key: cord-0828664-aoszhtca
authors: Morley, Dawn; Kilgore, Cliff; Edwards, Mary; Collins, Pippa; Scammell, Janet ME; Fletcher, Kelsie; Board, Michele
title: The changing role of Advanced Clinical Practitioners working with older people during the COVID- 19 pandemic: a qualitative research study
date: 2022-03-26
journal: Int J Nurs Stud
DOI: 10.1016/j.ijnurstu.2022.104235
sha: dec8f225f84e5fc86267f3f52c1f9a4b0798ef19
doc_id: 828664
cord_uid: aoszhtca

BACKGROUND: COVID-19 was identified as a pandemic by the World Health Organisation (WHO) in December 2020. Advanced Clinical Practitioners (ACPs) in England working with older people with frailty, experienced their clinical role changing in response to the emergency health needs of this complex population group. In contrast to other countries, in England Advanced Clinical Practitioners are drawn from both nursing and allied health professions. Whilst much of the literature emphasises the importance of ensuring the sustainability of the Advanced Clinical Practitioners’ role, the pandemic threw further light on its potential and challenges. However, an initial review of the literature highlighted a lack of research of Advanced Clinical Practitioners’ capabilities working with uncertainty in disaster response situations. AIM: To capture the lived experience of how English Advanced Clinical Practitioners working with older people adapted their roles in response to the COVID-19 pandemic (October 2020 – January 2021). DESIGN, SETTING AND PARTICIPANTS: A qualitative research design was used. Following ethical approval, 23 Advanced Clinical Practitioner volunteer participants from across England with varied health professional backgrounds were recruited from Advanced Clinical Practitioners’ professional and social media networks on Twitter using a snowballing technique. METHODS: Depending on preference or availability, 23 participants (nurses (18), physiotherapists (2), paramedics (2) and a pharmacist (1)) were interviewed singularly (n=9) or as part of 3 focus groups (n= 14) using Zoom video communication. Audio recordings were transcribed and using qualitative data analysis software, NVivo 12 pro, coded for an essentialist thematic analysis of Advanced Clinical Practitioners’ responses using an inductive approach. 27 codes were identified and collated into five themes. For the purposes of this paper, four themes are discussed: experiencing different work, developing attributes, negotiating barriers and changing future provision. FINDINGS: Advanced Clinical Practitioners successfully transferred their advanced practice skills into areas of clinical need during the pandemic. Their autonomous and generic, high level of expertise equipped them for management and leadership positions where speed of change, and the dissolution of traditional professional boundaries, were prioritised. Barriers to progress included a lack of knowledge of the Advanced Clinical Practitioner role and friction between Advanced Clinical Practitioners and physicians. DISCUSSION AND CONCLUSION: The study demonstrated the successful adaption of the Advanced Clinical Practitioner role to enable more creative, personalised and sustainable solutions in the care of older people living with frailty during the pandemic. The potential of Advanced Clinical Practitioner development is in a juxtaposition to the threat of pandemic services being dismantled once the emergency nature of care has passed. Healthcare organisations have a vital part to play in considering the enablers and barriers of Advanced Clinical Practitioner capability-based practice when responding to uncertainty.

Advanced Clinical Practitioners' capabilities working with uncertainty in disaster response situations.

To capture the lived experience of how English Advanced Clinical Practitioners working with older people adapted their roles in response to the COVID-19 pandemic (October 2020 -January 2021).

A qualitative research design was used. Following ethical approval, 23 Advanced Clinical Practitioner volunteer participants from across England with varied health professional backgrounds were recruited from Advanced Clinical Practitioners' professional and social media networks on Twitter using a snowballing technique.

Depending on preference or availability, 23 participants (nurses (18), physiotherapists (2), paramedics (2) and a pharmacist (1)) were interviewed singularly (n=9) or as part of 3 focus groups (n= 14) using Zoom video communication. Audio recordings were transcribed and using qualitative data analysis software, NVivo 12 pro, coded for an essentialist thematic analysis of Advanced Clinical Practitioners' responses using an inductive approach. 27 codes were identified and collated into five themes. For the purposes of this paper, four themes are discussed: experiencing different work, developing attributes, negotiating barriers and changing future provision.

Advanced Clinical Practitioners successfully transferred their advanced practice skills into areas of clinical need during the pandemic. Their autonomous and generic, high level of expertise equipped them for management and leadership positions where speed of change, and the dissolution of traditional professional boundaries, were prioritised. Barriers to progress included a lack of knowledge of the Advanced Clinical Practitioner role and friction between Advanced Clinical Practitioners and physicians.

