In this assignment, I will attempt to focus on the development of the Advanced Clinical Practitioner (ACP) and its role within health services. I will discuss the role of reflection, to assist in acquiring skills whilst also acknowledging the role of decision making, which is directly related. The ACP role within my area of practice, forensic mental health, and the focus on inter-professional working will also be highlighted.
Despite the ACP role being in practice for a number of years, the role itself has been applied inconsistently (DoH, 2010). In 2017, the NHS multi-professional framework document for Advanced Clinical Practice, set out a framework for practice to be implemented by 2020. The framework categorises capabilities within the already established four pillars of practice; clinical practice; leadership & management; education, and research (Health Education England, 2016).
Due to a depleted workforce of medical staff, the AP role is often seen as a suitable replacement, a “medical substitution” (Jones et al, 2015). Gray (2016) suggests that being identified as a substitute results in a role being restricted and compromised by having to fit in to that particular job description. Instead, Gray (2016) proposes a second type of AP within the 4 pillars, describing the role as an “advancing” practitioner of clinical expertise, whereby the practitioner is able to manage complex problems, through the use of effective decision making, as it is imperative that skills often embedded within the student AP, are developed and further acquired. An obstacle to development of existing skills and acquisition of new skills, have been identified as lack of self-confidence, hesitation, lack of cultural sensitivity, and lack of understanding of the role from other professionals (Jones et al, 2015, Latham & Fahey 2006, Crane 2005).
To acquire new skills, along with increase in knowledge via the academic process, reflection has been highlighted as integral to professional competence. Reflection is known to assist learners to understand and assimilate new concepts in order to enable improved performance (Azer et al, 2013).
Reflection is particularly important to the novice Advanced Practitioner as “experts” who commence the trainee AP role, often experience what Fitzpatrick & Gripshover (2016) describe as “transition shock” characterised by anxiety, doubt, exhaustion and insecurity that leads to “suboptimal performance”. Imposter syndrome, whereby students are at fear of being disowned as an “intellectual fraud” is also present, despite the student displaying sufficient abilities to have acquired that role of student (Villwock et al, 2016). To overcome transition shock and “imposter syndrome” an ability to reflect, to accept feedback and to remain open and honest (emotional honesty) is required (Mount, 2015).
Moon (1999) describes reflection as “a form of mental processing with a purpose and/or anticipated outcome that is applied to relatively complex or unstructured ideas for which there is no obvious solution”. Rather than reflection being used to situations where there is no obvious solution, Brannigan & Moores (2009) suggest reflective practice is used to “achieve some anticipated outcome”, which is drawn from past experiences and the application of knowledge.
There are a number of models to assist in the reflection process, whose general aim is to improve competency of the practitioner and to improve the patient experience (Schmutz & Eppich, 2017). Rolfe et al (2001) asks three simple questions; What? So What?, And Now What?. The problem and action to solve the problem is identified. Observations are then made, with a view to put new learning into actions if the situation was to repeat itself. Gibbs (1998) six stage model takes a similar view to Rolfe et al (2001) but differs in that it has been criticised as too superficial (Atkins & Murphy 1993) and does not consider socio-political perspective or biases which may be present when considering the decision making process.
My area of practice is within a forensic mental health environment. The majority of patients treated within the service, are admitted from the courts and prison estate. Patients are deemed to have committed their offence because of mental health problems, or are prisoners that have become unwell in prison, though there offences are not related to mental health difficulties. A review of the literature highlights the possibility that professionals working within such an environment encounter service users who, as well as evoking feeling of empathy, also evoke feelings of fear and repercussion, therefore affecting the important therapeutic relationship and the need to remain objective (Jacob et al 2009). This fear of repercussion, based on service users offending behaviours, may encourage restrictive interventions as staff are not always able to understand and identify such feelings (Parker 2004, Holmes & Jacob 2007). Zapf & Dior (2017) suggest that those who undertake forensic evaluation are unable to eliminate all bias as they are human. Therefore they conclude that unbiased and impartial examination is aspirational in nature. This presumed inability to identify bias has a detrimental effect on the ability to reflect and learn. A process to mitigate bias would be to develop expertise to manage a particular situation. Zapf & Dior (2017) also state that although this would enhance performance in that particular area, this would be at the cost of “cognitive trade-offs” resulting in confirmation bias, where the practitioner attempts to fit a solution to a previous problem, to the current situation.
The ACP within forensic mental health services has a dual role of treating and managing both the physical and mental health needs of patients. Inherent within forensic mental health, is the requirement to undertake comprehensive risk assessments to determine the nature and to what degree, service users present as a risk to themselves and/or others. Ultimately, the risk assessment process should produce a judgment from which decisions are then made. Judgment has been described as “a choice between a number of alternatives” (Dowie, 1993), whilst Dunwoody et al (2000) define decision making as “a trade-off between accuracy and cognitive effort”. Inherent within this decision making is a remaining level of uncertainty as there are “rare” factors that influence violence within each individual case (Skeem & Monahan, 2011). Uncertainty remains constant, to varying degrees, within risk assessment dependent on knowledge and understanding of known risk factors. For risk judgment and associated risk management plans to remain relevant, these uncertainties should be acknowledged and represented “in the most faithful manner” (Aven & Zio, 2011).
Kahneman (2011) states his view that decision making is a battle between intuition and logic. When making decisions the clinician is prone to a range of biases. Decision makers are influenced by bias, via previous decisions which have been made but are not always related to the problem or task in hand. These biases also result in risk aversion, over confidence and “confirmation bias” where rather than a decision being reached on available evidence, the clinician looks for evidence to back up an already established view or belief (Nickerson, 1998).
