Demand, policy context and future priorities

The context within which AP roles were commissioned and practised was dominated by the increasing demand for healthcare services due to an ageing population and associated growth in numbers of comorbid conditions. As the following extract demonstrates a related need was to develop different ways of working in order to fulfil Welsh Government policy targets:The biggest pressure is the increasing amount of referrals year on year, and I think that's tied into the ageing population, we see a lot of people who are elderly and also with co-morbidities and against that pressure we've got the national driver so for example with stroke, the government targets so there's always pressures within that area as well. (Speech and Language Therapist 3)More and more patients and more and more policy guidelines are continually challenging us to tweek our services and the type of practitioners we have. It does feel relentless at times trying to keep up with all those demands and we don't have much time to take stock. (Workforce Development Manager 3)

However, there was little consensus around the priority areas for the development of AP roles. This reflected the unprecedented demand already referred to as well as the actual and potential broad scope of AP roles. Key clinical priority areas for AP roles discussed during the focus groups included (among others): unscheduled care, mental health, dementia, emergency care, neonatology, primary care and paramedic roles. One unifying theme to emerge from the data was that current and future AP roles had a crucial part to play in hospital avoidance and more timely discharge of hospital patients into the community.If we used advanced practice roles more in elderly care, in medicine pathway, in preventing the chronic bronchitic who regularly comes to hospital, getting admitted because they've got access to somebody who can manage their respiratory needs in a different way outside of hospital, then we stop thirty beds being blocked. (AP Nurse 5)Hospitals are failing to discharge people effectively and if you look at the evidence you have to say that the speed of discharge and people were assisted by those advanced practitioners is far greater than when you don't have advanced practitioners. So I think we must focus on community-based advanced practice to improve discharge. (Paramedic AP 4).

AP role clarity and standardisation

APs often drew attention to the lack of clarity with AP titles and subsequent understanding of AP roles. For example, many current AP roles have their origins in specialist nursing roles, resulting in the ‘advanced’ component of their role not being entirely clear, either at the point of taking up an AP job title or subsequently.My title is specialist nurse practitioner although my colleagues who have recently come into the same post have got the title of advanced practitioner so I would like to maybe clarify today whether I am an advanced nurse practitioner or an advanced practitioner or not [laughs]. (AP Nurse 1)

This confusion can be further compounded with the emergence of APs from different clinical professions including physiotherapy, paramedics, dietetics and radiography. However, AP roles in professions other than nursing have evolved more recently and seem to be shaped by Welsh Government guidelines. For example, one health region in Wales undertook a radical intervention to standardise the roles of non-nursing AP titles in response to government guidelines:As a result of the guidelines some of our advanced practitioners actually had the title taken off of them, not in nursing but in other professions and they couldn't have that rescinded until they'd done a portfolio which was interesting. (Nurse Manager 4)

Increased standardisation, in addition to clearer government guidance regarding the ‘buy-in’ of managers to policy guidance was also supported by practitioners who noted the current lack of parity in terms of work related terms and conditions for APs:I think there should be a clear all Wales policy direction on what AP is. Although the AP framework is there, managers need to sign up to that completely so that if you are an AP in various parts of Wales you are all working to the same level playing field. (Paramedic AP 2).

Lack of agreed understanding

Representatives from HEIs were keen to ensure that AP educational programmes were not seen as existing to teach specialist or advanced clinical skills only. The perceptions of many educators was that focusing only on skills could limit the potential of AP and lead to more entrenched professional groups:The truth is that we could just end up teaching skills but advanced practice is much more than this. The problem is there are different skills needed across professions and AP courses shouldn't just reinforce professional silos based on skills. (Educator 5)I realise the need for skilled advanced practitioners but these skills need to be about management and research too not just whether someone can undertake clinical assessment. (Educator 8)

However, participants from the NHS were keen that educational programmes prepared APs to undertake a set of specific, advanced skills, which were underpinned by the appropriate evidence. The need for skills reflected the ‘reality’ of the ever-changing demands of practising at an advanced level; the view of some was that HEI provision struggled to keep up with such demands.We need education to reflect the reality of our jobs at advanced level. We verify death, we take ABGs (arterial blood gases), we cannulate, we reassess patients clinically and obviously move forward and make independent decisions. The pressures on us are phone calls, emergencies, numerous sort of tasks that need to be done now. (AP Nurse 3)Sometimes I think HEIs are out of touch with reality and what they provide. (Paramedic AP 3)

Those managing and commissioning AP roles similarly demonstrated a lack of confidence in the educational preparation of APs. The first extract is taken from a medical consultant who had commissioned an AP nurse role. Despite the AP having the MSc AP qualification a further 18 months of practical training was arranged to ensure “she was proficient in doing the practical procedure”.We employed the individual as she was already a Band 7 sister but we employed her as a Band 7 advanced nurse practitioner, working day time with me for 18 months to make sure she could be trained and that she was proficient in doing the practical procedure that she needed to. (Medical Consultant 2)