The study demonstrated the successful adaption of the Advanced Clinical Practitioner role to enable more creative, personalised and sustainable solutions in the care of older people living with frailty during the pandemic. The potential of Advanced Clinical Practitioner development is in a juxtaposition to the threat of pandemic services being dismantled once the emergency nature of care has passed. Healthcare organisations have a vital part to play in considering the enablers and barriers of Advanced Clinical Practitioner capability-based practice when responding to uncertainty.

What is already known  Advanced Clinical Practitioners in England are uniquely drawn from a multi professional health and social care workforce and are guided by four pillars of advanced clinical practice.

 Advanced Clinical Practitioners play a significant role in the management of frailty and the older person through their ability to make complex and holistic decisions with a high level of autonomy, yet this 'capability' is under investigated.

 Early evidence suggests the potential of the Advanced Clinical Practitioner role to be interchangeable in some instances with physicians.

 In the context of a pandemic, Advanced Clinical Practitioners' ability to apply their advanced clinical skills to autonomous, generalist practice allowed them to fulfill a breadth of management and leadership roles.

 Advanced Clinical Practitioners' implementation of creative solutions to alternative care provision for the older person, strongly positions them as lead practitioners in future service delivery for this population.

COVID-19 was identified as a pandemic by the World Health Organisation (WHO) in March 2020 and remains a major health disaster (WHO 2020) . Significantly people living with long term conditions, and those of an older age, were identified as particularly at risk from COVID-19 of higher morbidity and mortality (National Health Service England, 2020) .

During the early stages of the pandemic, anecdotal evidence shared in online professional networks on Twitter commented on the adaption of advanced clinical practice roles to cope with demands. This adaption was particularly evident in England and by May 2020, a conversation via the social media site, Twitter, identified an interest by Advanced Clinical Practitioners (ACPs) to share their experiences of the expansion of their role. Perceiving a need, Health Education England (HEE) funded research to consider the role of Advanced Clinical Practitioners in the care of older people during the COVID-19 pandemic. The subsequent research was delivered through a co-partnership between local health service provider organisations and one university.

The study captured the lived experience of how English Advanced Clinical Practitioners working with older people adapted their roles in response to the COVID-19 pandemic (October 2020 -January 2021).

Prior to the study, the concept of Advanced Clinical Practitioners dealing with uncertainty was under explored and this provided the impetus for research into this crucial area during the COVID-19 pandemic. Currently, there is a lack of guidance on the specific role responsibility for Advanced Clinical Practitioners in situations that are unpredictable with a strong suggestion that many are ill-prepared in the management of disasters (Fil et al., 2020) .

Advanced Clinical Practitioners (ACPs) can, and do, play a significant role in the management of the older person due to their holistic care approach (Ferinde and Hebdon, 2019) and their in-depth understanding of the fundamental differences between normal ageing and illness in older people. There is a strong emphasis within United Kingdom health policy to ensure that clinical staff are developed to match the requirements of a modern healthcare system for patients that have complex needs (The National Health Service Long Term Plan, 2019).

Internationally, the expansion of the scope of nursing practice has been in response to workforce challenges often arising from the perceived need to manage areas underresourced by physicians (Torrens et al., 2020) . Lawler et al. (2020) argue that the advanced practice role in the UK was also developed as a reaction to workforce gaps.

One of the major global challenges to the healthcare workforce has been seen in the context of an ageing patient demographic and the associated complexity for this patient group (Torrens et al, 2020) . Thompson et al (2014) suggest that the rise in complex healthcare needs of older people internationally have led to a stronger focus on this population group. As healthcare has evolved, and more is understood regarding the diagnosis of frailty in older people, there has been a need to adapt and manage the physiological decline and associated reduction of physiological reserve within this condition.

Within the literature, the term Advanced Clinical Practitioner (ACP) has developed in differing ways internationally (Evans et al., 2020) . For example, although there is a history to advanced roles dating back to the 1960s, it was not until the early 2000s that the United Kingdom started to develop this concept into what is now understood to be advanced clinical practice (Department of Health, 2006; . However, where countries such as Canada, USA and Australia have regulated practice, the United Kingdom has allowed roles to evolve (Lawler et al,. 2020 This framework attempts to provide national consistency and a clear definition of the level of practice expected of an Advanced Clinical Practitioner (ACP) (Lawler et al, 2020) .

'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 master's 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 people's experience and improve outcomes.' (Health Education England, 2017).

