The Advanced Practitioner
A Framework for Practice
Advanced Clinical Practice
1. Edition September 2023
464 Pages, Softcover
Wiley & Sons Ltd
ISBN:
978-1-119-88203-9
John Wiley & Sons
The Advanced Practitioner
An essential text for Advanced Practitioners
In The Advanced Practitioner: A Framework for Practice, a team of distinguished Advanced Practitioners (APs) and academics deliver the go-to text for trainee APs, with a strong focus on the four pillars that underpin advanced practice: clinical practice, education, research, and leadership.
The patient is at the core of this essential resource, which offers the knowledge required to care safely for people in a variety of care settings, as well as with a range of common and specialised holistic interventions. Readers will also find:
* A thorough introduction to the core principles of advanced practice, including the AP curriculum and the principles of physiology, pharmacology, and pathophysiology
* Comprehensive exploration of the clinical pillar, including discussions of clinical history taking and physical examination
* Practical discussion of the education and research pillars, including an exploration of research principles and education and learning
* Discussion of innovation in practice, the leadership pillar, and how to deal with difficult situations
Perfect for trainee advanced practitioners, The Advanced Practitioner: A Framework for Practice will also benefit healthcare students and trainee medical associate professionals.
Contributors xviii
Preface xxv
Acknowledgements xxvii
Chapter 1 Advanced Clinical Practice 1
Sadie Diamond-Fox and Vikki-Jo Scott
Learning Outcomes 1
Introduction 1
The Concept and History of Advanced-Level Practice 3
Frameworks and Toolkits for Advanced Clinical Practice 3
Ensuring Quality and Governance in Advanced Practice 3
How to Use this Book 5
Conclusion 5
References 7
Further Reading 8
Self-Assessment Questions 8
Glossary 8
Chapter 2 The Advanced Clinical Practice Curriculum 10
Rachael Daw and Ollie Phipps
Learning Outcomes 10
Introduction 10
Curriculum Development 12
Understanding the Context of ACP 14
The Clinical Practice Curriculum 14
The Leadership and Management Curriculum 15
The Education Curriculum 15
The Research Curriculum 16
Assessment for ACP 16
Specialist Curriculums, Credentials and Capability Frameworks 18
First Contact Practitioners and Advanced Practitioners - Roadmaps to Practice 19
Supervision and CPD Strategies 19
Conclusion 21
References 22
Further Reading 23
Self-Assessment Questions 24
Glossary 24
Chapter 3 Scope of Practice and Management of Patient Care 25
Ollie Phipps
Learning Outcomes 25
Introduction 25
The Multi-Professional Framework (MPFFACP) 26
Governance 27
Legal Issues 27
Regulation Statements of Standards and Code of Conducts 28
Nursing and Midwifery Council (NMC) 28
Health and Care Professions Council (HCPC) 28
General Pharmaceutical Council (GPhC) 28
Scope and Capability 28
Defining Scope of Practice 28
Competency vs Capability 29
Knowledge, Skills and Behaviours 29
Competence 29
Multiprofessional Registrations and Scope of Practice 30
Expanding Scope and Scope Creep 30
Responsibility and Accountability 30
Dunning-Kruger Effect 31
Imposter Syndrome 31
Professional Issues 31
Indemnity 33
Indemnity Insurance 33
Negligence 34
Duty of Care 34
Breach of Duty 34
Causation 34
Mental Health Act 1983 and Sections 35
Mental Capacity Act 36
Ethics 37
Autonomy 37
Non-maleficence 38
Beneficence 38
Justice 38
The Right to Life and the Right to Dignity 38
Consent 39
Gillick Competence 39
Confidentiality 39
Development and Regulation 39
Conclusion 40
References 40
Further Reading 42
Self-Assessment Questions 42
Glossary 43
Chapter 4 Principles of Physiology for Advanced Practice 44
Colin Chandler, Alison Wood, and Robin Hyde
Learning Outcomes 44
Introduction 45
How the Body Adapts to Different Situations 47
Key Concepts of the Cell 52
Contents vii
Control - How the Body Allows us to Achieve Action and Participation in Society 55
Changes to Physiology Through the Life Course 57
Microbiome/Microbiota and Interactions with the Microbiological Environment 61
Conclusion 62
References 63
Further Reading 64
Self-Assessment Questions 64
Glossary 64
Chapter 5 Principles of Pathophysiology 66
Sarah Ashelford and Vanessa Taylor
Learning Outcomes 66
Introduction 67
The Main Disease Mechanisms 68
Cancer 69
Aetiology and Pathogenesis of Cancer 70
Clinical Investigations 72
Learning Events 72
Clinical Effects of Cancer 72
Learning Event 72
Cardiovascular Disease and Stroke 73
Investigations 73
Pathogenesis of Atherosclerosis 73
Pharmacological Principles 76
Investigations 76
Diabetes 76
Clinical Presentation 76
Learning Event 77
Aetiology and Pathogenesis of Type 1 Diabetes 77
