Over half of the papers included findings from my literature review on the benefits of ACP related to the identification of barriers or facilitators of implementing effective advanced clinical practice or advanced clinical practitioner roles.
Several of the papers focussed research on a specific context (e.g. specialty, geographic area or professional group), however the findings identified potential barriers/ facilitators that could be applied in other contexts where ACP occurs or is being developed or introduced. The range and currency of many of the papers appears to also provide consensus that despite knowing about the barriers to effective implementation of ACP, they are still prevalent, and the facilitators are often not considered when planning development of an ACP role.
The barriers and facilitators of ACP broadly fit under the themes below:
- Access to training and education
- Support from others for role expansion
- Organisational structure, policy and protocols
Access to training & education
Some of the literature highlights the ‘adhoc’ way in which ACP roles have developed and that this has created a “confusing overlap” in many areas. The literature also makes claim that a lack of consistency in training and education (both in what is offered and how it is accessed) has hindered efforts to make full use of ACPs in health care.
A number of papers also highlight that there is a need for sufficient availability of appropriate interprofessional and financially viable education and training to provide the skills necessary to fill ACP posts. Without this it acts as a barrier to development and implementation of effective ACPs.
Inadequate protected time for education is commonly identified as a barrier and is often related to one of the other major findings of my literature review; that clinical practice dominates the role and the time allocated to duties/ tasks within this role. It was commonly reported that clinical demands took priority and that opportunities for development and education were missed if a clinical task was needed.
Support from others for role expansion
In a range of studies medical staff were the major professional group that had a significant impact on the development, implementation, level of autonomy, management, and operation of the ACP role. There is discussion in the literature of the need to ‘win round’ physicians if the role was to be considered as a worthwhile endeavour, to remove anxiety of ACPs ‘taking over’ and undermining their role, and to attract the funding and managerial or organisational structures to facilitate the role.
Where support was not in place ACPs often found they were unable to operate the full extent of the role and utilise the knowledge, experience, and skills they had gained. Significantly this was correlated with a lack of engagement in managerial or leadership functions of the role, including development of policy.
The perception and understanding of the role, particularly by physicians and employers, was discussed as having a major influence on how, what, and where ACP roles were developed. This reflects the ‘localisation’ of ACP, which, as noted in my previous blog post, has an impact on the definition, nomenclature, and scope of ACPs. This occurs even in situations where specific policy or protocols were in place to ensure consistency.
Personal relationships can be key and may require a long time to build up; ‘trust’ is required between professions to allow the sharing, re-allocation or shaping of health care services, roles, and tasks. The personal attributes of the ACP also has an impact here, with perceptions of ACPs that hold desirable attributes such as confidence being more likely to gain trust. The presence of a role model, mentor or support from senior managers, combined with opportunities to receive feedback or engage with a peer network were powerful enablers of the role.
However, the reliance on support from others makes the ACP role precarious. It requires professional relationships built up over time and if a supportive member of staff leaves, the ACP role may not be able to continue to develop or operate as it had done before.
Organisational structure, policy and protocols
Familiarity within an organisation and ‘localisation’ extends even in situations where national, professional, or organisational level policy is in place. Local arrangements may restrict ACPs from undertaking their full range of the role and the skills they hold. This includes protocols that define the path of clinical intervention, including what tasks are undertaken by whom, which may limit the development of these roles and ‘lock’ people into their current employer.
The impetus for the development of the role is seen as significant in providing the organisational structure in which ACPs operate and it is highlighted that when ACPs have been bought in to ‘fill the gaps’, this can impact the scope of their role. For example, advances in medical knowledge, clinical interventions, and technological advancement, especially in management of chronic illness, may create a need for roles that organise the various aspects of care required in this complex context. ACPs as a ‘generic’ rather than a specialist role can “fill up the space between the specialised practitioners, guiding the patient through the treatment trajectory”. De Bont et al. (2016, p. 11). In this organisational structure the ACP can therefore be seen as adding value in terms of promoting continuity of care through complex systems, services, and disease trajectories.
Funding mechanisms that support particular organisational structures (such as group GP practices and sharing of ACPs) may also provide an impetus (or disincentive) to support the ACP role. On a more functional level, the lack of access to administrative support funding, and resources for data management may affect the fulfilment of the role, particularly in leadership aspects. This also links to a lack of authority and position within an organisation because ACPs often sit outside of traditional hierarchical and committee structures, which impedes their influence on strategic decision making.
The need for clear communication of role definitions, job descriptions, and boundaries to reach consensus on expectations and facilitate transition into ACP roles is highlighted. The lack of clear agreement and communication of the career pathway for ACPs within the current or traditional organisational structure is noted as a potential barrier, with the risk that ACP is seen as a ‘dead end job’ or a ‘career cul-de-sac’. The lack of engagement with, or opportunity for non-clinical aspects of the role (leadership, education, research) may reinforce this, with few options for these health professionals in an organisation to progress in a clinically dominated career. Although the more recent development of the framework for consultant level practice may prove to overcome this to some extent (if similar barriers and facilitators as experienced within ACP are addressed).
Conclusion
There is broad consensus on the barriers and facilitators that by their presence/ absence affect full realisation of the potential benefits of ACPs, effective implementation, or measurable positive impact on outcomes. If we want ACP to be successful we do therefore need to address these, share best practice, and not repeat mistakes of the past.
Reference: de Bont A, van Exel J, Coretti S, Ökem ZG, Janssen M, Hope KL, Ludwicki T, Zander, B, Zvonickova M, Bond C, Wallenburg. 2016. Reconfiguring health workforce: a case-based comparative study explaining the increasingly diverse professional roles in Europe. BMC Health Services Res. 16:637.
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