Advanced practitioners (APs) have been part of the UK healthcare workforce since the 1990s. They emerged within a changing workforce landscape, as nurses extended their scope of practice and doctors reduced their hours through the working time directive (Pierce and Belling, 2011). The AP role has evolved more recently to the advanced clinical practitioner (ACP), whose work encompasses many practitioner roles, not just nursing.
A broadly similar definition of advanced clinical practice exists across the UK. Each endorses a framework; documents on the role, the frameworks and their development have been produced by Scotland's Chief Nursing Officer Directorate (2008; 2017), the Welsh Government (2010), Department of Health, Social Services and Public Safety Northern Ireland (2016), and Health Education England (HEE, 2017). These documents argue that ACPs have complex decision-making skills, are educated to master's level, can act autonomously and work in a variety of settings, which underline that the ACP role should be seen as an evolving level of practice rather than simply a position.
Many ACPs work in traditional health professional interface areas, such as hospitals. More recently, the ACP role has moved into innovative ventures in less traditional areas, such as GP surgeries.
The generic ACP role encompasses the use of advanced clinical competencies to assess, treat and refer people with a range of presentations, including mental illness, who present with physical health problems (Rogers, 2011). Research shows that one in four of the UK population will experience mental health difficulties (McManus et al, 2016). Some 15–40% of primary care consultations are attributed to mental health problems (Rogers, 2011). Further evidence suggests that up to 44% of people who attend emergency departments have panic disorders (Foldes-Busque et al, 2011). Moreover, patients with serious mental illnesses are more likely to develop comorbid physical health problems; this results in a reduction in life expectancy of up to 20 years, which equates to 1 in 3 of the 100 000 premature deaths in England each year (Thornicroft, 2011; NHS Confederation, 2013). Such statistics show that senior staff such as ACPs, who assess people attending their departments, will frequently see someone with a mental illness who is presenting with a concurrent physical health problem.
At present, many generic ACP programmes do not have modules specifically on mental health. This article will explore the outcomes regarding emergent mental health skills in the practice of a cohort who completed a generic ACP programme with a component specifically on mental health.
Aim and objectives
The aim of this research was to investigate the efficacy of mental health-specific content within an MSc ACP generic programme designed for healthcare disciplines including adult nurses, paediatric nurses, physiotherapists and paramedic personnel.
The objectives of the research were to evaluate the mental health-specific content within a bespoke module and to identify the utility of such skills by the advance clinical practitioner in training (ACPiT) in clinical practice.
Methodology
The research project adopted a qualitative approach, involving a single case study framework to examine a phenomenon (in this case, from the observations of the authors) from the accounts provided by ACPiTs on the programme.
Case study research is argued to adopt one of three modalities: exploratory, descriptive, or explanatory (Yin, 1984). Using the descriptive modality to articulate the ACPiT narrations related to mental health skills in clinical practice, the research employed semistructured interviews to establish the ACPiTs' experiences. This allowed them to voice personal beliefs related to the mental health component of the programme and its impact on their practice.
The interviews were designed to last no more than 45 minutes and were transcribed verbatim using voice recognition software. All information related to the research was stored securely in recognition of the ethical approval gained for this research from the university ethics committee.
The purposive sample of students was recruited from one cohort of the programme. Participants came from a range of backgrounds (adult inpatient, community nursing, emergency care and primary care practice centres; n=10), all agreed to take part and had the option to withdraw without challenge. All participants had received the mental health training in the 12 months before the data were collected.
Analysis
Analysis involved reading the transcripts to elicit themes that represented the narration of the ACPiTs. All the transcripts were read and reread by both authors. First and second level analysis was undertaken by both authors, which led to a range of codes and, ultimately, themes (Bazeley, 2013). Third level analysis was then used to subcode the elements in each theme, culminating in the final themes.
The findings are presented through verbatim personal statements using direct quotes to provide reflective insights as to the utility and purpose of mental health skills to the generic ACP role. Examples of participants' quotes are given below.
Findings
Ten interviews were held, averaging around 30 minutes each. The clinical experience of the ACPiT involved in the research was generally 5 years of postregistration practice in non-mental health areas. The researchers identified three main themes:
Themes
The following sections give excerpts from the interviews with ACPiTs to exemplify statements related to the themes.
Communication skills
Participants identified instances from their recent practice where they had found themselves persevering with events that they would normally have handled in a more ‘matter of fact’ manner. Considering the mental health material learned, they felt they acted in a more measured and less judgmental fashion,
‘I saw a patient yesterday on a home visit who had got a low mood and anxiety and she actually called because of pain but, when we talked about everything, we talked about social isolation and different things like that. She said to me “Thank you because you've just listened to me”. She said “I feel like you've actually listened to me and you didn't just stand at the side of me hovering and rush rush rush”.’
