Advanced Practice Toolkit 

9. Establishing the Role 

TIP: Ensure employers and line managers understand advanced practice and are openly supportive of the Advanced Practice role. 
TIP: Communicate role boundaries and limitations openly and honestly. 
Managerial support is a key enabler in adoption of the Advanced Practice [10; 43; 40; 46; 29]. Edwards [10] cites that a lack of managerial support, or an over-rigid approach to role development, can hamper adoption. Scott [40] also reports a need for “enlightenment” amongst managers on the benefits of the role. The appointment of a lead role for advanced practice in Primary Care [10], as Nottinghamshire has done, can help managers see the benefits of the role and the best way to implement it. Unsworth, writing in the context of Advanced Nurse Practitioners, highlights the role of nurse managers in ensuring the role is acceptable to colleagues, acting as a “catalyst” for involving other stakeholders in developing and embedding the role. Managerial support should extend to being cautious not to discuss the Advanced Practice role in terms of being a “cheap substitute for doctors” as this has, in the past, alienated both Advanced Practitioners and their colleagues. In our focus groups [25], there was still some negativity around the role where people misunderstood what Advanced Clinical Practitioners are capable of and thought they were there to help the GPs as “not quite a doctor” rather than to act as independent practitioners; one reported having “robust” conversations with some GPs. General practice was seen as highly variable and built on relationships; some practices were seen as “more doctor-centric” than others, and our attendees highlighted the importance of building relationships and working together. 
Advanced Practitioners will also need support from across the team for the role to embed [37; 46]. Leadership is needed to avoid problems where an Advanced Practitioner who is returning to a previous team is treated with jealousy or expected to step back into their previous roles [37]. This situation is also worsened by differences amongst Advanced Practitioners [37; 28], for example where some Advanced Practitioners can independently prescribe fluids and pain relief and others cannot [37]; whilst not entirely avoidable, clear communication and role descriptions will help mitigate this. Advanced Practice roles can be helped to embed by blurring the silos and professional boundaries around multi-disciplinary teams, co-location of professionals, shared goals and whole team meetings and handovers [27] and this can improve patient outcomes [27]. 
Taylor et al [43] highlight the challenges of being a pioneer Advanced Practitioner within a speciality, and therefore lacking defined development and training opportunities, explaining role content and lacking role models. They found that some Advanced Practitioners, who were passionate advocates for their role, would also not recommend others followed their path as they had found it challenging and demotivating. Stewart Lord et al [42] highlighted that rarer Advanced Practice professionals, for example art and drama therapists, could struggle to be recognised or understood by other professionals and that this hampered their opportunities to contribute. 
Thompson reported that some GPs may also see Advanced Practitioners as threatening, especially where they undertake the highly complex care that used to be reserved solely for doctors (e.g. 27). This could also be seen in pressure from secondary care, where some hospitals were reluctant to take referrals from Advanced Practitioners, or even refused to accept non-GP referrals, seeing GPs as the only safe professional for this role. Evans [10] found that this was reported as a historical, but not a present issue in their study. They also found the need for, and therefore the acceptability of, Advanced Practitioners was well established, and these issues were mitigated by the demonstrable impact of the role. 
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