Intuition has been described in many ways, ranging from “understanding without rationale” (Benner & Tanner, 1987), “an immediate knowing of something without the conscious use of reasoning” (Schrader & Fischer, 1987), to “a capacity for attaining direct knowledge or understanding without apparent intrusion of rational thought or logical inference” (Saddler-Smith & Shefy, 2004). Kahneman (2011), like other theorists, places intuition as separate to rational thought designating this as “System 1” whilst “System 2” is described as analytical, clever and rational. As system 2 is superior to System 1 it is also able to overrule it.
Custers (2013) counters this view by suggesting that rather than decision making being made using two separate systems, evidence shows that a range of everyday tasks are made utilising a combination of the two. The area between the poles of analysis and intuition has been described as “quasirationality”, a combination of intuition and analysis (Dhami & Thomson, 2012). Dunwoody et al (2000) state that quasirationality is both “robust and adaptive” agreeing with Custers (2013) view that this is evident in everyday life as most tasks present with both analytic and intuitive characteristics.
The complex and dynamic nature of risk assessment and decision making remains, and can only be made with the resources available, which makes the need for clinical knowledge and expertise imperative in not only the formulation of risk but within the requirement for clinical decision making to be based on the best evidence available (Coid et al, 2011; Thompson et al, 2004). Guy et al (2012) suggests that structured professional guidelines are in danger of becoming invalid and unreliable if undertaken by those who are not trained sufficiently. Whilst Hart et al (2011) agree with this requirement for the “need for competency” when formulating risk and making decisions regarding the correct treatment and risk management needs.
To understand decision making the clinician should appreciate that it is a combination of education and clinical experience which assists what is regarded as “intuition”. It is the individual or individuals administering the risk assessment process, who ultimately play the vital role in decision-making that effects, not only the safeguarding of members of the public, but also the quality of life of the person subjected to the risk assessment (Singh et al, 2011).
SMYTH & ZAREZADEH
When considering that the ACP is essentially an experienced clinician undertaking an advanced role, the model of reflection designed by Smyth (1989), in Table 1, may be considered as best suited to improve clinical practice of a professional, who has been exposed to a range of clinical and life experiences, to assist in the transition from novice to expert. Smyth (1989) described four elements to this model of reflection (Appendix 1):
When considering my area of practice, alongside Smyth (1989), it is useful to consider utilising the reflection model to enhance Inter Professional Education, designed by Zarezadeh et al (2009). The purpose of this model, is not only about increasing the awareness of “self” in relation to the practitioners roles and responsibilities but also awareness of the role and importance of other professionals, within the multi-disciplinary team responsible for making decisions regarding patient care.
In order to understand my current level of practice, whilst appreciating my progress since commencing the course, I undertook a self-analysis, utilising SWOT (Appendix..) and PESTLE (Appendix,,,) frameworks. I then matched this to my job description (Appendix…) and learning style (Appendix…)
WHERE I WAS
Prior to undertaking the trainee ACP role, I would have been described as a specialist within forensic services. My role was to provide support and practical management to junior staff, whilst also contributing to discussion within a multidisciplinary meeting, where treatment plans would be agreed and actioned. I would also provide teaching and mentorship, though this would focus on therapeutic interventions and risk management. My involvement in physical healthcare and research could have been described as minimal. My decision making was based on a combination of intuition and experience. When I commenced the advanced practitioner programme, whose initial focus is on physical examination and understanding the basis of disease, I considered myself an Impostor (Villwock et al, 2016) but I did not foresee transition shock (Fitzpatrick & Gripshover, 2016)
WHERE I AM
By challenging my belief that I was an impostor, I was able to pass the OSCE examination and Biological Basis of Disease module. I continue to consider this belief when undertaking physical examinations though counter this by seeking supervision from qualified colleagues. In relation to others area of practice, I am aware that the service is affected by poor morale and threatened by ongoing measures of austerity. I attempt to counter this by providing education to junior staff, based on evidence based practice. My focus on patient care has shifted to give equal consideration to physical and mental health assessment, as I had previously considered this to be a role mainly undertaken by medical colleagues, in terms of assessment and intervention.
I am fortunate, in that the ACP role is established within the service. This is useful in my development, as colleagues who had previously completed the OSCE assessments, had then been expected to undertake medical on-call, without 1:1 supervision. This had been subsequently evaluated and policy amended, to ensure all trainees have access to immediate guidance and supervision.
WHERE I WANT TO BE
The decision to categorise capabilities within the four established pillars of practice, provides flexibility to secure mental health services, when developing the role of the ACP. My job description mirrors this flexibility, whilst placing the ACP within a multidisciplinary framework. It provides opportunity for my role to be that of an “advancing” practitioner, to influence service development. I am also fortunate in joining an established, focused team, who are able to assist my development to achieve both individual and service goals.
Through carrying out a SWOT analysis, I was able to identify opportunities to develop, whilst also identifying threats to this. Through consideration of Smyth (1989) and Zarezadeh et al (2009) I not only consider “self” and how values and beliefs influence this, but also remain aware of the role of other professionals and the potential influence of interprofessional colleagues in my future development.
Effective reflection can only occur if the practitioner is aware of the factors that influence the decision making process. Without this knowledge, it could be argued that the ACP will not make the transition from novice to expert. Within my area of practice, the reflective process may be seen as being effective within an inter-professional context. The future of the ACP can only progress, if the role is moved from “substitute” to autonomous clinical expert who is valued within a multi-disciplinary environment.
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