Aetiology and Pathogenesis of Type 2 Diabetes 78
Acute Complications of Diabetes 79
Respiratory Disease 81
Asthma 81
Aetiology and Pathogenesis of Asthma 81
Pharmacological Principles 83
Learning event 83
Chronic Obstructive Pulmonary Disease 83
Aetiology and Pathogenesis of COPD 83
Conclusion 86
References 86
Further Reading 89
Self-Assessment Questions 89
Glossary 89
Chapter 6 Principles of Pharmacology 90
Ihab Ali and Phil Broadhurst
Learning Outcomes 90
Introduction 90
Pharmacotherapy 91
Pharmacokinetics (PK) 91
VIII Contents Pharmacodynamics (pd) 93
Pharmacodynamics: Drug-Receptor Interactions 94
Pharmacodynamics: Drug Concentration 94
Therapeutic Drug Monitoring (TDM) 96
Plasma Protein Binding 98
Drug-induced Adverse Effects 100
Drug Interactions 103
Contraindications 103
Excipients 104
Adherence 104
Conclusion 107
References 107
Further Reading 111
Self-Assessment Questions 111
Glossary 111
Chapter 7 Supplementary and Independent Prescribing 113
Brigitta Fazzini, Esther Clift, and Jill Bentley
Learning Outcomes 113
Introduction 113
Education 115
General Pharmacological Principles 115
Prescribing in Paediatrics 115
Prescribing in Mental Health 116
Prescribing in Critical Care 117
Absorption 117
Distribution 117
Metabolism 118
Excretion 119
Assessing Drug Therapy in Critical Illness 119
Prescribing in Older People 120
Medication Reviews 120
Pharmacokinetics 121
Guidelines on Drug Prescription for Older People 122
Antibiotics Stewardship 123
Authorisation of Blood Components and Products 125
Legal Aspects and Governance 125
Patient Consent 126
Clinical Decision Making 126
De-Prescribing 127
Health Promotion 127
Why is This Important to Us as Prescribers? 128
So What Can We Do? 128
Social Prescribing 129
Conclusion 130
References 130
Further Reading 131
Self-Assessment Questions 131
Glossary 131
Chapter 8 Core Procedural Skills 132
Mark Cannan, Kirstin Geer, and Stuart Cox
Learning Outcomes 132
Introduction 132
Consent/Assent 133
Clinical Competence for Procedures 134
Preparation: Positioning 135
Core Procedural Skills 137
Airway: Basic Manoeuvres and Adjuncts 137
Airway: Supraglottic Airway Devices 137
Breathing: Intercostal Drain Insertion 137
Preprocedure Set-up and Equipment for ICD Insertion 137
Procedure for ICD Insertion (Seldinger) - Small Bore 139
Procedure for ICD Insertion - Large Bore (Lloyd 2019) 141
Postprocedure Checks 141
Pearls and Pitfalls 141
Circulation: Venepuncture 142
Practitioner Safety 142
Technique 143
Postprocedure Checks 144
Pearls and Pitfalls 144
Circulation: Peripheral Intravenous Cannulation 144
Technique 145
Postprocedure Checks 146
Pearls and Pitfalls 146
Circulation: Arterial Puncture and Cannulation 147
Technique 148
Postprocedure Checks 149
Pearls and Pitfalls 149
Circulation: Central Venous Access Via Central Venous Catheter 149
Technique 150
Pearls and Pitfalls 151
Circulation: Intraosseous Needle Insertion 152
Preprocedure Considerations 152
Pearls and Pitfalls 152
Disability: Lumbar Puncture 153
Technique 154
Pearls and Pitfalls 155
Exposure: Nasogastric Tube Insertion 156
Technique - Awake Patient 156
Technique - Unconscious/Anaesthetised/Intubated Patient 157
Postprocedure Checks 157
Pearls and Pitfalls 157
Learning From Patient Safety Events 158
Conclusion 158
References 159
Further Reading 161
Self-Assessment Questions 161
Glossary 161
Chapter 9 Clinical History Taking and Physical Examination 162
Sadie Diamond-Fox, Rebecca Connolly, Alexandra Gatehouse, and John Wilkinson
Learning Outcomes 162
Introduction 162
The Consultation as a Diagnostic Tool 163
Communication 164
The Cone Technique 164
Ideas, Concerns and Expectations (ICE) 165
Triggers to Consultation 165
Consultation Models 165
Calgary-Cambridge Guide to the Medical Interview 167
Patient Perspective of Consultation 168
Kinesics Interviewing 168
Aspects of Obtaining a Medical History 169
History Taking in Special Circumstances: Time-Critical Situations 171
History Taking for Neurodiverse and Non-verbal Populations 172
History Taking for Ethnic Minority Populations 173
History Taking for LGBTQIA+ Populations 173
Clinical Assessment - Aspects of Physical Examination 175
Introduction 175
General Inspection 176
Vital Signs 176
Physical Examination Techniques 177
Hands and Nails 177
Upper Limbs 181
Head and Neck 181
Thorax 185
Abdomen 188
Lower Limbs 190
Closing the Consultation 190
Conclusion 191
References 191
Further Reading 194
Self-Assessment Questions 194
Glossary 194
Chapter 10 Clinical Decision Making and Diagnostic Reasoning 195
Helen Francis-Wenger and Colin Roberts
Learning Outcomes 195
Introduction 195
Clinical Reasoning and Clinical Decision Making 197
Recognition 200
Probability 200
Reasoning 200
Watching and Waiting 200
Selective Doubting 201
Iteration and Reiteration 201
