Advanced Practice Toolkit 

4. Advanced Practice Training and Development 

TIP: Design roles with an assumption that training and development time is included from day one, not a temporary additional burden to be added in an ad hoc manner. 
TIP: Protect study and development time, even in times of high clinical demand. 
TIP: Some Advanced Practitioners may require support and mentorship to re-enter academic study after a period of more experiential work. Discuss individual needs and monitor this on an ongoing and compassionate basis. 
TIP: Access educational or system support, for example by encouraging Advanced Practitioners to seek advice from the Nottingham Alliance Training Hub’s Information Specialist. 
Further training and development are essential for all clinical staff, in order to keep their practice up to date and deliver the best patient care. Balancing training with full time clinical practice can be very challenging [23]. Advanced Practitioners may be attempting to continue with their background profession whilst studying, and make up Advanced Practitioner hours, or study time, unpaid outside their core hours [23; 25]. Stewart Lord et al found that routes into Advanced Practice roles, and training within them, could be variable and ad hoc (even with access to Masters degrees), that they depended on operational budgets, and could still rely heavily on individual initiative. Even where managers support protected time, then a lack of backfill or short staffing can mean that people are asked to do clinical work in their study time [11; 39; 40; 43]. 
If Advanced Practitioners are studying in their own time, this can have severe negative impacts on their wellbeing and eventually on retention [11; 43]. Nurses in Nottinghamshire were more likely to be considering leaving their role if they did not have paid study leave [3]; this study looked at nurses rather than Advanced Practitioners, but we have no reason to believe that Advanced Practitioners are less likely to feel this way. 
As “health professionals’ education relies heavily on learning through experience within the clinical environment, mentorship and guided clinical supervision” [20] the more fragmented landscape of primary care, and the fact that there have not been many non-nurse Advanced Practitioners in primary care before now, can make Advanced Practice training an isolating experience for some professionals. Advanced Practitioners can be encouraged to form personal professional networks and to consult within them when needed (whilst respecting relevant confidentiality). Supervision remains a source of difficulty in education and training across primary care, with several trainees reporting multiple occasions when supervision sessions are cancelled, and several changes in educational supervisors. 
Primary care organisations may also face a challenge of keeping people’s competencies current once they are trained. Collins [6] drew a distinction between competencies (“can do”) and performance (“does do”), and noted that the former will decay without the latter. Thompson et al [44; 45] found that some Advanced Practitioner interviewees felt that their academic learning was insufficiently embedded in the realities of clinical practice, and that they did not have enough time engaged in practice-based learning to properly embed their skills. The more fragmented nature of Primary Care can reduce practice’s opportunities to keep competencies relevant, as they have different case mixes and their GPs have different specialist areas of interest; practices may wish to think about whether Advanced Practitioners would be more successfully deployed across groups of practices in that instance. 
Continuing professional development (CPD) is also important once someone is qualified and in role. Training and development can be seen as piecemeal and ad hoc [11]. To support easier access to a wide range of support with CPD, Nottinghamshire has introduced an App, The GrowNotts Primary Care App, as a single point of information on CPD and training. 
Advanced Practitioners who are performing management and leadership tasks may need specific support with project management and leadership skills. These skills become more important as people start to manage research, audit or other projects, as they step into roles where they are more likely to be supervising others who do not come from the same background profession that they do, and as they start having to achieve goals by influencing others at a higher level. This can be stressful at first, and Advanced Practitioners should be offered training (available through the Nottingham Alliance Training Hub where it is promoted on the GrowNotts Primary Care App, and also available to individuals through their own professional networks, formal training, or through the Massive Open Online Course providers such as Coursera or Open Learn). 
Work done in Nottinghamshire [3] found that nurses were more likely to be planning to leave their role if they had not had paid study time and that this effect was stronger in younger nurses. Attention must be given to workplace agreements and contracts, particularly surrounding leave entitlements. 
Academic study can be an intimidating experience if people have been out of formal education for some time [37; 26]. Advanced Practitioners have transferable skills such as communication skills, knowledge, experience, and may already be good role models themselves [37]. Translating these skills to their new role may support confident transition [37; 26]. 
Older Advanced Practitioners, who took on the roles before the expectation of a Masters level qualification was clear, can feel “pushed out” of their role, insulted or concerned that their skills and wisdom are undervalued compared to a less experienced colleague with a Masters degree [49: 16]. Conversely, Gloster and Leigh [14] argue that without a formal Masters degree, Advanced Practitioners may miss out on knowledge of current issues and developments in practice, critical skills such as analysing the quality of evidence, and some formalisation of professional ethics standards. They feel that “one could argue that ACPs [sic] who have not completed the full masters’ programme are unlikely to have studied the breadth or depth of subjects represented by the four pillars now synonymous with advanced level practice requirements.” This is controversial, but it is clear that some Advanced Practitioners may need some support with academic skills in order to gain the maximum possible benefit from a formal course. 
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