Although this is a level of practice that would be recognised internationally as advanced nursing practice, England and Wales extended the role of Advanced Clinical Practitioners to include any healthcare professional that met the requirements of the multi-professional framework regardless of professional background (Lawler et al, 2020 (Lawler et al., 2020) The nature of advanced practice can be seen to define the standards of excellence in patient care for health communities and subsequently many health care organisations have embraced the use of this professional group (Metzger and Rivers, 2014) . In England the work seen in papers such as Allied Health Professionals into Action (2017), and the position statement on advanced level nursing (2010), have culminated in the development of a single pathway for advanced clinical practice which is currently not replicated internationally.

Although there is little in the way of evaluation of this single pathway, Haidar (2014) suggests that there is credible evidence to describe advanced practice as a level rather than a role which in turn supports a multi-professional approach to advanced clinical practice. As advanced clinical practice is synonymous with a high level of autonomy, the language used in the UK is one of 'capability' as this indicates a scope of practice across a broad range of clinical practice (Health Education England, 2017) . Traditionally, the role of Advanced Clinical Practitioner has been undertaken by clinical professionals such as physiotherapists, nurses, pharmacists and occupational therapists but, in reality, the advanced clinical practice multi-professional framework (Health Education England, 2017) can provide the framework for any healthcare professional to develop advanced practice. and operation capability. The increasing demand on senior clinicians that are responsible for making initial assessments and diagnoses can be significant (Tichy et al., 2009) .

This interpretative qualitative study captured the lived experience of how English Advanced Clinical Practitioners working with older people adapted their roles in response to the COVID-19 pandemic (October 2020 -January 2021).

The inclusion criteria were that the Advanced Clinical Practitioner participants had to 1. Table 2 ).

The higher proportion of Advanced Clinical Practitioners with a nursing background within the study was also common to Lawler et al (2020) .

Ethical approval was successfully gained from the ethical review committee at the participating university. A participant information sheet, which outlined the aim of the study and the participant's role, was sent to volunteers prior to the study commencing and potential participants had the opportunity to contact a member of the research team with any questions via email. Informed consent was gained prior to data collection via a participant agreement form. Participants were able to withdraw from the study at any time up to the point of data analysis.

Depending on preference or availability, volunteer participants were organised into three focus groups (FG) (7, 4, and 3 participants respectively) and nine one to one interviews (Int).

Interviews were organised with participants who were unable to attend focus groups. Focus groups were facilitated by two members of the research team and with one member of the research team for the interviews. All interactions were recorded via the Zoom video conferencing platform.

Recordings were transcribed and using qualitative data analysis software NVivo 12 pro, coded for an essentialist thematic analysis of Advanced Clinical Practitioners' responses using an inductive approach (Braun and Clarke, 2006) . Overall, 27 codes and 5 themes were identified for analysis (see table 3 ). For the purposes of this paper, four themes are described: experiencing different work, developing attributes, negotiating barriers and changing future provision. The fifth theme, accessing support, was excluded as it did not directly inform the subject of this paper.

Findings COVID-19 brought immediate change to the provision of health and social care needs for the public. Specifically, for older people, the increased risk of infection led to a rapid decrease in the number of patients accessing traditional routes to care as hospital and clinic attendance ceased except for the very acutely ill. As the pandemic continued, older people became increasingly vulnerable to the effects of isolation and the delay of medical treatment. Advanced Clinical Practitioners were swiftly redeployed to areas of greater clinical need. The advent of the pandemic necessitated a rapid reassessment of patients' access and use of service across all sectors to reduce the risk of COVID-19.

The theme of 'experiencing different work' presents the areas that Advanced Clinical Practitioners were redeployed to. A major priority for Advanced Clinical Practitioners was reducing the older person's physical trips to health care services and assessing whether an older person could be managed through an alternative care package at home. Some community areas prioritised special provision for older people with 'hospital at home' models and the redeployment of staff to support these initiatives:

'We created a new service, so the frailty home treatment service, where we would be looking after almost like a virtual ward of poorly people in the community … it's been a massive change for our team. ' (Int7, physiotherapist) Consequently, staff work patterns rapidly changed, and Advanced Clinical Practitioners had 'to start fighting COVID until late at night when we didn't have to before. We started working weekends. We started doing a lot more in-patient work. And for a short period of time, I was redeployed to acute medicine.' (Int, nurse) . Redeployment was sometimes delayed due to a lack of understanding of the Advanced Clinical Practitioner role: 'There's a lot of specialist nurses [ACPs] had been basically taken off their clinics and were twiddling their thumbs. ' (Int8, nurse) The broad knowledge base and training of Advanced Clinical Practitioners meant that many successfully adapted to new triage roles within secondary, primary and community care:

