Applying national standards to advanced clinical practice
Regional academies for advanced clinical practitioner roles in Scotland are striving to improve consistency
Regional academies for advanced clinical practitioner roles in Scotland are striving to improve consistency in remote and rural areas
- Lone practitioners need autonomy and broad skill sets
- Academies focus on academic and clinical competence and inter-professional collaboration
- Scottish academies developing in parallel to NHS England’s Advanced Practice Academy
Political and healthcare leaders have stressed over the past five years the need to develop advanced clinical practitioner (ACP) roles.
To develop ACP roles there is a need for consistent standards in education and clinical competence in practice to ensure that patients receive the right quality of clinical care.
And to attain this consistency, three regional advanced practice academies have been set up to cover the north, west and east of Scotland.
Tips for developing advanced practice
- Use consistent methodology and standards to develop practitioners for new or evolved roles and consider the triangle of capability: academic preparation, clinical competence and effective supervision
- When maintaining or developing services, be sure to understand local patient healthcare needs and practical staffing models for a particular geographical area
- Appreciate the chance to use actual and potential staff skill sets differently
- Support innovation and development through a formalised structure with clear governance and excellent patient care at its heart
Key components to developing advanced clinical practitioner roles
The academies have a clear focus on inter-professional collaboration and on academic and clinical competency standards underpinned by academic achievement to master’s level, effective clinical supervision and clinical competency sign-off in practice.
When applied to ACPs, including advanced nurse practitioners (ANPs), the knowledge, skills and ability to undertake critical analysis of information is aligned with skills and competencies such as clinical assessment, diagnosis, management and treatment of health problems, prescribing medication and other complex interventions.
The development of three academies runs parallel to that of the NHS England Advanced Practice Academy.
However, an important element of the Scottish model is encouraging local solutions when appropriate while sharing learning regionally and nationally to achieve ‘once for Scotland’ solutions where possible.
Healthcare services in northern Scotland, for example, face particular development challenges due to remote and rural working, where broader skill sets and greater autonomy are required by lone practitioners to meet the local population’s healthcare needs.
How the regional academies work
The freedom to develop and operationalise solutions to address patient needs locally while collaborating at a national level can reach down to the level of NHS boards.
NHS Grampian is one of six NHS boards in the north, for example. It is linking creatively with partner boards through the North of Scotland Advanced Practice Academy to share support for safe practitioner development and meet community healthcare needs differently.
NHS Grampian has its own advanced care academy, which is the board-level governance structure that houses a nurse consultant in advanced practice, a suite of learning and ANP fellows, who can augment and substitute for clinical supervision requirements across a range of care platforms.
Three case studies detailed below focus on NHS Grampian as well as NHS Orkney, also in the northern region of Scotland.
The fellow experience
Arlene Chalmers, an advanced nurse practitioner fellow at NHS Grampian, on role-modelling and providing expert clinical supervision to trainees across the region
In our board area an initiative was launched to help provide clinical supervision in practice that would support trainee advanced nurse practitioners (ANPs) and help maintain safe service delivery.
Qualified and experienced ANPs were recruited to the local advanced care academy to provide clinical supervision on a locum basis.
After 12 years as an ANP and with experience in acute and primary care, I found it an interesting opportunity.
Following a successful interview, which included scenario-based elements aimed at testing knowledge and educational ability, it was time to put the model into action.
Advanced practice academies
have representation from all boards in the area and aim to provide consistent academic and clinical competency standards and inter-professional collaboration for advanced clinical practice roles
'I share expert practice at the point of learning'
As an academy fellow who is an ANP I share expert practice at the point of learning, including the following:
- Correlation of clinical signs and symptoms with underlying pathology
- Practical hints and tips, for example on where to find current guidelines to help with unfamiliar presentations
- Benchmarking safe, competent care and where to get help when needed
- Sharing experience of different service models to help colleagues identify what might work for them, particularly where the ANP role is new or senior cover is routinely provided by locum GPs
- Managing workload
- Ultimately, clinical supervision and sign-off for competencies achieved in practice
What’s in it for the fellow? As any educator will tell you, teaching is the acid test of how well you understand something.
Enhancing personal knowledge and skills
Helping trainees continuously improves knowledge and understanding. The academy arranges courses that enhance personal knowledge and skills, as well as improving the supervision and support on offer.
There are also regional working opportunities, such as assisting with ANP service development, which give me the opportunity to share ideas and ‘steal with pride’ any that may prove positive at home.
