The NHS in the UK is faced with a number of challenges, including an increase in the frail, elderly population, an increased demand for health and social care and significant health inequalities (Scottish Government, 2016). The modernisation of health care, including advanced professional roles for nursing and allied health professionals, is considered essential to address these challenges (Scottish Government, 2017a).
The International Council of Nurses (ICN) describes advanced nursing practice as:
‘Enhanced and expanded healthcare services and interventions provided by nurses who, in an advanced capacity, influence clinical healthcare outcomes and provide direct healthcare services to individuals, families and communities.’
The ICN (2020) goes on to define an advanced practice nurse as
‘One who has acquired, through additional education, the expert knowledge base, complex decision making skills and clinical competencies for expanded nursing practice.’
Advanced nurse practitioners (ANPs) are often characterised and shaped by the specialty in which they practice, which includes general practice.
The development of advanced practice roles in nursing is not purely a Scottish or a UK-wide initiative, but one that can be seen growing internationally. Countries around the globe are investing in advanced nursing practice roles to help alleviate staff shortages in healthcare in both developed and developing countries (Pulcini et al, 2010). There is, however, disparity regarding job titles and educational requirements for ANPs, although there is an aspiration to deliver all advanced nursing practice education to master's level. Not all countries have achieved this, however (Tracy and O'Grady, 2019).
The Scottish Government (2017b) has provided clarity on role definition, educational requirements and career pathways for ANPs. The minimum education standard is a postgraduate diploma in advanced nursing practice (level 11), with a focus on the development of clinical competence achieved through work-based learning (WBL).
Evidence from a study describing general practice multidisciplinary team (MDT) experiences of participation in WBL highlighted several challenges due to its inter-professional, cross-organisational and complex nature (Joynes et al, 2017). There is limited evidence specifically describing the experiences of nurses undertaking advanced practice education generally and fewer examining experiences from advanced practice students in general practice (Illingworth et al, 2013; Hallinan and Hegarty, 2016; Raleigh and Allan, 2017; Joynes et al, 2017).
Background: ANPs
ANPs have the clinical expertise to assess, diagnose, treat and discharge or refer patients with complex presentations across the life span (Scottish Government, 2017b). ANPs do not focus on one condition or specialty, but are able to assess and diagnose patients who present with complex conditions. Two systematic reviews concluded that ANPs can improve patient access to health care, patient outcomes, patient satisfaction and overall quality of care (Tsiachristas et al, 2015; Casey et al, 2017). A further systematic review of randomised controlled trials examining the quality of primary care by ANPs found that the ANP groups demonstrated equal or better outcomes than physician groups in the areas of patient satisfaction at an equal or lower cost (Swan et al, 2015).
WBL is defined as learning for work, at work and through work and it involves a partnership between the student, their employer and the higher education institution (HEI) (Eraut, 2004; Phillips, 2012). Significantly, it is proposed that WBL can meet the requirements of all stakeholders and contribute to role and service development (Marshall, 2012). This type of learning is consistent with experiential learning theory, which proposes that adults learn best when they are actively involved in the learning and have opportunities for experience, reflection and participation (Kolb, 2014).
There is a wealth of qualitative literature describing MDTs' experiences of WBL in general practice (Smith and Wiener-Ogilvie, 2009; Eddy, 2010; Illingworth et al, 2013; Hallinan and Hegarty, 2016; Joynes et al, 2017). In their systematic review, Mertens et al (2018) concluded that the MDT's experience of WBL is collaborative, patient focused and requires protected learning time.
In contrast, there is limited literature specifically describing the experiences of general practice-employed nurses' participation in ANP education. However, several themes have emerged from the literature:
- Shared responsibility for patient care provides learning opportunities but these need to be recognised as such and utilised (Illingworth et al, 2013; Raleigh and Allan, 2017)
- Nurses require the support of an experienced mentor and mentors need clarity to be able to provide this support (Illingworth et al 2013)
- Multiple learners within general practice can create tension and overwhelm mentors (Hallinan and Hegarty, 2016; Raleigh and Allan, 2017)
- The culture and traditional hierarchies have been demonstrated to influence engagement with WBL in general practice (Ilingworth et al, 2013; Raleigh and Allan, 2017)
- WBL for general practice-employed nurses occurs less frequently in general practices associated with a high workload and time pressures. Short consultation times, combined with the lack of an ability to delegate workload, makes participation difficult (Raleigh and Allan, 2017)
- Additional scheduled patient consultation time has been identified as helpful for other learners within general practice, and this may be significant for these nurses (Smith and Wiener-Ogilvie, 2009).
