Assessment of advanced clinical practitioners

ABSTRACT

To continue growing the advanced clinical practitioner (ACP) role nationally, and similar roles internationally, there must be widely held trust in the level of practice and the roles worked in service by ACPs. This requires infrastructure to support ACPs through their training and ensure they are fit to qualify. This short report focuses on an evaluation of assessment processes in the acute sector in a county in England, to understand their feasibility and suitability. The qualitative research design was attendance at assessment panels and 17 semi-structured interviews with assessors and ACP trainees, from nursing, physiotherapy, paramedicine and operating department practice backgrounds based at two hospitals. Key themes identified through thematic analysis were the different approaches to assessment and the support required to engage effectively with assessment. One hospital had a well understood process, including ACPs with a clear identity. The other hospital had a credible assessment process that continues to be developed. The insights from this study enabled lessons to be drawn for those responsible for workforce development who are key to the future development of the ACP role and to ensure high standards of interprofessional care.

KEYWORDS:

• Assessment
• advanced clinical practice
• acute health care
• professional development
• interprofessional collaboration
• evaluation

Introduction

The definition of “advanced practice” and what this means varies between countries. Most of the international literature on advanced practice focuses on nurses. The nurse practitioner role, as an advanced practice role, was introduced in the USA in 1965 (Maier et al., 2016) and today exists across the globe. Educational requirements and scope of practice vary between countries (Ketefian et al., 2001), although advanced practice roles tend to require masters level qualifications, for example, in North America and the nurse practitioner role in Australia. Although many factors influenced the introduction of advanced practice roles in different countries, a shortage of doctors and interprofessional collaboration were key considerations (Ketefian et al., 2001).

In the United Kingdom (UK), Advanced Clinical Practitioners (ACPs) are healthcare professionals with a specific clinical background, including nursing, paramedicine, radiotherapy and physiotherapy, who work across all healthcare sectors. This gives the opportunity for interprofessional education and interprofessional collaboration through expanding the professional boundaries of clinical practice. These individuals must be masters level educated and work at a level of “advanced” clinical practice (HEE, 2020). This level of work is a synthesis of skills across clinical practice, leadership, education and research (HEE, 2017). The ACP role requires the development of a high level of clinical capability usually through a programme of workplace learning to achieve a specific set of core competencies supported by concurrent academic learning. These competences are taught and assessed in practice, with annual Hospital-based monitoring and assessment of clinical progression (HEE, 2018).

Background

There are concerns in the UK around the variation in education of ACP roles (Evans et al., 2020) but the ACP assessment processes in one county in England are noteworthy. For example, a Core Competencies Framework was created in 2011 to specify the level of competence expected of every acute facing ACP within one hospital in this county since there were no national standards. This was then expanded to all Trusts in the county, not only acute but also community and primary care settings. The aim of this evaluation was to appraise the ACP assessment processes in the acute sector in one county in England. Assessment required the completion and presentation of a masters degree and a paper-based and competency-based portfolio (the focus of our research), which included workplace-based assessments, a multi-source feedback and an audit. This short report examines the experiences of trainees moving through this process and assessors within two hospitals to begin to understand the feasibility and suitability of this process. Whilst also exploring the interprofessional collaboration and education which takes place whilst trainees qualify. The study reported is the first evaluation of progress made in ACP assessment in England and helps to draw lessons for the future development of the acute ACP role and is of general interest to the wider international interprofessional community.

Methods

The research was qualitative with data collected through attendance at assessment panels and semi-structured interviews. Two Annual Review of Competency Progression (ARCP) panels were attended by the researcher (LW) at one hospital. The detailed notes taken contributed to understanding the assessment process and were used in the coding process.

The sample comprised trainees from nursing, paramedicine, physiotherapy and operating department practice backgrounds. Four trainees from the first hospital and seven trainees from a second hospital were interviewed. The sample also comprisied three training leads and three assessment panel members (two from the first hospital and four from the second).

Questions covered experience of the assessment process, strengths, challenges and future recommendations. For consistency, all interviews took place on the telephone and with the same experienced researcher (LW). The interviews were conducted between July and October 2019 and lasted approximately 50 minutes each. All interviews were recorded, with the permission of the participants, and transcribed. The analytical software package NVivo Version 12 was used for management of the data. Thematic analysis through inductive coding (Braun & Clarke, 2006) was carried out on the interview transcripts. Transcripts were analyzed by hospital.

Ethical approval was obtained from the University of Winchester’s Research and Knowledge Exchange Ethics Committee, reference: RKEEC190203.

Results

Two key themes were identified: the different assessment approaches and the support required to engage effectively in the process. These themes and participant quotes are presented in Table 1.

Table 1. Table showing illustrative quotes from the interviews.

