' own definitions of the term competency. Most participants referred to the ability to perform something, such as a task, procedure or skill. Others refined this, commenting that competency was performing something to the standard at which others would do it; one participant felt competency meant to do something successfully.
While health professionals need to be competent within their roles, there is no agreed definition of the term competency (Axley, 2008). It has been suggested that competency encompasses knowledge, skills, attitudes, traits and motives (Mitchell and Boak, 2009) but is usually related to job performance and the ability to perform in a manner that yields desirable outcomes. However, competency (can do) is different to performance (does do) (Kak et al, 2001).
Competency is linked to evidence-base practice (based on knowledge) (Melnyk et al, 2014) and therefore maintaining up-to-date knowledge and skills is essential to providing for individual patients.
Some participants referred to the comparison between junior doctors and ACPs. Historically, some ACP posts were introduced as a replacement for junior doctor roles (Easton et al, 2004). This is because ACPs were initially undertaking skills that had been performed by medical professionals, and the roles were created in a response to a reduction in the number of junior doctors and the increasing complexity of the healthcare system (McColm, 2017). ACPs should work collaboratively and hold shared responsibility for patients (Williamson et al, 2012) adopting a whole-systems approach to patient care (McDonnell et al, 2015). Therefore, while branding as ‘equivalent’ should be avoided, benchmarking against junior doctor grades may be required in ACP practice to ensure consistency of baseline competence.
Experiences of assessment
As mentioned previously, contemporary work is being carried out to create detailed frameworks and curricula for ACPs. At the time of research, only one participant in this study was working in a clinical area that had a published national curriculum, which was that of the RCEM (2017).
Central to fulfilling college curricula such as the above is the completion of WBAs (FICM, 2015; RCEM, 2017). Only one participant had completed a WBA to form part of their portfolio, with the others either not understanding their worth or had been discouraged from completing them until they had completed their MSc.
The RCEM (2017) and FICM (2015) ACP/advanced critical care practitioner training programmes require WBAs to be completed as they are an excellent marker of assurance in terms of trainee competence (Kim et al, 2016; Lörwald et al, 2018). This indicates that the same could be used for the trainee ACP population, with such assessments used as a marker to assess and provide assurance over competency.
Self-reflection is integral to ACP curricula such as the RCEM's (2017); it is also recommended in guidance by the professional bodies (Health and Care Professions Council, 2018; Nursing and Midwifery Council, 2018). Self-reflection may be beneficial for students studying master's degree programmes in advanced practice (Glaze, 2001) and may aid the transition from trainee to qualified ANP (MacLellan et al, 2015). Documenting reflections within a professional portfolio is essential to evidence the critical thinking required for the ACP role (Pearce and Breen, 2018).
Limitations
The participants were all registered nurses working in advanced practice roles within secondary care. This, coupled with the small sample size from only one academic institution, limits the generalisability of this study's findings to the wider ACP population.
Conclusion
This research aimed to explore what trainee ACPs understand by the term competency and how they evidence competency in their practice. The six trainee ACPs interviewed all had a shared understanding of the term competency and understood the importance of maintaining a portfolio to evidence competency; however, not all of the participants maintained such a portfolio.
KEY POINTS
- Trainee advanced clinical practitioner (ACPs) should work as supernumerary staff while training so they can develop the skills and competency needed to practise autonomously
- Benchmarking is required to standardise the point at which a trainee becomes a qualified ACP. This should include undertaking a full master's programme in advanced clinical practice
- Work to develop both generic and specialist curricula for ACPs is recommended so they can evidence their competency
- ACPs should maintain an up-to-date portfolio to evidence their competency in practice
CPD reflective questions
- How do we make sure practice by advanced clinical practitioners (ACPs) is safe?
- How do we ensure standards of competence for advanced clinical practitioners?
- What might a ‘gold standard’ training programme for ACPs look like?