Ensuring effective, responsive, patient-centred, innovative community and primary care services in England is a central theme of national and local health and social care policies and action plans. Commensurate with the scope and level of practice required from an Advanced Practitioner in this context is the need to demonstrate competence in management of patients with a broad range of common acute and long-term complex presentations.  Clinical complexity is a multi-dimensional concept which can stem from the practitioner, the setting, the patient and uncertainty that arises from the patients’ symptoms which can have multiple potential causes. For example, more people are living longer with multiple long-term conditions and associated poly-pharmacy. Many more people and carers have mental health issues which impact on their physical health and vice versa. In practice, individualised management plans may be determined and delivered solely by the Advanced Practitioner, may require a team approach initiated and possibly coordinated by the Advanced Practitioner, or may require referral to another health care professional or agency.  The actions of the Advanced Practitioner may also involve offering patient and/or carer education and support and advice on self-help strategies, health promotion and life-style modification.

Aims: 

To enable students to develop, implement and evaluate safe and appropriate management plans for patients with common acute, long term and complex disease presentations across the range of body systems. 

Teaching and Learning Pattern

Contact hours includes the following: Lectures, group Work, tutorial, skills lab, workshops, practical, VLE activities

Students will be required to actively participate in a variety of learning opportunities.  These will include:

• Pre and post teaching session activities to source and review pertinent on-line evidence-based resources to inform class and small group discussion of common approaches to management of patient conditions within their work settings  
• Interactive lectures 
• Case based learning using scenarios which reflect the realities of patient presentations in primary care and urgent care
• Critique of example documentation

Practice Based Learning forms an integral part of this module.  It enables consolidation and application of new knowledge and skills within the realities of clinical practice. To demonstrate that this has taken place, submission of a Practice Based Learning Record forms one of the elements of assessment for the module.

BLENDED LEARNING:

The Virtual Learning Environment (VLE) Moodle site will provide the on-line reading list and copies of power-point presentations and relevant supplementary material in advance of the classroom session for students to review.  This aims to facilitate informed discussion within the classroom setting.  Links to useful websites, Bates on-line OSCE video resources and guidance on further reading are provided after each session to consolidate and supplement learning. 

Indicative content

• Current policy for Advanced Practitioners including the NHSE Framework and other relevant professional regulations, and standards for demonstration of competence. 
• Complexity theories and their application to clinical practice
• Accountability in the context of autonomous advanced level clinical practice including appropriate documentation of findings and management decisions
• Safe and effective management of episodes of patient care including safety and assessing and managing risk, economic considerations, ethical issues, prioritising care, managing urgent situations, prescribing and non-pharmacological interventions such as health promotion, public screening programmes and motivation / behaviour change and self-care strategies
• Evidence-based practice including obtaining resources, application, sharing, and evaluation 
• Therapeutic communication, patient education, user/carer involvement and partnership-working, including consideration of factors such as age, gender, spirituality, culture, sexuality, learning and other disability, life style choices and health beliefs 
• The impact of long-term conditions and co-morbidities on patients, carers, families and the wider health system
• Communication, referrals and collaborative practice within and external to the multidisciplinary team
• Application to a variety of common acute and long-term complex patient presentations.

Employability

This module facilitates achievement of a number of competencies required for advanced clinical practice.  It will also develop students who are able to meet the needs for a flexible workforce that is able to respond to the changing patterns of service.   Successful completion of this module will therefore result in a student who can demonstrate knowledge and skills that are currently in high demand with existing and emerging services in health care. 

Indicative Sources (Reading lists)

Core materials:

Carrier, J. (2015) Managing Long-term Conditions Chronic Illness in Primary Care. (2nd ed.) Routledge.

Sturmberg, J.P. (2007) Systems and complexity thinking in general practice. Part 1 – clinical application Aus Fam Phys 36: 

Sturmberg, J.P, Martin C.M, and Katerndahl D.A (2014) Systems and Complexity Thinking in the General Practice Literature: An Integrative, Historical Narrative Review. Ann Fam Med: 12, 1. pp 66-74  Article

Wilson T, Holt T, and Greenhalgh T (2001) Complexity and clinical care BMJ 323:685-8 Article

Optional reading:

Shippe, N.D. et al (2012) Cumulative complexity: a functional patient –centred model of patient complexity can improve research and practice Journal of Clinical Epidemiology 65: pp1041-1051

Barton, T.D. and Allan, D. (Eds) (2015) Advanced Nursing Practice, changing healthcare in a changing world. London: Palgrave.McGee, S. (2012) Evidence-Based Physical Diagnosis. (3rd ed) Philadelphia: Elsevier Saunders.