Each participant could identify experiences where their practice had benefited from the use of enhanced communication, felt energised by content on the module, then synthesised this into to their current practice:
‘I really drew on the questions that we were taught to ask … before we did our OSCAs [Objective Structured Clinical Assessment] …’
During OSCAs, a clinical skill is practised in a role-play situation and rated by an assessor against a series of competencies related to clinical practice, knowledge and application.
The genesis of understanding related to the importance of communication skills, as presented in the module, was identified all participants and is exemplified in a reflective narrative.
‘Initially, it was listening observing, watching and then, it was that one little thing, if I hadn't observed then I wouldn't have gone any further … and then it was the questioning … non-direct questioning because the rest of the consultation had been yes or no answers … as some of the best conversations seem to have yes and no's but you don't seem to get much information, and this should have put signs in my head as an ACP trying to put all these pieces together, as it just seemed this was a shy young man.’
Emergence of competence
Reflections related to permanent changes to practice were identified, leading the participant to recognise that they had developed competence as a consequence of the module.
‘The key aspects like assessing mood, assessing risk, assessing thoughts, assessing well … insight. I feel that's more embedded in practice now but, before the programme, I would've just [pauses] just took a bit of history and risk assessed and referred on. I feel I can take it on just a little bit further now.’
The participants identified that, with time and knowledge gained from the module, they became confident to engage in more detailed assessments and linked these assessments to competencies. Such an approach led one participant to confidently engage in more detailed observation of non-verbal behaviour, and then analyse in the context of the presentation.
‘He was saying all the right answers, and everything seems OK. I then realised he was digging his fingernails into his hand. Unless I was in the right position, I would never have seen this …’
The interpretation of this non-verbal behaviour coupled with verbal content led to further exploration that identified a relapse of health and the need to admit the client into a medical unit. A change in mental health was often included in assessments, along with taking historical evidence into account when considering interventions.
‘This lady was having an abnormal response … it was a difficult situation that she was … very ill but she was clearly struggling and was responding in ways that are quite peculiar in terms of not wanting to take painkillers, not wanting to have any medicines … I suppose it's about investigating that and trying to get to the root causes of that rather than the just labelling her as a difficult patient … So yeah, so I suppose it's more about being aware of the possibilities of the impact that the previous diagnosis.’
There were reflections on developing competence in managing difficult situations, blending problem solving and advanced communication.
‘I think empathy is really important … I don't want to make assumptions. He [the patient] was quite upset by [a colleague] … but quite quickly I was able to make a rapport with him, engage with him, listen to a story, sort of acknowledge his feelings, really make him feel like I cared really but I had acknowledged what he was saying.’
Commonly, competence related to holistic assessment to explore physical health presentations with mental health differentials.
‘People will come in tired all the time [and ask] am I anaemic? Is it my thyroid? Well I could say that it could be that or I say how has your mood been? I will check some bloods but, if it's not that, it could be because of that [the mood]. People don't always like to be told that it's their mood rather than they've got something wrong with their blood.’
A measure some participants used to explore differential diagnoses was the use of psychometric or standardised tests to further assess elements of mental health presentation (for example PHQ–9 (Kroenke et al, 2001) and GAD–7 (Spitzer et al, 2006). Having acquired the knowledge of these tests then using them as another layer of assessment, participants found the process had become almost natural.
‘Sometimes it is just like instinct and you need to do it now.’
Self-awareness
Participants noted an increased awareness and analysis of their role and practice when working with emergent mental health presentations.
‘I might have felt confident before but now I've learnt more about mental health and assessments, I think I realise that I did have areas lacking, so I think … I had a broad understanding of lots and lots of conditions I've built up over the years, but it was realising how superficial that was in certain areas.’
There was an almost ‘eureka’ moment, when participants realised that giving patients more time to talk led to them unravelling something that had previously been too complicated to articulate. This led to a personal reflection on coping.
‘… acknowledgement that there was something wrong, so I question him and then his whole body language … everything just changed. It was a bit like popping the balloon, and he seemed deflated and it was just interesting to see that, especially as we put make-up on … you're having a bad day, get your slap on, you put your smile on, and it doesn't matter what else is going on. At home, you don't have that face in front of your patients, but he had that face in front of us. Unless you spend that time observing, you don't necessarily get or notice it.’
Improved skills also related to listening and pausing before acting.
‘I think some of it was about actively thinking about communication strategies, actively looking at body language that I was using and going into that … there was an awareness of this prior to the course but … not to the same extent I think and, again, I think I wouldn't say that my communication style or my communication have changed but certainly I have an awareness of the impact I suppose. Doing it badly could potentially have that impact on that therapeutic conversation.’
Discussion
The research aimed to investigate the efficacy of mental health-specific content within an MSc ACP generic programme, with the objectives of evaluating the utility of these skills within the ACPiTs' clinical practice. The method and methodology facilitated the collection of relevant data.