Thinking, Growing and Evolving 201
Contents xi
Decision-Making Theories 203
Normative, Prescriptive and Descriptive Interactions 203
Descriptive Approach 203
Normative Approach 203
Prescriptive Approach 204
Intuition 204
Hypothetico-Deductive Reasoning 205
Cue Acquisition Stage 205
Hypothesis Generation 205
Cue Interpretation 206
Hypothesis Evaluation 206
The Cognitive Process 206
Biases 207
Assistive Tools and Concepts: Risk Assessments/Probability Scores/Risk Stratification 210
Odds Ratios 210
Numbers Needed to Treat 210
Bayes' Theorem: Sensitive (Rule Out) and Specific (Rule In) 210
Risk Stratification 211
Conclusion 211
References 211
Further Reading 213
Self-Assessment Questions 213
Glossary 213
Chapter 11 Diagnostic Interpretation 214
Colin Roberts, Christine Eade, and Helen Francis-Wenger
Learning Outcomes 214
Introduction 214
Principles to Follow 216
Principles of Ordering and Interpretation 216
Reference Ranges 217
Patient and Clinician Factors to Consider When Interpreting Results: Context 217
The Full Blood Count 217
Haemoglobin 217
A Stepwise Approach 218
White Cells (Leucocytes) 219
Platelets (Thrombocytes) 219
Raised Platelets (>400) 219
Low Platelets (
Inflammatory Markers 220
C-Reactive Protein 220
Plasma Viscosity 220
Renal Function 220
Range 220
Creatinine (Cr) 221
Urea (U) 221
Acute Kidney Injury 221
Chronic Kidney Injury 221
Electrolytes: Sodium and Potassium 221
Electrolytes: Calcium and Magnesium 223
Liver Function Tests 225
Alanine Aminotransferase (ALT) 225
Alkaline Phosphatase (ALP) 225
Bilirubin (Br) 225
Patterns of Liver Disease 225
Thyroid Function Tests 226
Hypothyroidism (Underfunctioning) 226
Hyperthyroidism (Overfunctioning) 226
Subclinical Hypothyroidism and Hyperthyroidism 227
Diagnostic Interpretation: Imaging 228
Fundamental Principles 228
The Essentials of Each Imaging Modality are Considered Below 229
Plain Film 229
Ultrasound 232
Lung Ultrasound 232
FAST Scan 233
Echo 233
Computed Tomography 233
Imaging Summary 234
References 235
Further Reading 236
Self-Assessment Questions 236
Glossary 236
Chapter 12 Public Health: Prevention, Promotion and Empowerment 238
Joanna Lavery and Sharon Riverol
Learning Outcomes 238
Introduction 238
Accreditation Considerations 240
Clinical Examination 242
Leg assessment 244
Clinical investigation - point-of care (POC) D-dimer testing 244
Diagnosis - Class 1 Cellulitis 245
Pharmacology 245
Follow-up Plan 246
Clinical Examination 248
Results 249
Management 249
Pharmacology 249
Clinical Examination 251
NEWS2 - 0 But Blood Pressure Found to Be Hypotensive 251
Neuro assessment 251
Management 253
Reflections 255
Admission Avoidance 255
Advanced Care Practitioner and Patient Empowerment 255
References 256
Further Reading 261
Self-Assessment Questions 261
Glossary 262
Chapter 13 Managing Complexity 263
Jaclyn Proctor and Sadie Diamond-Fox
Learning Outcomes 263
Introductions 263
Medical Complexity 265
Measuring Complexity in a Healthcare Context 266
Situational Complexity 269
Systems Complexity 270
NHS Long Term Plan (2019) 270
Advanced Clinical Practice 272
Conclusion 275
References 276
Further Reading 277
Self-Assessment Questions 277
Glossary 277
Chapter 14 Frailty: Principles of Rehabilitation and Reablement, Palliative Care and Organ Donation 278
Esther Clift and Stevie Park
Learning Outcomes 278
Introduction 278
Discharge Planning 279
Intermediate Care 280
Rehabilitation 281
Reablement 282
Pathways 282
Technology 282
Home-based Care 282
Virtual Wards 283
Urgent Community Response 283
Palliative or End-of-Life Care 284
Gold Standard Framework 285
Care Plans 285
Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) 286
Pain and Symptom Control 286
Verifying Death 287
Organ Donation 287
Diagnosing Death by Neurological Criteria (Brainstem Death Testing) 287
Role of the SN-OD and Referral Process 288
Tissue Donation 288
Clinical Frailty 288
Diagnosis Tools for Diagnosis and CGA 288
Exercise 290
Nutrition 290
Social Isolation and Loneliness 291
Conclusion 293
References 293
Further Reading 295
Self-Assessment Questions 295
Chapter 15 Mental Health, Learning Disability and Autism 296
Clare Allabyrne and Jo Delrée
Learning Outcomes 296
Introduction 297
Parity of Esteem 297
Diagnostic Overshadowing and Unconscious Bias 297
Mental Health and Ethnicity 298
Communication 298
Therapeutic Communication 298
Fundamental Principles of Therapeutic Communication 298
Specific Issues in Communication Clients with ASD/LD 299
Clinical Investigations 299
Mental Health Screening Tools 299
Holistic Mental Health Assessment 299
Ten-point Guide to Mental State Examination 301
Risk Assessment in Mental Health 301
Assessing Different Groups 302
Assessing Children and Young People 302
Assessing People with Autism 303
