Section 1: The capabilities for advanced clinical practice in England
Section 1: The capabilities for advanced clinical practice in England
DefinitionThe definition of advanced clinical practice was developed and agreed by all stakeholders is outlined below and some of the terminology has been updated to reflect more current language: Advanced clinical practice is delivered by experienced, registered health and care practitioners. It is a level of practice characterised by a high degree of autonomy and complex decision making. This is underpinned by a masters level award or equivalent that encompasses the four pillars of clinical practice, leadership and management, education and research, with demonstration of core capabilities and area specific clinical competence.
Advanced clinical practice embodies the ability to manage clinical care in partnership with individuals, families and carers. It includes the analysis and synthesis of complex problems across a range of settings, enabling innovative solutions to enhance peoples experience and improve outcomes. This definition therefore requires that health and care professionals working at the level of advanced clinical practice will exercise autonomy and decision making in a context of complexity, uncertainty and varying levels of risk, holding accountability for decisions made.
1.2 Capabilities for advanced clinical practice in EnglandAll health and care professionals working at the level of advanced clinical practice should have developed their skills and knowledge to the standard outlined in this framework; the capabilities are common across this level of practice enabling standardisation.
The four pillars that underpin this practice are:
1. Clinical Practice
2. Leadership and Management
3. Education
4. Research
The language used to describe the capabilities is deliberately mapped to level 7 taxonomy to support and make clear the expectation that people working at this level are required to operate at masters level i.e. to have the ability to make sound judgements in the absence of full information and to manage varying levels of risk when there is complex, competing or ambiguous information or uncertainty. This framework acknowledges that the developmental pathway towards delivering advanced clinical practice may be different for individual practitioners. Health and care practitioners will demonstrate the capabilities in different ways, depending upon the nature of their scope and context of their practice, role and profession. It recognises there are many ways to gain and develop advanced practice capabilities, for further details please see the Education and development section. Listed below are the capabilities for health and care professionals working at the level of advanced clinical practice. The capabilities apply to all models of advanced clinical practice across sectors, specialties and professions and can be applied in either uni-professional or multi-professional models of care provision.
1. Clinical PracticeHealth and care professionals working at the level of advanced clinical practice should be able to:
1.1 Practise in compliance with their respective code of professional conduct and within their scope of practice, being responsible and accountable for their decisions, actions and omissions at this level of practice.
1.2 Demonstrate a critical understanding of their broadened level of responsibility and autonomy and the limits of own competence and professional scope of practice, including when working with complexity, risk, uncertainty and incomplete information.
1.3 Act on professional judgement about when to seek help, demonstrating critical reflection on own practice, self-awareness, emotional intelligence, and openness to change.
1.4 Work in partnership with individuals, families and carers, using a range of assessment methods as appropriate (e.g. of history-taking; holistic assessment; identifying risk factors; mental health 2The capabilities have been mapped to the Framework for Higher Education Qualifications FHEQ (2008) Qualifications Assurance Agency for Higher Education (QAA) level 7 descriptors relevant for masters level education (see http://www.qaa.ac.uk/en/Publications/Documents/qualifications-frameworks.pdf).
Multi-professional framework for advanced clinical practice in England assessments; requesting, undertaking and/or interpreting diagnostic tests; and conducting health needs assessments).
1.5 Demonstrate effective communication skills, supporting people in making decisions, planning care or seeking to make positive changes, using Health Education Englands framework to promote person-centred approaches in health and careviii.
1.6 Use expertise and decision-making skills to inform clinical reasoning approaches when dealing with differentiated and undifferentiated individual presentations and complex situations, synthesising information from multiple sources to make appropriate, evidence-based judgements and/or diagnoses.
1.7 Initiate, evaluate and modify a range of interventions which may include prescribing medicines, therapies, life style advice and care.
1.8 Exercise professional judgement to manage risk appropriately, especially where there may be complex and unpredictable events and supporting teams to do likewise to ensure safety of individuals, families and carers
.1.9 Work collaboratively with an appropriate range of multi-agency and inter-professional resources, developing, maintaining and evaluating links to manage risk and issues across organisations and settings.
1.10 Act as a clinical role model/advocate for developing and delivering care that is responsive to changing requirements, informed by an understanding of local population health needs, agencies and networks.