Similarly, a nurse manager provided justification for insisting that advanced practitioners had achieved a Masters level course and undertake further trainingMy view in terms of education as a manager is that I don't know what the curriculum is, what the curriculum is spitting out, what standards are actually worked out. The comment you made to me about “these practitioners do their Master's level course and then you're going to put them on a service training course” and yeah I'm going to do that because I'm not assured in terms of governance arrangement what it is they've been taught. So I want to be 100% sure so yeah I do make them jump through these additional hoops. (Nurse Manager 1)

The above data extract reveals some interesting things; first that the manager had little faith in educational provision and second, that the managers’ lack of faith was predicated on a lack of knowledge and understanding of the AP curriculum and academic standards therein. The following extracts convey how practitioners often considered their managers as being out of touch with the realities of AP roles and tasks:Managers don't know what you do, there's lack of education and understanding of what the roles can actually put into the organisation. (Speech and Language Therapist 1)I think there's a lot of skills that advanced practitioners have that a lot of people who organise services within the organisation don't know that they have, so almost like marketing, you know we can insert cannulas we can prevent a diabetic being admitted we can, you know, get somebody out of A&E with a toilet raise or whatever. (AP Nurse 5)My bosses don't think about the workforce planning they need to fit in and around my post, it feels like somebody's happy because you've met a service need but actually they don't get the totality of what it is we do. (Paramedic AP 3)

These extracts suggest there is a distinct possibility that some workforce decisions regarding the educational and developmental needs of APs in Wales are made from a position of relative ignorance of the realities of clinical practice and the fit that exists with educational programmes used to prepare APs. In addition, some practitioners also described how AP roles could be commissioned and introduced without managers fully appreciating the on-going support and development needed by those being employed; as well as those managing APs failing to keep up with evolving AP roles:They bring in the service but in my experience professional development often isn't planned for, it's not somebody thinking right we need a practitioner to do that and the managerial support then evolves to keep up with the demands and professional development that's happened. Managerial support just doesn't adapt with us. (Physiotherapist AP4)Regarding a nurse AP her manager whipped her off to London to do a course. She's come back and she's doing the job of a junior doctor on the ground without a consultant there. As a practitioner she hasn't got a job description that matches it. She's got no clinical supervision. She isn't doing any audit, which is scary. So basically some manager thought that's a good idea, our service needs that and I will just sort of do it. (AP Nurse 6).

Interprofessional working: benefits and challenges

In terms of role preparation another feature that was highlighted was that, although a focus on skills-based learning was preferred by many AP role holders, having a good understanding of other health professional groups was also seen as a priority, typified in the following extract.I think inter-professional working is absolutely key and I can see clear benefits of advance practitioners working across boundaries and understanding others’ development. (Physiotherapist AP2)

There was also evidence that AP courses were preparing practitioners who worked inter-professionally to a high standard.I've got a few medical colleagues, two teams and each of them have got a qualified AP attached to their ward team providing ward care and they would rather give up their foundation doctors than their AP I promise you’. (Medical Practitioner 1)

However, interprofessional working, especially between medics and APs from a variety of professional backgrounds, was not always harmonious.Interviewer: Have you had support from medical practitioners?Paramedic: Yes, with a gun held to their heads until they give in.Paediatric Nurse: I agree to a point but things changed, when the medics finally realised that we were an asset and we were a resource then the atmosphere changed and now if they want somebody to review patients with them, they don't pop along to the SHO or the House Officer, they will take one of the APs because they know that we'll know the history of the child, we'll know the current treatment plan and we'll give a better picture.

Similarly, in physiotherapy substantial barriers to advancing practice had to be overcome with the result that innovation in service provision was being stifledI came into post about 8 years or so ago and it's been a very long and arduous and frustrating journey because we never had that support from medics. Just to give an example it took me nearly 7 years to get an injection policy through to allow physiotherapists to inject. (Physiotherapist AP1)

Working with medical staff has historically proved to be very frustrating for APs from all professional groups, as they often had to endure several months of negativity and limited collegiality which would only be alleviated once certain unspecified but significant ‘rites of passage’ and ‘personal tests’ had been successfully negotiated by APs. Fortunately there are some signs of this improving, with abundant support and professional development offered more readily as the AP role proves its worth.

Thus, interprofessional working was perceived as a balancing act between those who traditionally had the power and carried out certain tasks—usually medics—being willing to co-operate and trust APs to carry out these tasks and functions safely. This process of monitoring was presented as unofficial, negotiated and context-specific.