Advanced Practice Toolkit
2. Designing an Advanced Practitioner role
2.2 How will you accommodate all four pillars of Advanced Practice?
TIP: Create a job plan and job description that allows for a set proportion of time for non-clinical work.
TIP: Identify how you can use Advanced Practice skills for research and research related tasks.
TIP: Support Advanced Practitioners to access skills and support for research, including project management, identifying evidence and implementation skills.
TIP: Identify how Advanced Practitioners can contribute to education in your organisation.
TIP: Identify how Advanced Practitioners can contribute to leadership and management tasks in your organisation and beyond.
TIP: Consider multi-disciplinary and cross-practice collaboration.
Advanced practitioners work across four pillars of practice: clinical practice, education, research, and leadership and management. Although there is no expectation that these pillars will take up equal time, an Advanced Practice role that provides no scope for research, education or leadership will not be successful or fulfilling. It will also not meet the national guidance on Advanced Practice Roles [16; 17].
a) Research
Research does not have to be restricted to large research trials. Advanced Practitioners can support audit, pragmatic evaluation and other research adjacent tasks.
Badu et al [2] felt that “the research pillar of clinical practice is often subjugated to the other pillars” and that research should be embedded within job plans and not seen as an additional luxury. They felt this would improve access to clinical trials for patients, which have been proved to improve care, and would ensure that more clinical research was delivered.
Fielding et al [12] highlighted that keeping abreast of the evidence base requires specialist skills and knowledge to identify relevant, high-quality research and to reduce biases. They argue that Advanced Practitioners are in a strong place to lead “pragmatic implementation” of research, due to their professional experience and their place in the clinical team, and the multidisciplinary nature of their training. In Nottinghamshire, there is specific access to an information scientist/librarian who can support Advanced Practitioners with these skills.
Interestingly, Advanced Practitioners interviewed by Thomson et al [45] fed back that research skills could be too divorced from their everyday work, and suggested that input on project management skills and service improvement should be included. Nottinghamshire has training for GP and Nurse Fellows in this area, which could be adapted for Advanced Practitioners.
Evans et al [11] found that there were limited opportunities and limited time for research in primary care; their participants felt that the role was “for” clinical work and that anything else was peripheral. Although many Allied Health Professional (AHP) Advanced Practitioners in Nottinghamshire [25] were positive about the chances to engage in research, teaching and leadership, some said that these aspects could be “shelved” when clinical pressures rose. “Clawing back” time for non-clinical work had got particularly difficult during the pandemic. One talked about how they used to have time for educational sessions but that nursing colleagues have left their roles, and covering staff absence could be extremely challenging.
b) Education
Stewart Lord et al [42] identified areas where Advanced Practitioners were writing up pathways, running training sessions for other professionals (for example in the role of art therapy) and had created training manuals; some had secured funding for doctoral study. Mentoring colleagues was also viewed as an essential part of advanced practice. Evans et al [11] found that mentorship and training for others was often informal and took the form of advice and support more than recognised educational roles. Lee [26] also found informal leadership education was important, including Advanced Practitioners who mentored and supported junior doctors. Advanced Practitioners expertise in these areas will need to be recognised, with senior medical colleagues being mindful to promote the advice and support that Advanced Practitioners can offer to clinical colleagues.
c) Leadership and management
Whilst considering this pillar from the perspective of Advanced Practice roles, it is helpful to consider that leadership and management can be tasks as well as roles; an Advanced Practitioner can show considerable leadership in offering advice, guidance and supervision to others even when they do not hold positional authority. A good example of this is that an Advanced Practitioner may often be an expert in an area which GP partners are not, and could show considerable leadership in redesigning a care pathway, advising doctors and other clinical colleagues and supporting service improvement [25; 48; 42; 43; 44]. Attendees at focus groups in Nottinghamshire [25] found that they were often the only representative of their background profession on a multi-disciplinary team.
Stewart Lord et al [42] identified leadership as one of the core differences between advanced practice and the professions that people initially trained in, potentially to a greater extent than clinical excellence. They found Advanced Practitioners “enthusiasm” important in redesigning pathways, and identifying potential pathway alterations that would be better for patients and more cost effective, such as direct access to physiotherapy Advanced Practitioners rather than seeing a GP. They also highlighted Advanced Practitioners taking on mentorship and advisory roles with junior staff and students, either with or without formal authority.
As smaller organisations, GP practices may not have large teams that require management or be able to support pathway redesign [11]. Employers designing an Advanced Practice role may be able to consider what opportunities exist at the PCN, ICS or professional network level.