This research explores how emergency nurse practitioners (ENPs) become role proficient given experience variation and lack of role standardisation.
To understand how ENPs experiences in practice influence their feelings of role proficiency.
A hermeneutic phenomenological study was undertaken utilizing an interpretive standpoint. A two-phase approach was adopted with ten participants using a digital diary informing a semi-structured interview. A three-stage data analysis approach was applied.
Six themes emerged: the meaning of role proficiency, relationships, confidence, learning and knowledge, exposure and experience, and care. Models of proficiency and its development are presented.
Proficiency is defined where confidence in the components that proficiency consists of and their application to each clinical presentation is required. Proficiency is a continuum supported by regulatory mode theory. Inconsistency of role understanding gives rise to three ENP groups, resistors, maintainers, and innovators.
Role clarity is required to establish a consistent culture within organisations founded on the voice of the ENP as captured in this research. This model of proficiency be incorporated in ENP role development for current and future ENPs.

OBJECTIVE: The prompt recording of the electrocardiogram (ECG) and its correct interpretation is crucial to the management of patients who present to the emergency department (ED) with cardiovascular symptoms. Since triage nurses represent the first healthcare professionals evaluating the patient, improving their ability in interpreting the ECG could have a positive impact on clinical management. This real-world study investigates whether triage nurses can accurately interpret the ECG in patients presenting with cardiovascular symptoms.
METHODS: Prospective, single-centre observational study conducted in a general ED of General Hospital of Merano in Italy.
METHODS: For all patients included, the triage nurses and the emergency physicians were asked to independently interpret and classify the ECGs answering to dichotomous questions. We correlated the interpretation of the ECG made by the triage nurses with the occurrence of acute cardiovascular events. The inter-rater agreement in ECG interpretation between physicians and triage nurses was evaluated with Cohen\'s kappa analysis.
RESULTS: Four hundred and ninety-one patients were included. The inter-rater agreement between triage nurses and physicians in classifying an ECG as abnormal was good. Patients who developed an acute cardiovascular event were 10.6% (52/491), and in 84.6% (44/52) of them, the nurse accurately classified the ECG as abnormal, with a sensitivity of 84.6% and a specificity of 43.5%.
CONCLUSIONS: Triage nurses have a moderate ability in identifying alterations in specific components of the ECG but a good ability in identifying patterns indicative of time-dependent conditions correlated with major acute cardiovascular events.
UNASSIGNED: Triage nurses can accurately interpret the ECG in the ED to identify patients at high risk of acute cardiovascular events.
UNASSIGNED: The study was reported according to the STROBE guidelines.
UNASSIGNED: The study did not involve any patients during its conduction.

BACKGROUND: An extended role being explored globally is the advanced clinical practitioner (ACP). In England this is an extended role for allied health professions, nurses and midwives in a range of settings.
OBJECTIVE: This paper focuses on three research questions: 1) What is the role of ACPs in England? 2) What are the barriers and facilitators to implementing the role? and 3) What is the contribution of ACPs to health services in England?
METHODS: A qualitative, exploratory study to explore perspectives on the ACP role in a range of clinical settings.
METHODS: We recruited 63 stakeholders, including 34 nurses, working in a ACP role or ACP education. A purposive snowball sampling technique identified participants meeting inclusion criteria.
METHODS: One-to-one semi-structured interviews throughout 2020, recorded and transcribed verbatim, anonymised and thematically analysed.
RESULTS: The ACP role in England was undertaken in a broad range of clinical contexts. In England \'advanced clinical practitioner\' was not a protected title. There were high levels of variability and ambiguity of understanding and deployment of the ACP role in England. Facilitators to the implementation process included training and education, clinical supervision and organisational support. Lack of protection for the role and variances in experience were barriers. Employer support facilitated development of the ACP role, however where support was limited, at either an individual or organisation level, this was a barrier. Our study highlighted the wide range of ways the ACP role benefitted patient outcomes and workforce development.
CONCLUSIONS: This study outlines the contribution that ACPs can make to health services, contributing factors and key barriers and facilitators to implementing this role. The work showed the positive contribution ACPs can make to service redesign, workforce development and patient outcomes, whilst accepting there is much work to do to ensure protected status and parity across all professions and clinical contexts.

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.
OBJECTIVE: 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).
METHODS: 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.
RESULTS: 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.
CONCLUSIONS: 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.