1.11 Evidence the underpinning subject-specific competencies i.e. knowledge, skills and behaviours relevant to the role setting and scope, and demonstrate application of the capabilities to these, in an approach that is appropriate to the individual role, setting and scope.
2. Leadership and ManagementHealth and care professionals working at the level of advanced clinical practice should be able to:
2.1 Pro-actively initiate and develop effective relationships, fostering clarity of roles within teams, to encourage productive working.
2.2 Role model the values of their organisation/place of work, demonstrating a person-centred approach to service delivery and development.
2.3 Evaluate own practice, and participate in multi-disciplinary service and team evaluation, demonstrating the impact of advanced clinical practice on service function and effectiveness, and quality (i.e. outcomes of care, experience and safety).
2.4 Actively engage in peer review to inform own and others practice, formulating and implementing strategies to act on learning and make improvements.
2.5 Lead new practice and service redesign solutions in response to feedback, evaluation and need, working across boundaries and broadening sphere of influence.
2.6 Actively seek feedback and involvement from individuals, families, carers, communities and colleagues in the co-production of service improvements.
2.7 Critically apply advanced clinical expertise in appropriate faciliatory ways to provide consultancy across professional and service boundaries, influencing clinical practice to enhance quality, reduce unwarranted variation and promote the sharing and adoption of best practice.
2.8 Demonstrate team leadership, resilience and determination, managing situations that are unfamiliar, complex or unpredictable and seeking to build confidence in others.
2.9 Continually develop practice in response to changing population health need, engaging in horizon scanning for future developments (e.g. impacts of genomics, new treatments and changing social challenges).
Multi-professional framework for advanced clinical practice in England.
2.10 Demonstrate receptiveness to challenge and preparedness to constructively challenge others, escalating concerns that affect individuals, families, carers, communities and colleagues safety and well-being when necessary.
2.11 Negotiate an individual scope of practice within legal, ethical, professional and organisational policies, governance and procedures, with a focus on managing risk and upholding safety.
3. Education Health and care professionals working at the level of advanced clinical practice should be able to:
3.1 Critically assess and address own learning needs, negotiating a personal development plan that reflects the breadth of ongoing professional development across the four pillars of advanced clinical practice.
3.2 Engage in self-directed learning, critically reflecting to maximise clinical skills and knowledge, as well as own potential to lead and develop both care and services.
3.3 Engage with, appraise and respond to individuals motivation, development stage and capacity, working collaboratively to support health literacy and empower individuals to participate in decisions about their care and to maximise their health and well-being.
3.4 Advocate for and contribute to a culture of organisational learning to inspire future and existing staff.
3.5 Facilitate collaboration of the wider team and support peer review processes to identify individual and team learning.
3.6 Identify further developmental needs for the individual and the wider team and supporting them to address these.
3.7 Supporting the wider team to build capacity and capability through work-based and inter-professional learning, and the application of learning to practice
3.8 Act as a role model, educator, supervisor, coach and mentor, seeking to instill and develop the confidence of others.
4. Research Health and care professionals working at the level of advanced clinical practice should be able to:
4.1 Critically engage in research activity, adhering to good research practice guidance, so that evidence-based strategies are developed and applied to enhance quality, safety, productivity and value for money.
4.2 Evaluate and audit own and others clinical practice, selecting and applying valid, reliable methods, then acting on the findings.
4.3 Critically appraise and synthesise the outcome of relevant research, evaluation and audit, using the results to underpin own practice and to inform that of others.
4.4 Take a critical approach to identify gaps in the evidence base and its application to practice, alerting appropriate individuals and organisations to these and how they might be addressed in a safe and pragmatic way.
4.5 Actively identify potential need for further research to strengthen evidence for best practice. This may involve acting as an educator, leader, innovator and contributor to research activityix and/or seeking out and applying for research funding.
4.6 Develop and implement robust governance systems and systematic documentation processes, keeping the need for modifications under critical review.
4.7 Disseminate best practice research findings and quality improvement projects through appropriate media and fora (e.g. presentations and peer review research publications).