Study aim
The aim of this small study was to gain an understanding of the educational experiences of nurses employed in general practice who were undertaking a master's degree in advanced clinical practice Identification of the facilitators and barriers to their participation was considered key in order to enhance provision for future nurses on this programme.
Method
This exploratory, qualitative study sought to understand and describe the educational experiences of a sample of nurses employed in general practice, with the aim of generating rich, accurate descriptions from their perspective. A purposive sample was sought from nurses enrolled on the master's programme who were being supported by their GP employers. The first five participants who volunteered were recruited, representing 23% of the overall target population. The participants were all female and had been nursing within general practice for between 4 and 19 years. Three of the participants were employed as general practice nurses (GPNs) and were being supported by their GP employers to undertake the ANP education pathway; the other two were employed as trainee ANPs, whose roles required them to undertake the education programme.
Individual, face-to-face, semi-structured interviews were conducted and recorded by the first author and the participants received the transcripts to verify their accuracy. Data analysis was conducted using Braun and Clarke's (2006) six step, thematic analysis process. Significant statements pertaining to the phenomenon were identified and extracted to generate themes, which were then further refined. The significance of a theme is not necessarily dependent on its prevalence but whether it answers the original research question (Braun and Clarke, 2006). This was an important factor in choosing thematic analysis as the authors aimed to provide a rich description across the entire data set. Analysis by theme also protected the anonymity of each participant, reducing the risk of identification of individual participants from the small study sample.
Ethical considerations
Ethical approval for this study was granted from the university's health and social care ethics committee. The study did not require NHS ethical approval as the participants were recruited by virtue of their student status and independently of their employers.
Findings
The participants' rationale for undertaking the educational programme included the motivation to improve the patient experience by reducing the potential requirement for multiple visits to see different health professionals, and career progression. The participants also described how the new GP contract in Scotland, which supports expansion of the roles of the MDT, allowed these nurses to take on patient responsibilities that were previously only fulfilled by GPs (Scottish Government, 2017c). This was an opportunity for them to influence the development of their role and they welcomed this.
On starting the education pathway, participants' confidence dropped as they began to consult on a one-to-one basis with patients with different conditions. This led them to question their clinical decisions. However, the participants described the importance of the education pathway in developing their knowledge, confidence and competence in their clinical decision making, particularly with new patients and more complex patient presentations.
‘My most significant change is being more confident with the more complex presentations. Also discussing with the patients what their point of view and perspective is regarding their presentation. Being able to listen and address their concerns is important.’
Participant 3
Two of the participants also described how the education pathway had given them the confidence and competence to rationalise their treatment and management plans. The participants also highlighted that completion of the pathway was not the end of their learning. In order to practise safely, a commitment to lifelong learning was essential.
Barriers to learning
Lack of clarity
The participants explained that, in general practice, GPNs may have previously adopted the title of ANP due to their length of service or a non-medical prescriber qualification. Although the participants recognised that this was not consistent with the education required or their role within the new GP contract, this had created confusion among their GP employers regarding the role of the ANP.
‘There is still a lot of ambiguity within primary care and I still think GPs are not entirely sure what an ANP in general practice is.’
Participant 1
The impact of this was that the participants described having a dual role of GPN and ANP while participating in the education programme. Their working hours would be timetabled for both ANP patient appointments and supervision and for GPN clinics. The participants explained that running these GPN clinics resulted in limited opportunities to observe their MDT colleagues and this was viewed as a barrier to learning.
One of the participants who was employed as a trainee ANP highlighted that her employer's expectations of her were the same as that of the qualified ANPs. The impact of this lack of recognition of the differences in her level of knowledge and clinical competence on her learning was described as significant.
‘The list of patients and complaints that I was seeing was the same as [that of the] qualified ANPs. I was not allocated extra appointment time or catch-up time in between patients, which I think would have been valuable. The expectations from me were the same as qualified ANPs. There was no allowance for me as a trainee.’
Participant 4
Pressure of work
Pressure of work was described as a barrier to learning by the participants. One of the participants described the impact of her clinical role on her learning as significant.
‘Short consultation times and a heavy (clinical) workload made learning really, really stressful.’
Participant 2
The length of patient appointment time also impacted on the participants' learning, with appointment times ranging from 10 to 30 minutes.