'I also have quite a lot of therapy skills, a lot of medical skills. I change and flex that according to who I speak to. And so I think that really helps when you're talking to people to get them to understand why [flexibility] is important and a medic can't do that but an ACP can with the unique skill set, we potentially have. ' (FG2, physiotherapist) For older people who need to be admitted to hospital, Advanced Clinical Practitioners described new triaging systems which were quickly put in place to streamline and prioritise patients' access to acute services. Emergency admissions were often requested to go straight to hospital wards. Novel solutions, and the order of work was altered, to improve the efficiency and safety of seeing patients:

'… we were able to clerk the patients in, [we] were able to do the treatment escalation plans, diagnose, come up with treatment plans, send patients to their correct places. So it took a while for the team to realise that we could actually help a lot more than just be another pair of hands. ' (FG3, nurse) The complexity of the older person was recognised by other staff as advance care planning had to be completed rapidly and to scale. Advanced Clinical Practitioners were accessible to these staff with their unique skills being drawn upon as essential to support the rapidly changing service:

'… those real complex, frail patients who … they know where the discharge planning is but then it goes wrong, or if someone's taking a deterioration or if they even just needing something prescribed … they'll come and find me rather than one of the doctors because they'll know I do it without a winge. ' (FG2, physiotherapist) The need to learn new skills, or assist with sharing knowledge to support others, was prevalent in the Advanced Clinical Practitioner interviews and focus groups.

As care developed at a distance, or away from the acute services, Advanced Clinical Practitioners noted a significant development in the use of technology with the older person.

'It means they don't have to come out of the house; they don't have to, you know get to the surgery because they struggle with that … they absolutely love it. ' (FG3, nurse) Telephone triage moved to the use of video. Advanced Clinical Practitioners involved themselves in care work but found that their knowledge, and their ability to bring together many aspects, was particularly helpful to colleagues 

The theme 'Negotiating barriers' highlights the areas of difficulty that Advanced Clinical Practitioners experienced during the pandemic. Advanced Clinical Practitioners found that previous areas of responsibility and training were sometimes inadequate to cope with their new areas of work. The inability to order advanced tests, such as X-rays without further training, caused frustration. One participant, with a professional background in physiotherapy, found that her Advanced Clinical Practitioner colleague, from an occupational therapy background, was unable to prescribe medicines thus limiting her advanced clinical skills in certain circumstances. ' (Int9, nurse) By having clinical experts working with them at a time of great pressure, other staff had benefitted from the leadership, support and knowledge that the Advanced Clinical Practitioners contributed. Long term, the potential for continued operational change was evident in many areas of the Advanced Clinical Practitioner's work, 'working with that camaraderie, that culture, I've never, ever experienced that in the NHS before and don't think I will again. ' (Int1, nurse) . However, this was balanced by frustration that some of the positive changes that had been made were due to be reversed after the second wave of the pandemic. Practitioners' role and its potential going forward. Currie, Finn and Martin (2010) found that this applied particularly to physician colleagues who were conflicted when role transition challenged established professional identities.

Managing older peoples' healthcare during the pandemic, and improving wellbeing in care homes and at home, were prevalent within the research. Crouch and Brown (2018) identified the importance of advanced clinical practice as key to developing new models of care. Reduced clinical placement opportunities for physician trainees has resulted in a reduced clinical experience and it is often Advanced Clinical Practitioners that are required to ensure that the high levels of complex patients receive the care they need (Crouch and Brown, 2018) . Despite differences in the professional background of the Advanced Clinical Practitioners within the study, the only discrepancy raised as the result of these differences was that of prescribing rights. It was commented upon in the study that not all Advanced Clinical Practitioners from an allied health profession (AHP) background were able to become nonmedical prescribers (NMP). Non prescribing was considered problematic to efficiency in patient care and concurs with Hardy (2021) who highlights that the lack of prescribing rights reduces employment opportunities and flexibility within multiple roles. Although it is expected that extension of prescribing responsibilities to other professional groups, such as Advanced Clinical Practitioners with an allied health professional background, is likely to continue (The Royal Pharmaceutical Society, 2021) the change to the prescribing rights of a profession has to be agreed through parliament legislation bill (MMBD09, 2020). Continuity of care, and the ability to diagnose and treat without onward referral, is important in the care of older people; especially in acute frailty and pandemic situations to ensure timely and efficient response to need. Clinical Practitioners flourished. There is good evidence that advanced practice can not only be equivalent to but can sometimes be better than physician-led care (Boman et al., 2021) and this was articulated by the Advanced Clinical Practitioners in this study. Boman et al., (2021) pandemic as essential to workforce planning regarding older peoples' care. The need for a highly skilled, adaptive and flexible non-medical workforce was revealed world-wide. There were dramatic changes made to healthcare law in the USA to allow advanced practitioners to treat patients (Zolat, 2020) . Kleipenell et al., (2021) later found that despite these new laws, advanced practitioners in the USA found it difficult to be autonomous, change their scope of practice and widen their prescribing practices. Often, physicians did not trust their knowledge and medical insurance companies did not support these new laws. Halliday et al., (2018) found that Advanced Clinical Practitioners directly influenced organisational effectiveness within acute ward settings often directly improving patient flow. As the first wave of the pandemic subsided, Advanced Clinical Practitioners in this study were anxious that their advancement might be curtailed as innovations in response to the pandemic were discarded even though cost and staff efficiencies were proven.