OBJECTIVE: To establish whether international musculoskeletal physiotherapy educational standards and associated governance framework align with advanced clinical practice (ACP) frameworks in England; and to evaluate physiotherapy stakeholders\' perceptions about potential accreditation and governance of ACP for musculoskeletal physiotherapists.
METHODS: A qualitative two-phase study. 1] An explicit documentary mapping process of established international educational musculoskeletal standards to the ACP frameworks for England, in terms of domains, standards and competencies by two independent reviewers. Results were evaluated by a third reviewer and focus group participants. 2] Focus groups enabled maximal insight into perceptions of musculoskeletal stakeholders through the interactive process facilitated by a topic guide. Groups were recorded and transcribed verbatim; data were analysed using thematic coding.
METHODS: Three focus groups in London, Birmingham and Manchester facilitated recruitment from all regions of England.
METHODS: Purposive sampling (n=26) ensured representation of stakeholders for ACP (e.g. Professional Networks, patients).
RESULTS: International educational standards fully mapped to both ACP frameworks, with 100% saturation of defined capabilities, and agreement across reviewers and focus groups. Four themes were identified from focus groups: musculoskeletal physiotherapy specific professional factors; fit for purpose, innovative educational opportunities; advocated recognition of musculoskeletal physiotherapy ACP as a discrete professional practice field; and advocating a potential vehicle for musculoskeletal physiotherapy ACP.
CONCLUSIONS: This study identifies the importance of musculoskeletal ACP specific to the physiotherapy profession. Fit-for-purpose innovative educational opportunities for musculoskeletal physiotherapists are required at Masters level to support preparation for ACP roles. The established national and international musculoskeletal frameworks afford an opportunity.

OBJECTIVE: A major issue facing all health systems is improving population health while at the same time responding to both growing patient numbers and needs and developing and retaining the health care workforce. One policy response to workforce shortages has been the development of advanced clinical practice roles. In the context of an English national policy promoting such roles in the health service, we explored senior managers\' and senior clinicians\' perceptions of factors at the organization level that support or inhibit the introduction of advanced clinical practice roles. The investigation was framed by theories of the diffusion of innovation and the system of professions.
METHODS: We conducted a qualitative interview study of 39 senior manager and clinicians in 19 National Health Service acute, community, mental health and ambulance organizations across a metropolitan area in 2019.
RESULTS: Small numbers of advanced clinical practice roles were reported, often in single services. Four main influences were identified in the development of advanced clinical practice roles: staff shortages (particularly of doctors in training grades) combined with rising patient demand, the desire to retain individual experienced staff, external commissioners or purchasers of services looking to shape services in line with national policy, and commissioner-funded new roles in new ambulatory care services and primary care. Three factors were reported as enabling the roles: finance for substantive posts, evidence of value of the posts, and structural support within the organization. Three factors were perceived as inhibiting developing the roles: confusion and lack of knowledge amongst clinicians and managers, the availability of finance for the roles, and a nervousness (sometimes resistance) to introducing the new roles.
CONCLUSIONS: While the national policy was to promote advanced clinical practice roles, the evidence suggested there was and would continue to be limited implementation at the operational level. Development scenarios that introduced new monies for such roles reduced some of the inhibiting factors. However, where the introduction of roles required funding to move from one part of a service to another, and potentially from one staff group to another, the growth of these roles was and is likely to be contested. In such scenarios, research and business evidence of relative advantage will be important, as too will be supporters in powerful positions. The paucity of publicly available evidence on the effectiveness of advanced clinical practice roles across the specialties and professions in different contexts requires urgent attention.

UNASSIGNED: Paramedics working in advanced practice roles in the UK can now train to prescribe medicine. This is anticipated to benefit patient access to medicines and quality of care where there is a national shortage of doctors, particularly in primary care.
UNASSIGNED: To explore the experience of paramedics who are early adopters of independent prescribing in a range of healthcare settings in the UK.
UNASSIGNED: A qualitative study involving interviews between May and August 2019, with paramedics in the UK who had completed a prescribing programme.
UNASSIGNED: Individual interviews with a purposive sample of paramedics recruited via social media and regional paramedic networks. Interviews covered experiences, benefits and challenges of the prescribing role. A framework analysis approach was used to identify key themes.
UNASSIGNED: Participants were 18 advanced paramedics working in primary care, emergency departments, urgent care centres and rapid response units. All participants reported being adequately prepared to prescribe. Key benefits of prescribing included improving service capacity, efficiency and safety, and facilitating advanced clinical roles. Challenges included technological problems, inability to prescribe controlled drugs and managing expectations about the prescribing role. Concerns were raised about support and role expectations, particularly in general practice.
UNASSIGNED: Paramedic prescribing is most successful in settings with a high volume of same-day presentations and urgent and emergency care. It facilitated advanced roles within multidisciplinary teams. Concerns indicate that greater consideration for support infrastructure and workforce planning is required within primary care to ensure paramedics meet the entry criteria for a prescribing role.