‘There was no time allowance to recognise that I was seeing more complex patients and therefore would need a longer consultation time to support my learning and develop my competence.’
Participant 4
However, one of the participants noted that short consultation times were the reality of GP medicine and their future role.
‘The pressure of time doesn't help or hinder your learning. You have to get your consultation down to within that time and if you dilly dally … then you are not focusing on the key feature or important elements of the patient's presentation. Time focuses you on the important issues.’
Participant 3
Participants also described the challenge of balancing demanding clinical roles with the requirement for independent study to complete the written assessments required.
‘What is very challenging is balancing a busy difficult role and learning at work and then coming home and appraising research for the portfolio.’
Participant 5
Facilitators to learning
Foundation level education
Four of the participants had completed an honours degree-level module in history taking and clinical examination before beginning the ANP course. These four participants commented on the importance and relevance of this as a prerequisite for ANP education.
Finance
The participants highlighted the importance of funding provided to their GP employers to support their participation. This funding enabled the participants and their GP mentors to be released from their clinical duties to participate in WBL activities while ensuring that patient appointments were not impacted. This was a facilitator to learning as it meant that the participants felt more comfortable asking to be released from their clinical commitments and more confident that their request would be supported.
Supportive network
The essential role of a supportive network was described by all of the participants. This included their patients, GPs who provided mentorship and other members of the MDT. However, there were inconsistencies within the group and not all participants felt they had the full support of their practice and this impacted on their learning experience.
‘The trainee GPs in my practice have tutorials and I asked to sit in on them. The practice did not think it would be advantageous for me to sit in on these so I was not allowed and I am not sure why this was the case.’
Participant 5
The participants described how nursing within general practice can be isolating because of the autonomous nature of the role and the limited opportunities to meet and work with other nurses. All of the participants described the value of the support they received from their peers. This support was not only pastoral; it was also a forum for the sharing of teaching and learning resources, signposting and professional networking.
‘What really helped was a WhatsApp study group with my peer group. It wasn't just a support group but there was a lot of sharing of teaching and learning resources and that was so helpful.’
Participant 4
Mentorship
The participants had each been allocated one GP mentor within their practice. This role included supervision and assessment of the participant's clinical practice, providing feedback and leading tutorials. This GP mentor was described by all of the participants as having a key role in supporting their learning for the duration of the pathway.
The participants clearly described the importance of observation and feedback on their clinical practice by their GP mentors. This activity was described as key to their learning and the development of clinical competence.
‘It's really important that someone does observe your practice as you don't know what you don't know. It's really good to get feedback whether it's positive or negative because you need support to learn.’
Participant 2
Several of the participants identified the requirement for GP mentorship time and engagement with WBL activities to be timetabled into the working week. Without this scheduling and allocation of time, there was acknowledgement that these activities would not occur.
Once again, there were inconsistencies within the group. Not all of the participants had weekly or regular timetabled sessions with their GP mentor or GP colleagues. Supervision was on a more ad hoc basis for these participants and this was highlighted as a concern.
Several of the participants felt that there was a lack of clarity for their GP mentors and employers regarding the amount of time they should allocate for supervised clinical practice. This contributed to supervision being ad hoc. However, there was recognition that the participants themselves needed to be active in identifying their learning needs and addressing these concerns.
‘You need to negotiate with your GPs and have the confidence to do so if you are not getting what is required to support your learning. If you are really clear on what is required, both clinically and academically, you are more likely to get that help.’
Participant 3
Participants also described how having regular meetings between the student, their GP mentor and HEI tutor was useful in planning their learning and understanding expectations.
Discussion
In this qualitative, exploratory study, the educational experiences of general practice-employed nurses undertaking ANP education were diverse and complex. Short consultation times and heavy workloads combined with patient complexity can make WBL difficult for ANPs within primary care (Smith and Wiener-Ogilvie, 2009; Raleigh and Allan, 2016). These problems were also expressed by participants in the present study. Joynes et al (2017) found that, when clinics run simultaneously and all members of the MDT have their own caseload, opportunities for participation in WBL are reduced. Participants in the present study also acknowledged such difficulties.
The Scottish Government's (2018) strategy on the transformation of the GPN role in integrated community teams provides clarity on the roles of ANP and GPN within general practice. Despite this, the participants experienced a lack of clarity regarding their role and educational requirements, which impacted on their experience of WBL. Those who described a lack of GP mentorship time, supervised clinical practice or opportunities for participation in WBL activities, attributed this to a lack of clear guidance and clarity, which meant that each GP employer interpreted their role differently.