Completion of the following modules: “Physiology for Advanced Clinical Practice”, “Advanced Clinical Assessment Skills”, “Clinical Reasoning and Diagnostic Skills” and Non Medical Prescribing course or “Enhancing Practice through Work Based learning”.

Co-requisites

PROFESSIONAL

• Current registration as health care professional with the Nursing and Midwifery Council (NMC), Health and Care Professions Council (HCPC) or The General Pharmaceutical Council (GPhC)
• A minimum of 3 years post-registration experience on entry to the module 

 PRACTICE

• Employed* for a minimum of 30 hours per week in one relevant clinical environment, with access to appropriate clinical support and supervision for the development of knowledge and skills to an advanced level.  *This excludes students who are working in a locum or agency basis.   
• Applicants must also be able to demonstrate employer support for all of the following (even where individuals are self-funding): 
• Support for development of the applicant to an advanced level within the workplace while on the module, to enable evolution of the scope of practice and responsibilities 
• Willingness to release the student to enable them to dedicate regular time throughout the module (in addition to attendance at the university) as protected learning time to enable the student to work in a 'supernumerary capacity' to focus on their clinical/professional development evidenced by completion of the Practice Based Learning record.
• Able to support the student to organise for a Doctor/qualified Advanced Practitioner to act as their designated "Practice Facilitator" to initially supervise and support the applicants overall clinical development and facilitate completion of specified practice-based learning activities. Sign off for specific aspects of learning is required (this responsibility can be shared with other senior experienced clinical colleagues however nomination of an overall Practice Facilitator is required). 
• Provision of day-to-day supervision and support by an experienced clinical team to enable the development of the knowledge, skills, behaviours, competence and confidence commensurate with this level of practice.

Formative Assessment: A 10-minute presentation to class of a complex case within the student’s clinical area.

Summative assessment: There are two elements, both need to be passed to be awarded credit for this module:  

CW1: A practice-based learning record Encompassing 30 certified clinical hours (direct supervision) and a student progress evaluation form completed by the Practice Facilitator. 

EX1: Viva

A 30-minute presentation of a complex case, selected from 3 possible cases published 6 weeks prior to the presentation

Mode of resit assessment (if applicable): 

Summative assessment: Students who are unsuccessful will receive written feedback on their first attempts and have a group or individual tutorial. Students have one further opportunity to retrieve relevant assessment components, amounting to a maximum of two for each component.

By the end of this module, students will be able to: 

Knowledge and Understanding:

• Systematically draw on a comprehensive knowledge base to provide holistic evidence-based complete episodes for patients with a wide variety of common acute, long term and complex health problems 
• Demonstrate depth of understanding of a wide range of strategies to monitor the impact of interventions and individual patient management plans

Intellectual Skills:

• Critically appraise and synthesise evidence from a wide variety of resources to inform the use of therapeutic interventions, pro-actively monitor the impact and/or make timely and appropriate referrals
• Critically evaluate and selectively apply suitable theoretical perspectives and skills to support effective communication and education with a range of stake holders in both straightforward and complex clinical situations

Practical Skills:

• Demonstrate competence in safe and evidence-based holistic individualised screening, assessment and pro-active management of adult patients experiencing existing and potential health problems of a common acute and/or long term nature 
• Demonstrate a health promotion and prevention orientation, including comprehensive assessment of patients for risk factors and early signs of disease
• Critically evaluate and selectively apply suitable theoretical perspectives and skills to support effective communication and education with a range of stake holders, including patients, carers, families and agencies, in both straight forward and complex clinical situations
• Plan, manage and critically evaluate complex and unpredictable events by working in partnership within a multi-professional and multi-agency context
• Use professional judgement in managing complex and unpredictable events and capture learning from these experiences to improve patient care and service delivery.

 Transferable Skills:

• Develop and refine their expertise as a reflective-practitioner in a variety of clinical encounters.