In this blog I will explore the key themes I identified in my systematic literature review on the benefits of the Advanced Clinical Practice for key stakeholders in relation to education and regulation.
15 of the 26 papers that had a theme of education within them, noted that there are a variety of education pathways ACPs have taken to be working in their current role, including formal, and ‘non-formal’ training, UG, PG, and Doctoral study. This concurs with the results of my recent survey as part of recruitment to my latest research project where 41% had achieved an academic qualification in ACP, 23% had received on the job training and only 4% had undertaken a credentialing programme. This variation has been identified as a potential barrier to effective implementation of ACP; creating confusion and lack of a clear career pathway for ACPs and their employers, and is linked by some authors to the lack of regulation structures for ACP.
There appears to be agreement that regulation may be a way to reduce variation and confusion over career pathways for ACPs. It is suggested that in countries where there is less developed regulation, the presence of barriers are higher. However the data to corroborate this statement is not presented in the research, only data that confirms that variation exists is presented. Conversely, others point to the lack of regulation in the UK as facilitating adaptation to the scope of practice which enables ACP roles to be effectively implemented at a local level. However again, this was not directly measured in the research data presented. I found limited evidence of directly researching different types of regulation and the impact this has on effective ACP, other than evidence based upon self-report surveys of a subset of organisations linked to nursing only organisations in some countries. The literature I found presents what regulation is present, but does not measure which may be more or less effective, particularly in the diverse, contemporaneous, UK ACP context.
Thus far regulatory bodies appear to have rejected the idea of adding a new level or type of regulation for their ACP members because of the belief that their regulation already covers practitioners to develop along a continuum, including advanced practice. This stance was endorsed by the Council for Healthcare Regulatory Excellence in 2009. The Nursing and Midwifery Council’s (NMC) review in 2019 however noted the repeated calls for regulation of ACP and highlighted an opportunity to draw together the “patchwork of education” and rationalise it under the leadership of the regulator. (Noting that a new standard for post-registration education in SCPHN and SPQ, has now been produced, NMC, 2022). The work conducted by Leary et al 2017 which more broadly looked at titles used within nursing found proliferation, inconsistency, and poor clarity which they concluded could be attributed, at least in part, to lack of regulation.
However, ACP is multi-professional and there continues to be no national regulation of ACP . The somewhat newer introduction of ‘credentialling’ as an effort toward standardisation, remains patchy. There is insufficient longitudinal evidence found in my review that directly assesses whether regulation is a barrier or facilitator specifically of ACP, or what types and degrees of regulation may be more or less effective in realising the benefits of ACP. Further research that particularly focuses on the impact of changes to regulation or standardisation of ACP may provide evidence to support or reject changes to regulation. (For example research that investigates the impact of the work being undertaken by the Centre for Advancing Practice and ACP accreditation by Health Education England (2022), or the independent research conducted by Hardy et al 2021 to explore issues of ACP regulation in the allied health professions as part of a review by the Health and Care Professions Council).
Similarly evidence has not been established that one form of education and training better equips the ACP for their role. It is proposed however that the form of training and education undertaken by ACPs may have an influence on their ability to provide, & support others in providing, evidence based practice, critical thinking, decision making and professional identity, and leadership. There is a self-reported perception that certain types of training/ education preparation (Masters study) provides personal benefits including opportunities for service improvement and that it enhances confidence, autonomy, and external authority. There is broad consensus that ACP preparation should be at Masters level, although there is also recognition that in the UK a number of routes continue to exist.
Hughes et al. (2017) included a Training Needs Analysis in their study of pharmacist ACPs in which 4 main themes were identified as needed to carry out the ACP role;
- clinical examination and assessment,
- diagnostic skills,
- medical management and treatment, and
- specialist training course components (e.g. radiology or minor injuries).
Whilst the Hughes et al. (2017) study focussed on assessing if ACPs could effectively manage a clinical case load within an emergency department, it is interesting to note that other aspects of training such as in leadership, policy development, or research and evidence based practice were not identified as significant or valued by ACPs in this study. This is contrary to the position of requiring a Masters level qualification noted by many of the papers, and one that does not align to the Multi-Professional framework which necessarily entails training in a broader range of knowledge and skills than those focussed purely on clinical practice.
Some types of education methods within ACP training programmes have been tested for their effectivity on achieving their stated aims or purpose, (including simulated video OSCEs, coaching, gamification, action learning sets). There was potential for bias in these studies, and it was noted that there exists variation in the quality of ACP training and education programmes, (particularly in relation to their relevance for specific fields of clinical practice). However, in general, these were seen as useful and effective education strategies for ACP. The use of distance learning and alternative forms of delivery are recommended for further investigation in relation to their effectiveness as more ‘traditional’ options can be costly, inconvenient, and not sustainable. The wide uptake and cultural shift in utilising technology and other forms of education delivery and interaction in the Covid-19 pandemic presents a good opportunity for this to be investigated. Evidence is though limited in terms of measuring long term outcomes and application of ACP education approaches to contemporary contexts in which ACPs practice.
So the key themes here seem to be variation, a desire for standardisation, and uncertainty as to how best to address this, especially noting the need to address the four pillars of ACP, and the diverse range of ways and fields in which ACPs practice.
Council for Healthcare Regulatory Excellence (2009) “Advanced Practice: Report to the Four UK Health Department” [cited 19th February 2020] Available from https://www.professionalstandards.org.uk/docs/default-source/publications/advice-to-ministers/advanced-practice-2009.pdf?sfvrsn=38c67f20_6
Hardy M, Snaith B, Edwards L, Baxter J, Millington P, Harris M, 2021. Advanced Practice: Research Report. Health and Care Professions Council [cited 2021 January 27] Available from https://www.hcpc-uk.org/cy-gb/adnoddau/policy/advanced-practice-full-research-report/
Health Education England, (2022). ‘Programme Accreditation’. [cited 2022 November 4] Available from https://advanced-practice.hee.nhs.uk/our-work/programme-accreditation/
Hughes, E., Terry, D., Huynh, C., Petridis, K., Aiello, M., Mazard, L., Ubhi, H., Terry, A., Wilson, K. and Sinclair, A. (2017) ‘Future enhanced clinical role of pharmacists in Emergency Departments in England: multi-site observational evaluation’, Int J Clin Pharm, 39(4), pp. 960-968.
Leary A, Maclaine A, Trevatt P, Radford M, Punshon G, 2017. Variation in job titles in the nursing workforce. J Clin Nurs. 26:4945-4950
Nursing and Midwifery Council (2019) ‘Evaluation of post-registration standards of proficiency for specialist community public health nurses and the standards for specialist education and practice standards’. [cited 2020 February 19] Available from https://www.nmc.org.uk/globalassets/sitedocuments/education-programme/evaluation-post-registration-scphn-and-spq-standards.pdf
Nursing and Midwifery Council (2022) ‘Part 3- Standards for Post-Registration Programmes’. [cited 2022 November 4 ] Available from https://www.nmc.org.uk/standards/standards-for-post-registration/standards-for-post-registration-programmes/