UNASSIGNED: Little is known about paramedics who have left the ambulance service to work in emergency departments (EDs). This study sought to explore the lived experiences of paramedics working in specialist/advanced ED roles, focusing on role transition, influences on effective clinical practice and perceptions of role optimisation. A secondary aim of the study was to make recommendations on the future development of specialist/advanced ED roles for paramedics.
UNASSIGNED: This was a qualitative study utilising descriptive phenomenology to collect and describe the lived experiences of participants via semi-structured interviews. The final sample comprised three emergency care practitioners (ECPs), three student ECPs and two advanced clinical practitioners (ACPs), all Health and Care Professions Council registered paramedics. Interview data were transcribed verbatim and analysed using inductive thematic analysis.
UNASSIGNED: Transition to the ED involves significant adjustment to a new clinical environment, responsibilities and decision making.Pre-hospital physical assessment and history taking skills, and experience of autonomous working are pertinent enablers to effective practice within the ED.Difficulties in accessing medication in the ED emerged as a significant barrier to daily practice that could affect the patient experience and influence perceptions of sub-optimal working.Misconceptions by ED staff regarding paramedic competencies could lead to role confusion and make inter-professional working difficult.Opportunities exist for future role expansion into areas such as resus, majors and paediatrics within the ED environment.
UNASSIGNED: While role transition to the ED represents a turbulent period for paramedics, elements of pre-hospital paramedic practice transfer directly into ED roles and contribute to effective practice. Participants found that they were accepted and supported to work in the ED setting and spoke positively of future role expansion. A lack of access to medicines presents a significant barrier to current clinical practice and a disparity in practice between paramedics and their nursing counterparts. The change in legislation to allow independent prescribing for advanced paramedics will address some of these issues, but interim improvements are required to extend existing arrangements to paramedics, improving the quality and safety of care they provide and ultimately the patient experience.

Escalating costs and changing population demographics are putting pressure on primary care systems to meet ever more complex healthcare needs. Non-medical \'advanced clinical practitioner\' (ACP) roles are increasingly being introduced to support service transformation. This paper reports the findings of a qualitative evaluation of nursing ACP roles across General Practices in one region of the UK. Data collection involved telephone interviews with 26 participants from 3 different stakeholder groups based in 9 practice sites: ACPs (n = 9), general practitioners (n = 8) and practice managers (n = 9). The data was analysed thematically. The study found a high degree of acceptance of the ACP role and affirmation of the important contribution of ACPs to patient care. However, significant variations in ACP education, skills and experience led to a bespoke approach to their deployment, impeding system-wide innovation and creating challenges for recruitment and ongoing professional development. In addition, a context of high workforce pressures and high service demand were causing stress and there was a need for greater mentorship and workplace support. System wide changes to ACP education and support are required to enable ACPs to realise their full potential in primary care in the UK.

BACKGROUND: Research has not yet fully investigated links to consultation duration, patient expectations, satisfaction, and enablement in nurse practitioner consultations. This study was developed to address some of these research gaps in nurse practitioner consultations, particularly with a focus on expectations, satisfaction, and enablement.
OBJECTIVE: To explore the influence of pre-consultation expectations, and consultation time length durations on patient satisfaction and enablement in nurse practitioner consultations in primary health care.
METHODS: Survey component of a larger convergent parallel mixed methods case study designed to conjointly investigate the communication processes, social interactions, and measured outcomes of nurse practitioner consultations. The survey element of the case study focusses on investigating patients\' pre-consultation expectations and post-consultation patient satisfaction and enablement.
METHODS: A questionnaire measuring pre-consultation expectations, and post-consultation satisfaction and enablement, completed by a convenience sample of 71 adults consulting with nurse practitioners at a general practice clinic. Initial fieldwork took place in September 2011 to November 2012, with subsequent follow-up fieldwork in October 2016.
RESULTS: Respondents were highly satisfied with their consultations and expressed significantly higher levels of enablement than have been seen in previous studies of enablement with other types of clinicians (P=0.003). A significant, small to moderate, positive correlation of 0.427 (P=0.005) between general satisfaction and enablement was noted. No significant correlation was seen between consultation time lengths and satisfaction or enablement.
CONCLUSIONS: Higher levels of patient enablement and satisfaction are not necessarily determined by the time lengths of consultations, and how consultations are conducted may be more important than their time lengths for optimising patient satisfaction and enablement.