4.8 Facilitate collaborative links between clinical practice and research through proactive engagement, networking with academic, clinical and other active researchers
Multi-professional framework for advanced clinical practice in England11Section 2: Key principles for the implementation of advanced clinical practice
2.1 Planning the workforce and governance How to ensure the right people, with the right skills, are in the right place at the right time is a key priority to enable delivery of sustainable health and care services. This framework is relevant for any service looking to transform its workforce to meet the needs of the population through the employment of advanced clinical practice roles. How these are integrated into service delivery and team structures for a sustainable, consistent approach to the advanced clinical practice workforce development are presented as broad principles. This is so as to embrace the multiple settings and roles at this level and local context. In this section, both planning and governance of this workforce are addressed.
The governance of advanced clinical practice roles is vital to their success. Good governance involves inclusive, participative decision making with clear lines of accountability and responsibility. Policies and processes need to be in place and must include the evaluation of effectiveness, impact, ongoing sustainability and responsiveness.
Multi-professional framework for advanced clinical practice in England12Key principles for planning the workforce and governance: In identifying the need for such roles and their potential impact, employers need to: 1. Consider where advanced clinical practice roles can best be placed within health and care pathways to maximise their impact Historically there have been many drivers for the introduction of the level of advanced clinical practice: clinical, operational, financial and professional. However, primary consideration must be given to where this level of practice would be best placed for greatest impact in health and care pathways. This may mean that those working in advanced clinical practice might operate outside traditional service delivery boundaries and potentially, traditional professional boundaries. The intention should be to move towards developing and planning the workforce to meet local population needs. Therefore, at the local area level, organisations should be working to generate a sustainable supply of health and care workforces who are able to work more flexibly across these boundaries. 2 Define a clear purpose and objectives for advanced clinical practice roles. The level of advanced clinical practice typically exists across professional boundaries within multi-professional teams. Planning must not be done in isolation, local consideration must be given to workforce supply, existing roles and support for development. In addition, attention must be paid to the starting points for different professions relative to their core training, as well as to their duties and responsibilities. The capabilities which reflect the area of work or specialty will be required to be clearly defined. Clinicians and service managers should be involved in planning the workforce together. Such planning should focus on the wider team, thinking about the value of the role and its purpose and objectives. Practitioners must be working to national standards, where these exist. 3. Consider and evaluate the impact of advanced clinical practice roles on service user experience and outcomes and on service delivery and improvement objectives. Patient/service user and public involvement in understanding these roles, their functions and boundaries as part of the wider health and care teams, is essential and must be built into this process. The importance of ensuring continuous improvement in the quality of care to individuals is widely recognised. It is therefore necessary to measure the impact of the activities of all staff, with a particular focus on new roles added to the workforce. The development and utilisation of robust evaluation methods is essential. In addition, evidence demonstrating value for money and good quality of care may be required to influence senior management teams to support the introduction of new roles. This will include how the organisation or employer should quality assure itself to ensure the safety and effectiveness of the advanced clinical practice roles. For example, by using methods for monitoring and evaluating both effectiveness and impact such as, the monitoring of complaints, incidents and patient/service user outcomes and feedback. This is an essential part of governance, i.e. the observation and evaluation of intended and unintended consequences.There are specific questions employers need to address in considering advanced clinical practice roles and to ensure good governance of those roles What objective outcomes are expected from the advanced clinical practice role? When will these outcomes be achieved and how will these be measured pre and post implementation? What risks and unintended consequences might there be to the introduction of this role and how may they be mitigated against? What resources and support are required for role development and succession planning? Is workforce optimised to ensure clinical and financial benefits are maximised? How will on-going competence and capability be reviewed and enabled?