Identification of the key role of the GP mentor as a facilitator to learning and the importance of GP mentorship being scheduled into the working week were also identified by the participants. Weekly timetabling of all WBL activities, especially supervised clinical practice time, was considered essential and a facilitator to WBL. Tripartite meetings between the students, GP mentors and the HEI tutor were considered key to providing clarity and the development of a supportive infrastructure. A multidisciplinary, collaborative approach is also required to support the dissemination and use of the national guidance regarding nursing roles within general practice.
Participants also highlighted the importance of self-awareness of their individual learning needs in order for their employers and GP mentors to support their development. Future education pathways need to prioritise supporting students to develop these self-awareness and critical reflection skills. The tripartite meetings aim to support the development of these skills.
The participants reported that the education pathway gave them confidence and competence in their clinical decision making, the ability to enter into shared decision making and rationalise treatment and management plans. These findings are significant. An increasingly elderly population and the number of people living with multiple and complex conditions has created an increase in the demand for clinical services (Scottish Government, 2016). There is a requirement to use healthcare resources more efficiently and the realistic medicine strategy is considered the route to embracing these challenges (Scottish Government, 2016). This strategy involves putting the patient's views and needs at the centre of care. The experience of participation in WBL for these participants has enabled them to implement this strategy.
All of the participants had previously undertaken disease-specific, continuous professional development activities and education. However, this education had not prepared them for the role of the ANP in assessing and diagnosing patients with complex conditions across the life span. However, having completed a foundation level of education in history taking and clinical examination before commencing the ANP education was a facilitator for the participants. In the UK, registered nurses are now required to be competent in person-centred nursing assessments and education in history taking and clinical examination is included within undergraduate nursing programmes (Nursing and Midwifery Council (NMC), 2018a). This is seen as a facilitator for future ANP roles and access to education.
The participants described the importance and value of peer support, both face to face and via social media platforms. Professional isolation for general practice-employed nurses is well documented but these social media platforms may create supportive environments that facilitate peer learning and the development of self-awareness and critical reflection skills (Chen et al, 2016). These opportunities for peer support should be integral to future education pathways as facilitators to learning.
Study limitations
This study was conducted within one group of general practice-employed nurses undertaking ANP education at one university in Scotland and the results are not generalisable. The first author, as module leader, had a professional interest and relationship with the participants. This potential limitation of bias was acknowledged, reduced and managed through reflexivity.
Conclusion and recommendations
The educational experiences of the participants in this study were diverse and complex. They identified several facilitators to learning—foundation level education, finance, a supportive network and mentorship. Barriers to learning were a lack of clarity on roles learning needs and the pressure of work in primary care.
Given the key role that these nurses will have in future healthcare models, there is a requirement for a national education standard. The NMC (2018b) has defined the programme learning outcomes, clinical practice hours and the role of the practice supervisor and assessor for undergraduate nurses. There are also national education standards for trainee GPs (Royal College of General Practitioners, 2019).
The authors recommend that the NMC lead on defining general practice ANP programme learning outcomes, clinical practice hours, including supervised hours, and the role of the mentor. Within Scotland, NHS Education for Scotland would have a key role in implementing these standards in collaboration with HEIs, health boards and independent GP contractors. This would ensure that all students participating on the pathway would be supported by a lead GP mentor, have defined supervised clinical practice hours, including clinical appointment time, access to a GP supervisor while consulting and the opportunity for participation in WBL activities. In order to support learning for future trainee ANPs, length of appointment times needs to be defined, agreed and protected as the trainee ANP progresses through the education pathway.
KEY POINTS
- A small qualitative study was undertaken to describe general practice nurses' experience of participation in advanced practice education
- Although a shared responsibility for patient care creates opportunities for learning, the educational experiences of the participants were complex and diverse
- Facilitators and barriers to learning were identified with the aim of improving the experience for future participants
- The Nursing and Midwifery Council should lead on defining general practice, advanced nursing practice programme outcomes
CPD reflective questions
- Work-based learning requires a partnership between general practice, the higher education institute and the participant. How can you strengthen these partnerships to enhance your own or other's educational experiences?
- Work-based learning in general practice presents many challenges but also opportunities. How can you can utilise these opportunities to enhance the experience of yourself or others?
- The participants in the authors' study highlighted the importance of peer support. How can you enhance your own or other's peer support when the pandemic has resulted in education being delivered virtually and in different models of healthcare delivery?