So far, I have been to Shapinsay in NHS Orkney and Fort William in NHS Highland.
Finally, networking with other academy fellows and ANPs offers access to a vast array of experience, knowledge and skills – a win-win situation. Why would you not?
Rural practice: a new nurse-led model
Olive Watt and Diane Cameron, ANPs in NHS Grampian, explain how academy fellows support trainee practitioners in Aberdeenshire to achieve their qualification and maintain service delivery with only locum GP cover available
A health and social care partnership urgently sought to maintain services for 5,000 people who use a two-site rural practice following the loss of permanent GP cover.
As part of the solution two ANP trainees were recruited to deliver clinical services and sustain person-centred care in the community. The Transforming Roles agenda and the local availability of academy ANP fellows enabled robust development of the roles while maintaining service delivery.
Triangle of capability
represents the three components underpinning the development of advanced clinical practice roles
The initial focus was on learning needs analyses to inform educational and clinical competency requirements.
Positive outcomes that have improved patient care
Academy fellow mentorship and supervision enabled the safe development of clinical competence and provided clinical leadership for the senior clinical team members. It also enabled development of the existing team.
One year on and the ANPs are qualified, but difficulties remain because there is still no permanent medical practitioner, although there is decision support from locum GPs.
Reflecting on this journey there are positive outcomes that have enhanced patient care. Communication has improved with a daily multidisciplinary ANP-led team huddle, which highlights acutely unwell, vulnerable or palliative patients and those with new diagnosis care concerns.
This enables planning, shared ownership, enhanced patient experience and a person-centred approach. We try to deliver our service ‘right person, right place and right time’.
Our project is near completion, with both of us working autonomously and effectively in the multidisciplinary team. We have a clear agenda to support ongoing service development, provide clinical leadership and allow our GP practice to operate with our patients at the heart.
Remote island working and the role of the academy
Ian Hall, an advanced nurse practitoner in NHS Orkney, gives his perspective on lone-working advanced practice roles encompassing aspects of GP, district nurse and paramedic skill sets
NHS Orkney has six non-doctor islands with a resident advanced nurse practitioner (ANP) providing 24/7 healthcare to their populations. There is normally a GP visit twice weekly.
Shapinsay has the largest population of about 300 people, with a wide demographic spread from babies to the very old. The primary school has 28 pupils and there are about 20 teenagers who have a 30-minute daily commute by ferry to the mainland secondary school.
With the need for chronic disease management and urgent care from cradle to grave, the ANP needs to be competent and confident in various aspects of GP, district nurse and paramedic skill sets.
'Emergency care provision is essential'
The ferry moors at the island overnight. If needed for an emergency evacuation, there is a volunteer ambulance driver, a trained Scottish Ambulance Service responder and the ferry crew, who mobilise to support rapid transport.
Emergency admission audit shows an average of two emergency admissions a month. Emergency care provision is an essential part of the ANP’s role and there is regular training with the British Association for Immediate Care (BASICS) Scotland to keep these skills fresh.
'We rely heavily on videoconferencing'
As a small health board, there are no relief staff trained to ANP level, which creates difficulties in providing cover for absences, and geographical isolation makes training and networking a challenge.
We rely heavily on videoconferencing to virtually access mainland education and development opportunities.
De-skilling is also an issue when based on remote islands. This is felt most acutely on the smallest islands, where the scope of exposure to less common problems and to prescribing is limited.
Collaboration through the North of Scotland Advanced Practice Academy not only supports networking, skills maintenance and training opportunities; it also broadens access to appropriately trained ANPs who can provide locum cover.
Karen Kindness is nurse consultant at NHS Grampian and can be contacted at firstname.lastname@example.org; Arlene Chalmers is an advanced nurse practitioner fellow at NHS Grampian; Olive Watt and Diane Cameron are advanced nurse practioners at NHS Grampian; and Ian Hall is an advanced nurse practitioner at NHS Orkney
Find out more
- Docherty E, Cooper M, Hudson E et al (2018) Transforming the Advanced Practice Landscape in Scotland
- Health Education England (2017) Multi-professional Framework for Advanced Clinical Practice in England
- International Council of Nurses (2019) Definition and Characteristics of the Nurse Practitioner and Advanced Practice Roles
- Kindness K, Gray H, Moggach A et al (2019) Establishing an advanced care academy and its role in advanced practitioner development. Nursing Management
- King’s Fund (2019) Closing the Gap: Key Areas for Action on the Health and Care Workforce