Assessing People with Learning Disability 304
A Note on Challenging Behaviour 307
Pharmacological Principles 307
Resources 309
Learning Disability Learning Event 309
Mental Health Learning Event 309
Mental Health UK states 309
Conclusion 310
References 310
Further Reading 313
Self-Assessment Questions 313
Glossary 313
Chapter 16 Education and Learning 315
Joe Wood and Elizabeth Midwinter
Learning Outcomes 315
Introduction 316
Principles of Teaching and Learning 316
Understanding How We Learn 316
Recognising Adult Learners 317
Dual Coding Theory 317
Evidence-based Practice 318
Contents xv
Self-directed Learning 318
Supporting Others to Develop Knowledge and Skills 318
Feedback 318
Appraisal Processes and Continuing Professional Development 319
Learning From Mistakes: Safety I and Safety II 319
Coaching, Mentoring and Role Modelling 319
Creating an Effective Learning Environment 320
Optimise the Space 320
Physial 320
Virtual 321
Ensure Learner-centredness 321
Get to Know the Learner 322
Plan the Process 322
Create Psychological Safety 323
Promote Continual Improvement Via Reflection 324
Simulation and Technological Advances in Healthcare Education 324
Simulation 324
Teaching Practical Skills - Reflections from Clinical Experience 325
Human Factors 325
Interprofessional Education 326
Types of Simulation 327
The Concept of Fidelity 328
In Situ Simulation 329
Designing Simulated Learning 329
Scenario Writing 330
Practical Considerations 330
Introductions and Orientation 330
Pre-brief 330
Programmed vs On the Fly 331
Debrief 331
Technology-enhanced Learning 333
Conclusion 334
References 334
Further Reading 338
Self-Assessment Questions 338
Glossary 338
Chapter 17 The Advanced Practitioner as Educator 339
Phil Broadhurst
Learning Outcomes 339
Introduction 339
Providing Feedback 342
Feeding Back and Feeding Forward 343
The One-Minute Preceptor 345
Conclusion 347
References 347
Further Reading 349
Self-Assessment Questions 350
Glossary 350
Chapter 18 Research Principles 351
Brigitta Fazzini and Roberta Borg
Learning Outcomes 351
Why Research Is Important 351
The Research Process 352
Critical Appraisal and the Hierarchy of Evidence 353
Designing a Research Project 354
Every Research Project Starts with a Question 354
Research Methods 355
Scientific Hypothesis 355
Quantitative versus Qualitative Research Methods 356
Quantitative Research Method 357
Qualitative Research Method 359
Healthcare Research Ethics 360
Quality Improvement 362
Conclusion 364
References 364
Further Reading 365
Self-Assessment Questions 366
Glossary 366
Chapter 19 Leading Research in Advanced Practice 367
Leanne Dolman, Joanna De Souza, and Sara Stevenson-Baker
Learning Outcomes 368
Introduction 368
Enabling Evidence-Based Practice 369
Using Local Procedures and Protocols - Role Modelling and Ensuring Continuity of Practice 370
Auditing Current Practice 370
Utilising Clinical Audit 371
Setting Standards and Developing New Protocols 371
Setting Intended Outcomes 371
Patient-reported Outcome Measures 372
Reviewing your Protocol (Quality Control) 372
Developing Guidelines at a National/International Level 373
Developing New Evidence for Practice 373
Leading on Quality Improvement 374
Dissemination of Existing and New Knowledge 377
Local Dissemination 377
Presenting at an External Conference 377
Developing a Conference Abstract 378
Developing a Poster 378
Developing an Oral Presentation 378
Writing for Publication 378
Joining a National Forum or Guideline Development Group 378
Developing the Advanced Practitioner as a Clinical Academic 379
Creating A Research Culture at Organisational Level to Improve Person-Centred Healthcare 380
Conclusion 381
References 382
Further Reading 384
Self-Assessment Questions 384
Glossary 384
Chapter 20 Innovations in Practice 386
Vanessa Taylor and Sarah Ashelford
Learning Outcomes 386
Introduction 386
Innovation, Practice Development and Service Improvement 388
Innovation and Advanced-level Practice and the Advanced Practitioner Role 392
Advanced-level Practice and Workforce Transformation: An Example of Healthcare Service Innovation 392
Advanced Practitioner as Clinical (Practice Development/ Improvement) and Professional (Service/System Development) Innovator 394
Conclusion 400
References 401
Self-Assessment Questions 403
Glossary 403
Chapter 21 Professional Development and Transition 404
Vikki-Jo Scott and Esther Clift
Learning Outcomes 404
Introduction 405
Personal Professional Development 405
Continuing Professional Development and Role Transition 410
Supporting Professional Development Within a Team 412
Contribution to Broader Development of Advanced Practice 415
What Next? 416
Conclusion 416
References 417
Further Reading 417
Self-Assessment Questions 418
Glossary 418
Index 419