Although the English Advanced Clinical Practitioner participants uniquely came from different professions, it was not within the scope of this study to explore the influence of these alternative perspectives. Our research alludes to possible differences in the scope of Advanced Clinical Practitioner practice due to these differences and a further study is recommended to ascertain the influence of multi professional membership on the emerging professional identity of Advanced Clinical Practitioners as a whole.

The purpose of this study was explorative and therefore the use of qualitative methodology was to reveal some rich data of Advanced Clinical Practitioners' experience. Clearly this is not generalisable but, given the findings, a further wider scale survey that builds on these aspects might prove insightful.

This study revealed that Advanced Clinical Practitioners were an integral part of the healthcare workforce during the exceptional, uncertain times of the pandemic; able to work across professional boundaries, provide leadership and manage the clinical complexity and uncertainty that arose in an older population. A synthesis of the four pillars of advanced practice -clinical practice, education, leadership and research (Health Education England, 2017) was evident throughout the findings and arguably key to the success of the Advanced Clinical Practitioner role. Our study provides evidence for the potential benefits of a capability model of advanced clinical practice to enable advanced clinical practitioners to deal with a high level of unpredictability and uncertainty as presented during the COVID-19 pandemic. In particular, the capability of leadership came to the fore and provides a potential emphasis for Advanced Clinical Practitioner training and role creation in the future.

The pandemic enabled practitioners to work outside of their traditional disciplinary boundaries implementing more efficient and personalised services. Part of this was the increased use of technology to conduct consultations at a distance. In times of heightened expectations, Advanced Clinical Practitioners were given the authority to work in ways that The UK Core Capability Frameworks for Advanced Clinical Practice regardless of setting HEE 2020a; HEE 2020b) states the ability to manage complexity alongside uncertainty is a key capability for advanced practice. They emphasise the difference between highly specialist practitioners and advanced clinical practice. Our study shows, that in the uncertain times of COVID-19, Advanced Clinical Practitioners' response was often appropriate and responsive to the constant changing environment and stressors. Renegotiation of professional boundaries and traditional ways of working were part of the pandemic response. The pre COVID-19 strategy to create a multi-professional non-medical Advanced Clinical Practice workforce in the UK to sustain and transform all sectors of the NHS, has contributed to the ability to manage the uncertainty and complexity of older peoples' health in a pandemic.

In conclusion, Advanced Clinical Practitioners articulated more investment was needed to define and promote the Advanced Clinical Practitioner role; to allow other professionals to recognise and value the role and to provide support and learning across professional boundaries. There remains debate amongst practitioners as to whether Advanced Clinical Practice is a level of practice or a qualification. The Centre of Advancing Practice (HEE) is now tasked with setting national training standards and accrediting courses as the number of Advanced Clinical Practitioner apprenticeships increase in order to reduce disparity in capability, set apart Advanced Clinical Practitioners as a distinct role and demonstrate that the NHS value Advanced Clinical Practitioner in the workforce.

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Dawn Morley: conceptualisation, methodology, formal analysis, investigation, writingoriginal draft, visualisation, supervision, project administration, funding acquisition. Cliff Kilgore: conceptualisation, writing -original draft, funding acquisition. Mary Edwards:

investigation, writing -original draft, Pippa Collins: investigation, writing -review and editing, Janet ME Scammell: conceptualisation, writing -review and editing, funding acquisition. Kelsie Fletcher: : conceptualisation, resources, Michele Board: conceptualisation, methodology, investigation, writing -review and editing, supervision, project administration, funding acquisition. 

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This research was funded by a grant from Health Education England (HEE) (project no.

Respondents (% of total)

10 (2) Acute medical (adult) 92 (17) Acute medical (paediatric) 6 (1)