Multi-professional framework for advanced clinical practice in England13 What reporting and line management structure will be in place? What processes will identify gaps in performance and/or shortfalls in implementation and how will these be addressed? Has a quality assurance model been considered to measure this e.g. CQC 5 key lines of enquiry which will support inspection.Thinking through these questions and finding answers will then guide governance structures and policy development but also evaluation against expected and unexpected outcomes.4. Ensure clarity about the service area the individuals will work within Understanding the level of advanced clinical practice relative to the wider team, requires the roles of all team members, i.e. those above, below and surrounding this level, to be understood. Multi-professional engagement in this work is essential to build trust, understanding, supervision and support (see the Education and development section for more information on supervision). Those working in an advanced clinical practice role will need to negotiate their individual scope of practice with service managers and the rest of the team. The wider team needs to understand the level of accountability of those in this role. To achieve these objectives there needs to be clarity and understanding as well as a proactive culture of working in partnership. By advancing the level of practice of some staff, the people in the grades below may need some development to increase their skills and knowledge as the expectation of their roles develops too. Staff in the grades above may need some support to potentially change some aspects of their role and potentially start doing some work differently. This must be understood, supported and widely communicated. Employers also need to consider impact planning and the evaluation of the team into which the new role is introduced, and those it may impact on outside this team, reflecting on the implications for the skills mix and any changes that might be needed. This process may then enable career and succession planning opportunities. 5. Ensure clear and unambiguous support for the role from the organisation/ employer at all levels The employer must recognise the responsibilities and capabilities of someone working in these roles. This must be reflected and supported at a local and organisational level. The support must be wider than educational, the voice of the those working in an advanced clinical practice role must be heard via existing or new governance and reporting structures. The board level directors, the clinical leads for the profession and managers must be aware of, understand and recognise the value of, advanced clinical practice roles. This must be cited in the governance arrangements, so that there are clear lines of professional and managerial accountability up to board level.In addition, the employer must be aware that certain skills, e.g. prescribing, are only legally allowed for certain professions, and that this does not preclude all professions from working in an advanced clinical practice role. 6. Develop a succession plan for future workforce. This should be actively supported for service sustainability, succession planning and staff retention. Clarity in the above principles will enable a clear pipeline to be developed and will support rete
5.1 Your evidence
You should ensure that you submit a range of high-quality, individual pieces of evidence that directly relate to and derive from your personal activity and achievements.
5 Filling the portfolio with lots of evidence, which only has tenuous links to the capabilities is not beneficial.
The portfolio needs to comprise a range of different kinds of evidence, some of which are considered essential and should be confirmed as current and authentic by a colleague who meets the criteria set out below.
Essential evidence The following range of evidence should be submitted as part of the portfolio and
confirmed as current and authentic by a colleague who meets the criteria:
At least two critical reflective case studies of a minimum 800 words each, critically reflecting on different presentations / situations demonstrating assessment and management of complexity and unpredictability in relation to the clinical pillar.
At least two critical reflective accounts of a minimum of 800 words each, critically reflecting on the other pillars of advanced practice. Note, The critical narrative, critical reflective case studies, and critical reflective accounts should be written in a level 7 / Masters style, supported with citations and references.
A record that your advanced practice competence/ clinical capabilities have been assessed as being met by an appropriate health professional. Such assessment might be completed in a formal or informal workplace or other educational setting or a (re)validation or accreditation by a professional, statutory regulatory body. For example, if an advanced practice course with competence / clinical capabilities assessed via a module / OSCE has previously been completed, that can be submitted as evidence.
Evidence of leadership skills, for example attendance at an NHS leadership course or other similar courses, 360-degree feedback report, self-assessment of transformational leadership and development plan; facilitation/co-creation of shared direction/purpose; peer review, observations of practice, open forum, using claims, concerns and issues tool or similar, action learning, peerconsultant, and clinical supervision.
Summary account of team leadership episode, such as critical incident / significant event analysis demonstrating leadership skills; initiation, involvement, implementation of business case and/or change proposal demonstrating leadership skills as an advanced practitioner. Note, this could be done via a reflective case study or reflective account.
Evidence of applying research in practice, for example knowledge translation activities in relation to national standards, local policies research, identifying gaps in evidence - curiosity, contributing to developing a research culture, participating in research, reflective reviews and blending different types of evidence.
Provision of a short critical appraisal of a research article or similar exercise to demonstrate critical analysis and appraisal skills.
Evidence of undertaking or significant involvement in/contribution to audit, service improvement, practice development and quality improvement.
Complex Case Studies Evidence AAA Medical Team
A 61 years old male (Patient X) was referred to Spinal Service in secondary care for face-to-face consultation. He reported low back pain on and off for the past two to three years. The pain had worsened in the last eight months with bilateral posterior thigh pain and occasional groin & calf pain. He had already undergone five sessions of physiotherapy treatment and private osteopath treatment with minimal benefit. He had also attended Accident and Emergency Services two years ago with low back pain when X-ray of his lumbar Spine was performed which was reported as L4/L5, L5/S1 degenerative disc. His past medical history included type two diabetes, asthma, hypertension and duodenal ulcer.