Preface xxv
Acknowledgements xxvii
Chapter 1 Advanced Clinical Practice 1
Sadie Diamond-Fox and Vikki-Jo Scott
Learning Outcomes 1
Introduction 1
The Concept and History of Advanced-Level Practice 3
Frameworks and Toolkits for Advanced Clinical Practice 3
Ensuring Quality and Governance in Advanced Practice 3
How to Use this Book 5
Conclusion 5
References 7
Further Reading 8
Self-Assessment Questions 8
Glossary 8
Chapter 2 The Advanced Clinical Practice Curriculum 10
Rachael Daw and Ollie Phipps
Learning Outcomes 10
Introduction 10
Curriculum Development 12
Understanding the Context of ACP 14
The Clinical Practice Curriculum 14
The Leadership and Management Curriculum 15
The Education Curriculum 15
The Research Curriculum 16
Assessment for ACP 16
Specialist Curriculums, Credentials and Capability Frameworks 18
First Contact Practitioners and Advanced Practitioners - Roadmaps to Practice 19
Supervision and CPD Strategies 19
Conclusion 21
References 22
Further Reading 23
Self-Assessment Questions 24
Glossary 24
Chapter 3 Scope of Practice and Management of Patient Care 25
Ollie Phipps
Learning Outcomes 25
Introduction 25
The Multi-Professional Framework (MPFFACP) 26
Governance 27
Legal Issues 27
Regulation Statements of Standards and Code of Conducts 28
Nursing and Midwifery Council (NMC) 28
Health and Care Professions Council (HCPC) 28
General Pharmaceutical Council (GPhC) 28
Scope and Capability 28
Defining Scope of Practice 28
Competency vs Capability 29
Knowledge, Skills and Behaviours 29
Competence 29
Multiprofessional Registrations and Scope of Practice 30
Expanding Scope and Scope Creep 30
Responsibility and Accountability 30
Dunning-Kruger Effect 31
Imposter Syndrome 31
Professional Issues 31
Indemnity 33
Indemnity Insurance 33
Negligence 34
Duty of Care 34
Breach of Duty 34
Causation 34
Mental Health Act 1983 and Sections 35
Mental Capacity Act 36
Ethics 37
Autonomy 37
Non-maleficence 38
Beneficence 38
Justice 38
The Right to Life and the Right to Dignity 38
Consent 39
Gillick Competence 39
Confidentiality 39
Development and Regulation 39
Conclusion 40
References 40
Further Reading 42
Self-Assessment Questions 42
Glossary 43
Chapter 4 Principles of Physiology for Advanced Practice 44
Colin Chandler, Alison Wood, and Robin Hyde
Learning Outcomes 44
Introduction 45
How the Body Adapts to Different Situations 47
Key Concepts of the Cell 52
Contents vii
Control - How the Body Allows us to Achieve Action and Participation in Society 55
Changes to Physiology Through the Life Course 57
Microbiome/Microbiota and Interactions with the Microbiological Environment 61
Conclusion 62
References 63
Further Reading 64
Self-Assessment Questions 64
Glossary 64
Chapter 5 Principles of Pathophysiology 66
Sarah Ashelford and Vanessa Taylor
Learning Outcomes 66
Introduction 67
The Main Disease Mechanisms 68
Cancer 69
Aetiology and Pathogenesis of Cancer 70
Clinical Investigations 72
Learning Events 72
Clinical Effects of Cancer 72
Learning Event 72
Cardiovascular Disease and Stroke 73
Investigations 73
Pathogenesis of Atherosclerosis 73
Pharmacological Principles 76
Investigations 76
Diabetes 76
Clinical Presentation 76
Learning Event 77
Aetiology and Pathogenesis of Type 1 Diabetes 77
Aetiology and Pathogenesis of Type 2 Diabetes 78
Acute Complications of Diabetes 79
Respiratory Disease 81
Asthma 81
Aetiology and Pathogenesis of Asthma 81
Pharmacological Principles 83
Learning event 83
Chronic Obstructive Pulmonary Disease 83
Aetiology and Pathogenesis of COPD 83
Conclusion 86
References 86
Further Reading 89
Self-Assessment Questions 89
Glossary 89
Chapter 6 Principles of Pharmacology 90
Ihab Ali and Phil Broadhurst
Learning Outcomes 90
Introduction 90
Pharmacotherapy 91
Pharmacokinetics (PK) 91
VIII Contents Pharmacodynamics (pd) 93
Pharmacodynamics: Drug-Receptor Interactions 94
Pharmacodynamics: Drug Concentration 94
Therapeutic Drug Monitoring (TDM) 96
Plasma Protein Binding 98
Drug-induced Adverse Effects 100
Drug Interactions 103
Contraindications 103
Excipients 104
Adherence 104
Conclusion 107
References 107
Further Reading 111
Self-Assessment Questions 111
Glossary 111
Chapter 7 Supplementary and Independent Prescribing 113
Brigitta Fazzini, Esther Clift, and Jill Bentley
Learning Outcomes 113
Introduction 113
Education 115
General Pharmacological Principles 115
Prescribing in Paediatrics 115
Prescribing in Mental Health 116
Prescribing in Critical Care 117
Absorption 117
Distribution 117
Metabolism 118
Excretion 119
Assessing Drug Therapy in Critical Illness 119
Prescribing in Older People 120
Medication Reviews 120
Pharmacokinetics 121
Guidelines on Drug Prescription for Older People 122
Antibiotics Stewardship 123
Authorisation of Blood Components and Products 125