Theme	The first hospital	The second hospital
The assessment processes	Yes, it is a review of, how are you getting on? Have you got your evidence for your research? You know, show it to me and saying, how are you doing? (Assessor 2). We do it on a more informal basis, so portfolios are reviewed at appraisal, and any issues or concerns from the appraiser will then be fed up to the leads, but whether that needs to be a more formalized approach, I think it probably does, but again, we come back to that time element, don’t we? (Assessor 1). I think because at the moment [with appraisals] we’re reliant on one individual and there is always the chance that there might be an element of bias either way – when we get our clinical portfolios signed [for the ARCP] that’s done with a panel making it more robust (Trainee 1).	I think the strength of it is that it is a point in time when we can take a pause and formally review how the trainees are performing against the end point becoming a fully trained ACP … I think having it as a formal process, as opposed to a more traditional appraisal, I think is a strength because I think it raises the profile of it (Assessor 2). I think it’s important for the trainees to attend the panel. Otherwise there’s a risk that the trainee can feel that it’s a closed shop and they’re not included in decisions about their career, when it should be inclusive … I think if the candidate has the opportunity to see the thought processes being played out, however uncomfortable that might be at times, at least there’s integrity there, there’s honesty there, and there’s probably less opportunity for confusion and appeal, why have you made that decision. To me that’s more efficient (Assessor 3). I wouldn’t like to think that I’d got all the way through my training without anybody checking what I was doing and in a robust way … Yes, as much as I don’t want to go and sit in front of a panel of seven people, and have the work I’ve done throughout the year absolutely scrutinized, you do come away from that feeling that you’re achieving what you should be and you’re where you should be (Trainee 7).
Support	The fact that there are more ACPs because it’s more standardized, people are aware of the role now … I think it’s certainly become more embedded here. There’s a lot of ACPs now, and certainly speaking from the oncology perspective, they love the ACPs (Trainee 3). I think it’s tricky to say that one size will fit all essentially, because looking at our portfolios that we get in, they’re all a little bit different … I think for some of our trainees, getting their heads around triangulation of evidence that is quite tricky and that actually having a head full of knowledge doesn’t always translate into being able to display that when you’re stood at that patient’s bedside (Assessor 1). We’d always want to recruit, where we can, in a cohort so that they’ve got clear support (Assessor 2). We all come from different non-medical backgrounds and because of that – we’re all aiming toward the same end point – we come with different experiences and knowledge, so there have been some times where I’ve been a lot more comfortable than some of the other guys and vice versa. I think that helps because we have this multi-professional learning … so we can all help each other to develop. I think that’s one of the nice things we’ve got here, we aren’t all nurses. We aren’t all coming with the same qualification and background. We’ve got paramedics, physios. We all bring something different (Trainee 1).	I think one of the biggest challenges is not just within the hospital staff but also with patients and families, knowing who we are and what we do (Trainee 7). The junior doctors, some of them, they’ve worked with ACPs before, and they’re very on-board with us, so they don’t feel threatened (Trainee 5). I think it’s [the ACP role] become more accepted within patient circles than doctor circles. Patients are more accepting of them than say, for example, other doctors on the ward. It’s happening, but I think it’s patients before doctors. Three years ago, they weren’t very much accepted. Now it’s much better (Assessor 1). Obviously they’ve got used to it, but just the simple understanding of how do you use those formats [of the portfolio] … so I can see that as an immediate challenge straightaway, the nitty-gritty of suddenly adopting a medical model, when you’ve been used to a nursing model, or a physiotherapy model, or your paramedic training – the core educational concepts are the same, it’s just the mechanism by which you display that, is not familiar (Assessor 3). The culture is on a Friday we actually do peer teaching. It has been really useful, I don’t actually think that people understand – other than the trainees ourselves – how important it is for us to be collectively sat together and talk about our experiences … it is some kind of clinical supervision … some of the time I get the feeling we’re talking about, “Well what was our role in that?” and we can have ACPs, everybody with the same job title, but some people are doing wildly different things. It is really interesting to hear other people’s experiences of being a trainee (Trainee 8).

Assessment processes

The purpose of the assessment process was understood to provide evidence of clinical competence. The process was also used by the training leads to identify knowledge gaps and ascertain whether the training was appropriate.

Trainees at the first hospital had annual appraisals with their leads where portfolios were reviewed and progress and personal development were discussed. Whilst formal, these did not have the formality of medical ARCPs. However, the final year ARCP where trainees’ portfolios were signed off by a panel provided the appropriate level of robustness to declare trainees as fit to qualify as acute ACPs. Trainees attended their annual appraisals in person, but not the ARCP. The assessors perceived that attendance was unnecessary as depending on the outcome, this may lead to additional discussions by the panel.

For trainees at the second hospital, they submitted their portfolios to an annual ARCP, which they attended in person, where their suitability to progress was assessed. This more formal process involved a diverse panel, including qualified ACPs and a lay representative providing quality assurance and a governance structure. Although an ARCP was seen as credible by the trainees and assessors, the trainees had negative feelings about panel attendance believing that their presence was “redundant” because the outcome decision was based on the portfolio not any input at the event by the individual.

