This week’s Blog is written by Emma Innes (@emmainnes3), Senior Lecturer in Advanced Clinical Practice and Matthew Harris (@mattdh86), Senior Lecturer in Pharmacology and Medicines Optimisation at the School of Nursing and Midwifery, Department of Midwifery and CPD at the University of Worcester (@UW_AdvPractice).

Nurses continue to be the largest professional group embarking on the advanced clinical practice journey (1). However, there are increasing numbers of pharmacists and allied health professionals who are transitioning into advanced roles previously held in isolation by the nursing profession.

The multi-professional framework for advanced clinical practice in England (2017) sets the standard at which all professionals should be able to demonstrate capability at an advanced level of practice (2). The framework was written broadly to allow application across a range of settings, professions, populations, and roles to ensure parity of education, performance, and execution of any role at an advanced level. There is potential for misinterpretation of the framework by applying it in a rigid, inflexible manner propagating the incorrect assumption that all advanced clinical practitioners (ACPs) are generic workers (3), as opposed to a diverse group of healthcare professionals who are developing their practice to work at an advanced level to meet the needs of their population.

Not all ACPs are created equal

Although there are clear capabilities for the level of practice an ACP must meet to work at the advanced level, not all professionals will demonstrate their capability in the same way. The base professional training and working experience of each individual will vary and differences will be wider across professional boundaries (4). This has significant implications for the education and training of ACPs from the outset of their post-registration education and ongoing development in the workplace.

Anecdotally, trainee ACPs are struggling with their professional identity with a sense of not belonging anywhere. They report feeling detached from their base profession with little affinity for their developing identity as ACPs. Job titles for ACP’s frequently make no reference to the original profession which not only perpetuates identity loss but also causes confusion with patients who may have little understanding of the role of an ACP (3,5). As Nadaf (2018) writing eloquently states ‘’when did advanced practice stop being nursing?’’ Or any other profession for that matter?

Ambiguity of identity

Creation of the title of “advanced clinical practitioner” has created ambiguity for healthcare professional identity. Social identity theory helps explain why healthcare workers have historically worked within professional silos maintaining their identity propagating professional tribalism (6,7) . The creation and expansion of generic ACP roles further erodes the core identity of those who wish to advance their practice whilst adding another “tribe” to the mix, ultimately resulting in ACPs being alienated and lacking any tangible identity.

Anderson et al. (2020) (8) recognised that the weak professional identity of advanced practice caused advanced nurse practitioners to develop an isolated identity. This had the cyclical effect of preventing the development a strong and cohesive professional identity as nurses who practice at an advanced level, which may impact acceptance and delivery of the role.

Professional identity can be lost in ACP roles as organisations increasingly move to fill medical rota gaps (3). This is further compounded by the lack of clinical career progression and the further enhancement of those in roles such as a clinical nurse specialist, where advanced clinical practice is seen as a separate role not a continuum of specialist nursing practice (9).

It is important that stakeholders consider the original intention of the multiprofessional framework for advanced clinical practice in England (2) when workforce planning. Workplace culture is likely the stimulus for the propagation of tribalism, hierarchical and stereotypical behaviours experienced in healthcare settings (7), perpetuating the myth that advanced clinical practitioners are there to replace junior doctors as opposed to developing their own level of practice linked to their core identity.

Educators through curricula should drive the debate with trainee ACPs to support them to critically discuss this issue and the underpinning theories and research to develop the confidence to challenge the misconceptions that they will become generic practitioners. Instead advocating for the development of their professional identity maximising their core skillset for the benefit of improving patient care. To succeed in this aim, academics must promote a safe multidisciplinary learning environment to facilitate discourse where professionals can learn with, from and about each other.

References

1. Lawler J, Maclaine K, Leary A. Workforce experience of the implementation of an advanced clinical practice framework in England: a mixed methods evaluation. Hum Resour Health [Internet]. 2020;18(1):1–11. Available from: https://doi.org/10.1186/s12960-020-00539-y
2. Health Education England. Multi-professional framework for advanced clinical practice in Englandt [Internet]. Health Education England. 2017. Available from: https://www.hee.nhs.uk/sites/default/files/documents/multi-professionalframeworkforadvancedclinicalpracticeinengland.pdf
3. Nadaf C. Perspectives: Reflections on a debate: When does Advanced Clinical Practice stop being nursing? J Res Nurs. 2018;23(1):91–7.
4. Evans C, Poku B, Pearce R, Eldridge J, Hendrick P, Knaggs R, et al. Characterising the outcomes, impacts and implementation challenges of advanced clinical practice roles in the UK: A scoping review. BMJ Open. 2021;11(8):20–6.
5. Thompson W, McNamara M. Constructing the advanced nurse practitioner identity in the healthcare system: A discourse analysis. J Adv Nurs. 2022;78(3):834–46.
6. Willetts G, Clarke D. Constructing nurses’ professional identity through social identity theory. Int J Nurs Pract. 2014;20(2):164–9.
7. Braithwaite J, Clay-Williams R, Vecellio E, Marks D, Hooper T, Westbrook M, et al. The basis of clinical tribalism, hierarchy and stereotyping: A laboratory-controlled teamwork experiment. BMJ Open. 2016;6(7):1–10.
8. Anderson H, Birks Y, Adamson J. Exploring the relationship between nursing identity and advanced nursing practice: An ethnographic study. J Clin Nurs. 2020;29(7–8):1195–208.
9. Fealy GM, Casey M, O’Leary DF, McNamara MS, O’Brien D, O’Connor L, et al. Developing and sustaining specialist and advanced practice roles in nursing and midwifery: A discourse on enablers and barriers. J Clin Nurs. 2018;27(19–20):3797–809.