Legal Aspects and Governance 125
Patient Consent 126
Clinical Decision Making 126
De-Prescribing 127
Health Promotion 127
Why is This Important to Us as Prescribers? 128
So What Can We Do? 128
Social Prescribing 129
Conclusion 130
References 130
Further Reading 131
Self-Assessment Questions 131
Glossary 131
Chapter 8 Core Procedural Skills 132
Mark Cannan, Kirstin Geer, and Stuart Cox
Learning Outcomes 132
Introduction 132
Consent/Assent 133
Clinical Competence for Procedures 134
Preparation: Positioning 135
Core Procedural Skills 137
Airway: Basic Manoeuvres and Adjuncts 137
Airway: Supraglottic Airway Devices 137
Breathing: Intercostal Drain Insertion 137
Preprocedure Set-up and Equipment for ICD Insertion 137
Procedure for ICD Insertion (Seldinger) - Small Bore 139
Procedure for ICD Insertion - Large Bore (Lloyd 2019) 141
Postprocedure Checks 141
Pearls and Pitfalls 141
Circulation: Venepuncture 142
Practitioner Safety 142
Technique 143
Postprocedure Checks 144
Pearls and Pitfalls 144
Circulation: Peripheral Intravenous Cannulation 144
Technique 145
Postprocedure Checks 146
Pearls and Pitfalls 146
Circulation: Arterial Puncture and Cannulation 147
Technique 148
Postprocedure Checks 149
Pearls and Pitfalls 149
Circulation: Central Venous Access Via Central Venous Catheter 149
Technique 150
Pearls and Pitfalls 151
Circulation: Intraosseous Needle Insertion 152
Preprocedure Considerations 152
Pearls and Pitfalls 152
Disability: Lumbar Puncture 153
Technique 154
Pearls and Pitfalls 155
Exposure: Nasogastric Tube Insertion 156
Technique - Awake Patient 156
Technique - Unconscious/Anaesthetised/Intubated Patient 157
Postprocedure Checks 157
Pearls and Pitfalls 157
Learning From Patient Safety Events 158
Conclusion 158
References 159
Further Reading 161
Self-Assessment Questions 161
Glossary 161
Chapter 9 Clinical History Taking and Physical Examination 162
Sadie Diamond-Fox, Rebecca Connolly, Alexandra Gatehouse, and John Wilkinson
Learning Outcomes 162
Introduction 162
The Consultation as a Diagnostic Tool 163
Communication 164
The Cone Technique 164
Ideas, Concerns and Expectations (ICE) 165
Triggers to Consultation 165
Consultation Models 165
Calgary-Cambridge Guide to the Medical Interview 167
Patient Perspective of Consultation 168
Kinesics Interviewing 168
Aspects of Obtaining a Medical History 169
History Taking in Special Circumstances: Time-Critical Situations 171
History Taking for Neurodiverse and Non-verbal Populations 172
History Taking for Ethnic Minority Populations 173
History Taking for LGBTQIA+ Populations 173
Clinical Assessment - Aspects of Physical Examination 175
Introduction 175
General Inspection 176
Vital Signs 176
Physical Examination Techniques 177
Hands and Nails 177
Upper Limbs 181
Head and Neck 181
Thorax 185
Abdomen 188
Lower Limbs 190
Closing the Consultation 190
Conclusion 191
References 191
Further Reading 194
Self-Assessment Questions 194
Glossary 194
Chapter 10 Clinical Decision Making and Diagnostic Reasoning 195
Helen Francis-Wenger and Colin Roberts
Learning Outcomes 195
Introduction 195
Clinical Reasoning and Clinical Decision Making 197
Recognition 200
Probability 200
Reasoning 200
Watching and Waiting 200
Selective Doubting 201
Iteration and Reiteration 201
Thinking, Growing and Evolving 201
Contents xi
Decision-Making Theories 203
Normative, Prescriptive and Descriptive Interactions 203
Descriptive Approach 203
Normative Approach 203
Prescriptive Approach 204
Intuition 204
Hypothetico-Deductive Reasoning 205
Cue Acquisition Stage 205
Hypothesis Generation 205
Cue Interpretation 206
Hypothesis Evaluation 206
The Cognitive Process 206
Biases 207
Assistive Tools and Concepts: Risk Assessments/Probability Scores/Risk Stratification 210
Odds Ratios 210
Numbers Needed to Treat 210
Bayes' Theorem: Sensitive (Rule Out) and Specific (Rule In) 210
Risk Stratification 211
Conclusion 211
References 211
Further Reading 213
Self-Assessment Questions 213
Glossary 213
Chapter 11 Diagnostic Interpretation 214
Colin Roberts, Christine Eade, and Helen Francis-Wenger
Learning Outcomes 214
Introduction 214
Principles to Follow 216
Principles of Ordering and Interpretation 216
Reference Ranges 217
Patient and Clinician Factors to Consider When Interpreting Results: Context 217
The Full Blood Count 217
Haemoglobin 217
A Stepwise Approach 218
White Cells (Leucocytes) 219
Platelets (Thrombocytes) 219
Raised Platelets (>400) 219
Low Platelets (
Inflammatory Markers 220
C-Reactive Protein 220
Plasma Viscosity 220
Renal Function 220
Range 220
Creatinine (Cr) 221
Urea (U) 221
Acute Kidney Injury 221
Chronic Kidney Injury 221
Electrolytes: Sodium and Potassium 221
Electrolytes: Calcium and Magnesium 223
Liver Function Tests 225
Alanine Aminotransferase (ALT) 225