The process of gathering and analysing information enabled the authors to elicit ACPiTs’ personal beliefs. The beliefs that emerged from the interviews highlighted improved levels of self-awareness, and an understanding of the impact of communication and use of things such as specific assessment tools on the identification of problems. Such problems were commonly not the main reason for the clinical contact, but it soon became clear they were underpinning and influencing the presentation. An awareness of improved communication skills led to an understanding of how competence improved and how this linked to the module, and is highlighted by the reflections given by the ACPiT. Awareness related to the self was conflated with clinical practice and personal growth, particularly in seeking alternate evidence and identifying changes to non-verbal communication.
Although past documents have emphasised the need for the ACP to demonstrate competencies in advanced higher-level communication skills that can aid negotiation and influence practice (NHS Education for Scotland, 2008), more recent documents have downgraded the competence to a more generic ‘effective communication’ in a person-centred fashion (HEE, 2017). The complicating factor is that little direction is offered as to how to do this in practice, and this study argues the use of a mental health module for all ACPiT can address such a competence.
Enhanced communication skills, using questioning skills and understanding when to adjust how they communicated were seen as crucial, as were giving time and using active listening skills to allow patients to ‘open up’. Such skills are more often seen in counselling-type encounters (see the seminal work of Rogers (1957)) than in frequently busy and highly stressed clinical environments.
Non-verbal communication cues, in particular observation skills and noticing subtle behaviour changes in patients, were seen to indicate something that differed from what patients were saying. This level of awareness of communication related to knowledge gained from the module and synthesising this with clinical evidence; this echoes the training direction argued for by HEE (2017) and was overtly provided by the mental health module in the programme. Ultimately, these enhanced communication skills, combined with nursing and medical skills, support the development of these ACPiTs into expert practitioners (Elsom et al, 2005). Often the modular work was carried out using role-play and simulation-type approaches. McKenna et al (2010) argued that interpersonal skills can be learnt from such approaches.
The realisation and awareness of permanent changes to practice were related to the theme of emergence of competence. The development of skills related to engaging in detailed holistic assessments, and analysing and interpreting findings around mood, risk and thoughts, including verbal and non-verbal behaviour, support advanced practice (Department of Health, 2010).
Fawcett and Rhynas (2012) acknowledged that obtaining a comprehensive history that includes social and psychological elements alongside biomedical factors can be challenging, but paves the way for person-centred care, which is promoted by HEE (2017) within advanced clinical practice. Further deliberations resulted in the identification of the ability to handle difficult situations using problem solving and advanced communication skills (Svarovsky, 2013).
The authors observed an increase in confidence in the participants' approaches through their discussions, which is congruent with the notion of confidence being synonymous with Bandura's (1984) self-efficacy theory. This belief was attributed to the acquisition of knowledge and skills through the mental health module together with exposure in clinical practice. The relationship of new knowledge and opportunity to practice increased the appetite to seek learning experiences in practice and pursue clinical cases involving individuals with mental health problems.
A change in practice was identified in that the practitioners assessed and treated people with comorbid mental health problems rather than just referring them on, as may have been done in the past. This previous practice did concern ACPiTs as they were then left wondering about the quality and level of support that ensued after referral. A key problem of exploring reflective-type themes from practice is an increasing level of self-awareness, which may lead to personal questions related to past practice. Such an approach can ‘lead to the painful experience of working through, or coming to terms with, the issues raised’ (Rawlinson, 1990: 113). However, with a level of professionalism, the ACPiTs were able to contextualise past and current practice and acknowledge how they had changed as important.
ACPs should autonomously be using complex decision-making skills, which can improve people's outcomes (HEE, 2017). The findings from this study suggest these skills can be further enhanced and developed to meet the needs of a large proportion of the population.
As no study exists that has explored the mental health-related skills at the end of a generic programme, it is difficult to state whether such skills may have emerged in ACPiT practice without the mental health module. What can be seen is that the skills developed following the mental health module were durable and still recognised by the ACPiT and used 12 months after the training.
Limitations
Both authors taught elements of the mental health module and interviewed the participants. This could have produced bias in the results as it may have meant the participants were more likely to give favourable answers. The use of a digital recording device could have increased participants' anxiety levels and deterred them from offering personal experiences.
Finally, using a case study approach limited to ACPiTs from one institution in one area of the country may not reflect experiences elsewhere.
Such limitations were mitigated by adhering to the aim and objectives and blind analysis with only the use of matching themes. Both authors analysed the raw data separately, without discussion from the participants or the other researcher. They developed their own themes independently and those from the independent analysis that matched were the ones only used.
Conclusion
The ACP role involves possessing enhanced knowledge and skills supported by advanced clinical decision-making and autonomous practice; it is also one that requires a truly holistic approach when assessing individuals. This includes recognising of mental as well as physical health problems while using a combined medical and nursing skillset.
Unique to this role are the use of enhanced communication skills, and competence in the assessment and initial management (including using referral pathways) of those with emerging or established mental health needs in all healthcare settings.
This study has provided insights from ACPiTs who recognised the value of additional mental health teaching and exposure within their training programme to advance their knowledge base, skillset and, ultimately, confidence in their advanced clinical practice.