Guidance & training (framework)
Guidance for trainees and supervisors
Becoming a Trainee ACP (tACP) will be challenging. Generally, it will involve a senior registered allied health professional leaving their comfort zone to learn and take on new knowledge, competencies and skills. Undertaking a MSc and meeting the Derbyshire ACP Core Competencies will necessitate a lot of work from the trainee and support from peers and supervisors. Being a trainee in primary care can be isolating, but should be exciting.
Please encourage your tACP to take utilise fellow trainees as support, to attend drop in practice sessions (offered by Derby Uni on clinical decisions module etc) Peer support and review is very helpful.
If you are a training practice or part of a CEPN please include your tACP in any tutorials/educational sessions on offer to trainees, medical and non-medical, within your practice. Utilise the skills in your team.
Each tACP needs a clinical supervisor who will be a GP or a senior ACP (fully qualified and competent)
Setting up surgeries, debriefing
Trainees need to see appropriate patients with presenting problems that allow them to develop and practice their skills. Please be realistic with appointment times and clinics by allowing catch up slots for questions/second opinions to be asked. Most tACPs will require 15-minute appointments. Consider 20 minutes in the early stages – particularly when on the clinical decisions/advanced assessment type modules.
Some consideration should be given to the ‘types’ of problems that the tACP will see initially. This may vary depending on the background and levels of competence of the trainee. Many trainees start by seeing minor illness or first presentation of certain problems. Certain patients may be excluded from booking with tACP such as children, mental health patients, pregnant patients. Debrief initially may be best in line with foundation level doctors ie a debrief after each patient or a joint surgery until such time the clinical supervisor is happy the tACP can be debriefed at the end of a surgery.
Please ensure the tACP know who to access for support, advice, a second opinion during surgery If needed. Referrals, investigations and admissions should all be discussed in the early stages of training.
Daily debrief sessions are a necessity not only to ensure patient safety, by checking patients have been dealt with appropriately, but also serve an important educational purpose. Feedback relating to patient presentations are much more likely to be remembered as it is pertinent to patient needs and clinicians educational needs. Educational needs can be identified, included on the PDP and addressed, possibly by a tutorial, educational meeting etc
Guidance on debriefing can be found here
Requesting tests/investigations & referrals
All referrals for tests/investigations and referrals to other agencies should be discussed with the debriefing clinician.
Results from tests may initially need to be reviewed by someone other than the tACP until such times they are competent to review/action their own results for their patients.
Please remember the MSc in advanced practice is a three-year programme. The tACP will need to develop over the three years with clinical skills developing alongside academic knowledge. It is a progressive process. Please see next page.
tACPs need to maintain a portfolio of evidence to demonstrate their progress and evidence which competencies they have met.
It is advised that the portfolio should include the following;
PDP identifying SMART objectives (Template can be found here)
record of assessments
Quality Improvement Projects/audit
Information relating to leadership and education
Any patient compliments or complaints
Significant Event Analysis
Each trainee ACP should keep a Learning Log detailing the evidence of competency. There should be a couple of learning log entries a week reflecting on cases where they have identified learning needs, achieved competency
Reflective templates to help can be found here.
tACPs should undergo regular assessment using COT and CBD much in the same way as foundation & registrar level medics do. Advice re numbers of WPBA are included at the back of the Derbyshire Advanced Practice Core Competencies document. Page 60 onwards – the numbers of assessments suggested are minimum levels and it is likely that these will be amended upwards.
COT/Mini-cex can be achieved either by shadowing a surgery or by reviewing a videoed surgery (videoed with patient consent – the consent form should be scanned into patient notes) consent form
CBD – ideally the trainee should provide their supervisor with 2-3 cases in brief for the supervisor to select which case they feel would be most beneficial to discuss. A selection of cases will be needed to evidence a variety of competencies
Directly Observed Procedures (DOPs)
Any procedural skills carried out as part of the advanced role should be assessed.
Obviously, these vary depending on the place of work.
Intimate examinations are not covered in detail by local HEIs therefore before any are carried out the tACP needs training. There should be an understanding of the anatomy and physiology, an understanding of when it is or is not appropriate to carry out the procedure, informed consent, the examination process including consideration of the patient always. One DOP is not enough to demonstrate competence – there should be a number of each. For example, a vaginal examination DOP – a variety will be required to demonstrate a variety of competence – identifying the cervix, assessing for prolapse, use of speculum, bi manual etc
Adapted from P. Benner (1984) Model of Skills Acquisition
• Beginner with no experience
• Taught general rules to help perform tasks
• Rules are: context-free, independent of specific cases, and applied universally
• Rule-governed behaviour is limited and inflexible
• Demonstrates acceptable performance
• Has gained prior experience in actual situations to recognise recurring meaningful components
• Principles, based on experiences, begin to be formulated to guide actions
• Typically a practitioner with 2-3 years experience on the job in the same area or in similar day-to-day situations
• More aware of long-term goals
• Gains perspective from planning own actions based on conscious, abstract, and analytical thinking and helps to achieve greater efficiency and organization
• Perceives and understands situations as whole parts
• More holistic understanding improves decision-making
• Learns from experiences what to expect in certain situations and how to modify plans
• No longer relies on principles, rules, or guidelines to connect situations and determine actions
• Background of greater experience
• Has intuitive grasp of clinical situations
• Performance is now fluid, flexible, and highly-proficient
It is proposed that Benner’s 5 stages of performance can be used to describe your performance at this advanced level. For example, in Pillar 1, entitled ‘Management and Leadership ’, the first criterion is described as:
‘Identifying need for change, leading innovation and managing change, including service development’.
In assessing your current level of performance against this particular criterion consider whether you would assess yourself as functioning at the stage of:
• Advanced Beginner
Benner’s (1984) Stages of Skill Acquisition are used to finely describe practice, in terms of advanced level. As such, the practitioner, new to working at this level of practice may be seen as an ‘advanced beginner’. Alternatively the practitioner who has been working at this advanced level for some time will have moved from the ‘novice’ stage to another stage, for example, that of ‘proficient’. All practitioners may vary in differing aspects of their roles.