Alkaline Phosphatase (ALP) 225
Bilirubin (Br) 225
Patterns of Liver Disease 225
Thyroid Function Tests 226
Hypothyroidism (Underfunctioning) 226
Hyperthyroidism (Overfunctioning) 226
Subclinical Hypothyroidism and Hyperthyroidism 227
Diagnostic Interpretation: Imaging 228
Fundamental Principles 228
The Essentials of Each Imaging Modality are Considered Below 229
Plain Film 229
Ultrasound 232
Lung Ultrasound 232
FAST Scan 233
Echo 233
Computed Tomography 233
Imaging Summary 234
References 235
Further Reading 236
Self-Assessment Questions 236
Glossary 236
Chapter 12 Public Health: Prevention, Promotion and Empowerment 238
Joanna Lavery and Sharon Riverol
Learning Outcomes 238
Introduction 238
Accreditation Considerations 240
Clinical Examination 242
Leg assessment 244
Clinical investigation - point-of care (POC) D-dimer testing 244
Diagnosis - Class 1 Cellulitis 245
Pharmacology 245
Follow-up Plan 246
Clinical Examination 248
Results 249
Management 249
Pharmacology 249
Clinical Examination 251
NEWS2 - 0 But Blood Pressure Found to Be Hypotensive 251
Neuro assessment 251
Management 253
Reflections 255
Admission Avoidance 255
Advanced Care Practitioner and Patient Empowerment 255
References 256
Further Reading 261
Self-Assessment Questions 261
Glossary 262
Chapter 13 Managing Complexity 263
Jaclyn Proctor and Sadie Diamond-Fox
Learning Outcomes 263
Introductions 263
Medical Complexity 265
Measuring Complexity in a Healthcare Context 266
Situational Complexity 269
Systems Complexity 270
NHS Long Term Plan (2019) 270
Advanced Clinical Practice 272
Conclusion 275
References 276
Further Reading 277
Self-Assessment Questions 277
Glossary 277
Chapter 14 Frailty: Principles of Rehabilitation and Reablement, Palliative Care and Organ Donation 278
Esther Clift and Stevie Park
Learning Outcomes 278
Introduction 278
Discharge Planning 279
Intermediate Care 280
Rehabilitation 281
Reablement 282
Pathways 282
Technology 282
Home-based Care 282
Virtual Wards 283
Urgent Community Response 283
Palliative or End-of-Life Care 284
Gold Standard Framework 285
Care Plans 285
Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) 286
Pain and Symptom Control 286
Verifying Death 287
Organ Donation 287
Diagnosing Death by Neurological Criteria (Brainstem Death Testing) 287
Role of the SN-OD and Referral Process 288
Tissue Donation 288
Clinical Frailty 288
Diagnosis Tools for Diagnosis and CGA 288
Exercise 290
Nutrition 290
Social Isolation and Loneliness 291
Conclusion 293
References 293
Further Reading 295
Self-Assessment Questions 295
Chapter 15 Mental Health, Learning Disability and Autism 296
Clare Allabyrne and Jo Delrée
Learning Outcomes 296
Introduction 297
Parity of Esteem 297
Diagnostic Overshadowing and Unconscious Bias 297
Mental Health and Ethnicity 298
Communication 298
Therapeutic Communication 298
Fundamental Principles of Therapeutic Communication 298
Specific Issues in Communication Clients with ASD/LD 299
Clinical Investigations 299
Mental Health Screening Tools 299
Holistic Mental Health Assessment 299
Ten-point Guide to Mental State Examination 301
Risk Assessment in Mental Health 301
Assessing Different Groups 302
Assessing Children and Young People 302
Assessing People with Autism 303
Assessing People with Learning Disability 304
A Note on Challenging Behaviour 307
Pharmacological Principles 307
Resources 309
Learning Disability Learning Event 309
Mental Health Learning Event 309
Mental Health UK states 309
Conclusion 310
References 310
Further Reading 313
Self-Assessment Questions 313
Glossary 313
Chapter 16 Education and Learning 315
Joe Wood and Elizabeth Midwinter
Learning Outcomes 315
Introduction 316
Principles of Teaching and Learning 316
Understanding How We Learn 316
Recognising Adult Learners 317
Dual Coding Theory 317
Evidence-based Practice 318
Contents xv
Self-directed Learning 318
Supporting Others to Develop Knowledge and Skills 318
Feedback 318
Appraisal Processes and Continuing Professional Development 319
Learning From Mistakes: Safety I and Safety II 319
Coaching, Mentoring and Role Modelling 319
Creating an Effective Learning Environment 320
Optimise the Space 320
Physial 320
Virtual 321
Ensure Learner-centredness 321
Get to Know the Learner 322
Plan the Process 322
Create Psychological Safety 323
Promote Continual Improvement Via Reflection 324
Simulation and Technological Advances in Healthcare Education 324
Simulation 324
Teaching Practical Skills - Reflections from Clinical Experience 325
Human Factors 325
Interprofessional Education 326
Types of Simulation 327
The Concept of Fidelity 328
In Situ Simulation 329
Designing Simulated Learning 329
Scenario Writing 330
Practical Considerations 330
Introductions and Orientation 330
Pre-brief 330
Programmed vs On the Fly 331