Age :61, Male, LBP and Bilateral Posterior thigh pain and occasional calf pain for the past 1 years.
HPC: Patient reported that his Low back ache on/off for the past 2-3 years. His pain became worse in the last 8 months with n. His pain in VAS 4-6/10. He was referred by his GP to MSk Service and had undergone physiotherapy treatment for 5 treatment. He also had private Osteopath treatment with minimal benefit. He was then referred to our spinal clinic. He had attended A&E and had Xray 2 years ago which showed L4/L5, L5/S1 Deg disc. He also complained of Abdominal pain and groin pain at times. Patient wad admitted in the hospital 1 year ago and had diagnosed with duodenal ulcer. On further questioning he did mention of losing weight in the last 3-4 months
Aggravating factors: Standing, Sitting, Lying, His symptoms became worse as days goes on
Easing Factors:
Had been to A&E Xray L4/L5, L5/S1 Deg disc , Hip xraySmokes: 20 Cigarettes a day for the past 20 years
Drinks: Approximately 6 pints a weeks
Blood Test: NAD
Investigation Xray. Patient had Blood test few days ago
PMH: Diabetes not under control, Asthma, HTN, Indigestion problem
Family history: Ischaemic Diseases
Surgery: Gall bladder removed ( 28 years) ago, Appendicectomy
Medications: Gliclazide, Insulin, Paracetamol, Amitriptyline, Co-codamol, Lansoprazole
Living with his wife His wife had Surgery 3 months ago TKR. He also visits his Mother (87 years old) who lives in sheltered accommodation. His hobbies include socialising, Gardening, walking
Previous treatment: Osteopath-3 treatment , 2 different Physiotherapy undergone 5 treatment Short term relief. Eventually he was referred to Ortho spinal clinic and he was triaged to be seen by me.
Clinical examination:
Questionnarie: EQ5d
Gait was Normal, There was no Balance problem
Modified Oswestry Index 40%Moderate disability
I have completed physical examination to test the hypothesis of a suspected vascular pathology and investigate subtle signs of left hip and groin pain. Full range of motion at the Thoracic spine, lumbar spine and hip was achieved with no symptoms induced, Hip range of motion was adequate and no significant arthropathic change was seen on pelvic X-ray. Neurologically he was intact. Muscle tone and Muscle strength as well as pin prick test, reflexes were normal. His Peripheral pulses were all normal.
Neurological exam was completed in case there was a radicular cause of the hip pain, but no remarkable findings were identified. SLR right and Left were equal. Specific Accessory Movements there was Stiffness at Mid to end range L4/L5, L5/S1. Heel walk Test, Tow walk test and Squatting were Normal. The patients LBP was not reproduced on physical examination, with the exception of mild temporary increase in hip pain only, during prone knee bend test with overpressure, which increased the which increased the likelihood that this was a non-mechanical problem.
When I palpated the patient abdomen he was complaining of discomfort
In my clinical experience this does not appear to be mechanical problem. In my opinion there is a degree of abdominal aortic aneurysm , Degenerative changes of Lumbar spine. Hence I have requested Urgent Pelvis and Lumbar Xray in the erect posture
MRI scan was requested as the clinical symptoms were not concordance with the findings
MRI result come with 54mm Aortic aneurysm with alert on them. My office manager contacted me once she received the report.I have immediately contacted and discussed with my consultant regarding this patient. On the same day I have contacted A&E consultant and explained the issue and he has requested patient to attend. At the same time I have also contacted the patient to attend Accident and Emergency to be reviewed ASAP.
It is important to learn abdominal examination. The importance of subjective examination Listen carefully to patient as patient will not answer until we question them
What will happen next the key reflective questions such as:
What was the situation and what weremy role(s) and actions?
What decisions did I make and why?
What led me to those decisions?
What aspects went well and why?
What didnt go so well and why?
If I did this again, what would I do differently?
What was the service users perspective?
Did I evaluate the situation or collect sufficient data to demonstrate my impact?
How can I share what I have learned with others?
What reading or learning do I need to develop further in this area?