Support

Assessors at both hospitals acknowledged the difficulty for trainees in developing and presenting a portfolio without prior experience of this type of portfolio. The same finding was identified in research with musculoskeletal practitioners (Locke et al., 2020). The role of clinical supervision was seen as key by the assessors. This included ensuring that supervisors understood and engaged in the portfolio process. Trainees in both hospitals highlighted the importance of peer support and the value of undertaking training in cohorts. Many trainees spoke of the interprofessional education which took place during group reflection sessions and the benefits of learning from trainees with different healthcare backgrounds.

Overall, there was confusion surrounding the role and level of autonomy of ACPs. There was a greater understanding of the role and assessment in the first hospital though where the training programme had run for longer and there were a large number of ACP trainees (51) and qualified ACPs (33). The process was new in the second hospital with only two training cohorts and 11 trainees in total. In terms of interprofessional collaboration, trainees from the second hospital had concerns about some medical staff’s understanding of the ACP role. However, they did highlight the benefits of junior doctors’ exposure to ACPs through working at different trusts. Disharmony in interprofessional working between advanced practitioners and doctors has been recognized (Jones et al., 2015). Trainees in the first hospital, acknowledged that when their training programme began, medical staff were unsure of the role but as it has grown, interprofessional collaboration has become more positive as the value of the ACP role has been recognized.

Discussion

This discussion provides recommendations for the future development of the ACP role based on the evaluation of the processes in one county in England. The first hospital had a process which was well understood and the second hospital had implemented a credible assessment process which continues to be developed. Both clinical training programmes were three years similar to the nurse practitioner role in Australia which requires three years of advanced practice nursing for demonstration of clinical focus (Nursing and Midwifery Board of Australia, 2013). The ACP assessment process was dependent on the evidence submitted by the trainee which reflects how well they had understood the portfolio. To address this, we recommend key engagement from those responsible for workforce development, especially supervisors.

It is recommended that trainees begin their ACP training in an environment where the role and assessment is understood. A key barrier to effective interprofessional collaboration is a lack of awareness of each professional role of the team (Supper et al., 2014). Recognition of the ACP role will help to deliver high quality patient care whilst assisting the training and assessment process. Trainees also need a clear understanding of the role which should be delivered through a formal induction. This will give trainees the confidence needed to develop a dual professional identity and fully engage in the assessment process. A study exploring experienced nurses transitioning to advance practice nurses found that role ambiguity led to feelings of inadequacy and insecurity (Fleming & Carberry, 2011). However, having a formal orientation was positively correlated with role transition (Barnes, 2015). Where possible, it is also recommended that trainees undertake their training in cohorts for peer support with group reflection and learning sessions helping trainees share knowledge. This will build better communication between healthcare professionals. Additionally, if a hospital department is accommodating trainee ACPs, it is recommended that the training leads provide specific training to supervisors in preparation for supervision. Supervisors need to understand the role and assessment to provide sufficient support for trainees, pastorally, clinically and educationally. Quality clinical supervision for ACPs was identified as the most important factor in successful transition to becoming ACPs (Moran & Nairn, 2018). Where possible, qualified ACPs should take on this role because of their experience of the ACP training process and assessment (O’Grady, 2019).

Conclusion

To continue growing the ACP role nationally, and similar roles internationally, there must be widely held trust in these roles and this can be achieved through the establishment and ongoing development of a robust assessment process. Additionally, this trust will ensure confidence in the provision of interprofessional care involving ACPs. This report drew key lessons for those responsible for workforce development.

Acknowledgments

We would like to thank Professor John Sandars at Edgehill University for his helpful comments on a draft of the paper.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This evaluation was funded by Health Education England.

Notes on contributors

Lucy Wallis

Lucy Wallis is a researcher in the Faculty of Health and Wellbeing at the University of Winchester. Her research interests include health workforce development nationally and internationally. Her involvement in projects has included a national project exploring Allied Health Professions career choice motivations for students in the UK and global health projects with research partners in Ghana and Tanzania.

Rachel Locke

Rachel Locke is a Senior Lecturer in Global Health in the Faculty of Health and Wellbeing at the University of Winchester. She leads on collaborative research with health and education-related partners concerning health profession education, development, and practice. Rachel’s work employs distinctive qualitative research that enables her to explore the experiences of professionals and broker their narratives to wider audiences.

Clare Sutherland

Clare Sutherland is a registered nurse who trained at St Bartholomews Hospital and qualified in 1990. She now works part time for Health Education England national teams, part time for east Midlands post graduate medical and dental education as an associate dean for interprofessional learning and part time as Associate Director for Advanced Clinical Practice in University Hospitals of Derby and Burton.

Beverley Harden

Beverley Harden is the Health Education England lead for the Allied Health Professions and Deputy Chief Allied Health Professions Officer (England). Her role also leads nationally on the multi-professional advanced and consultant practitioners.  She has a background as a physiotherapist.