Debrief 331
Technology-enhanced Learning 333
Conclusion 334
References 334
Further Reading 338
Self-Assessment Questions 338
Glossary 338
Chapter 17 The Advanced Practitioner as Educator 339
Phil Broadhurst
Learning Outcomes 339
Introduction 339
Providing Feedback 342
Feeding Back and Feeding Forward 343
The One-Minute Preceptor 345
Conclusion 347
References 347
Further Reading 349
Self-Assessment Questions 350
Glossary 350
Chapter 18 Research Principles 351
Brigitta Fazzini and Roberta Borg
Learning Outcomes 351
Why Research Is Important 351
The Research Process 352
Critical Appraisal and the Hierarchy of Evidence 353
Designing a Research Project 354
Every Research Project Starts with a Question 354
Research Methods 355
Scientific Hypothesis 355
Quantitative versus Qualitative Research Methods 356
Quantitative Research Method 357
Qualitative Research Method 359
Healthcare Research Ethics 360
Quality Improvement 362
Conclusion 364
References 364
Further Reading 365
Self-Assessment Questions 366
Glossary 366
Chapter 19 Leading Research in Advanced Practice 367
Leanne Dolman, Joanna De Souza, and Sara Stevenson-Baker
Learning Outcomes 368
Introduction 368
Enabling Evidence-Based Practice 369
Using Local Procedures and Protocols - Role Modelling and Ensuring Continuity of Practice 370
Auditing Current Practice 370
Utilising Clinical Audit 371
Setting Standards and Developing New Protocols 371
Setting Intended Outcomes 371
Patient-reported Outcome Measures 372
Reviewing your Protocol (Quality Control) 372
Developing Guidelines at a National/International Level 373
Developing New Evidence for Practice 373
Leading on Quality Improvement 374
Dissemination of Existing and New Knowledge 377
Local Dissemination 377
Presenting at an External Conference 377
Developing a Conference Abstract 378
Developing a Poster 378
Developing an Oral Presentation 378
Writing for Publication 378
Joining a National Forum or Guideline Development Group 378
Developing the Advanced Practitioner as a Clinical Academic 379
Creating A Research Culture at Organisational Level to Improve Person-Centred Healthcare 380
Conclusion 381
References 382
Further Reading 384
Self-Assessment Questions 384
Glossary 384
Chapter 20 Innovations in Practice 386
Vanessa Taylor and Sarah Ashelford
Learning Outcomes 386
Introduction 386
Innovation, Practice Development and Service Improvement 388
Innovation and Advanced-level Practice and the Advanced Practitioner Role 392
Advanced-level Practice and Workforce Transformation: An Example of Healthcare Service Innovation 392
Advanced Practitioner as Clinical (Practice Development/ Improvement) and Professional (Service/System Development) Innovator 394
Conclusion 400
References 401
Self-Assessment Questions 403
Glossary 403
Chapter 21 Professional Development and Transition 404
Vikki-Jo Scott and Esther Clift
Learning Outcomes 404
Introduction 405
Personal Professional Development 405
Continuing Professional Development and Role Transition 410
Supporting Professional Development Within a Team 412
Contribution to Broader Development of Advanced Practice 415
What Next? 416
Conclusion 416
References 417
Further Reading 417
Self-Assessment Questions 418
Glossary 418
Index 419
The Editors
Ian Peate is Visiting Professor of Nursing at St George's University of London and Kingston University London; Visiting Professor, Northumbria University; Senior Clinical Fellow, University of Hertfordshire; Professorial Fellow, University of Roehampton; Editor-in-Chief of the British Journal of Nursing, Consultant Editor of the Journal of Paramedic Practice, and Consultant Editor of the International Journal of Advancing Practice.
Sadie Diamond-Fox is an Advanced Critical Care Practitioner (FICM member) at Newcastle upon Tyne Hospitals and Strategic Lead for Advanced Practice Programmes, Assistant Professor in Advanced Critical Care Practice (Fellow - HEA) and a PhD Candidate ('ImpACCPt' Study) at Northumbria University, UK. She is also a Training Programme Director for Critical Care within Health Education England's Advancing Practice Faculty in the North East & Yorkshire, UK and an Honorary Assistant Professor in Advanced Clinical Practice at Nottingham University, UK and External Examiner for Advanced Clinical Practice programmes at Southampton University. Sadie is also a council member and education committee member of the Intensive Care Society.
Barry Hill is an Associate Professor of Nursing Science and Critical Care at Northumbria University, UK. Barry has been a Registered Nurse for almost 20 years and is skilled in clinical settings and Higher Education in the area of acute and critical care, and advanced practice. He worked in general, cardiac and neuro trauma Intensive Care Units at Imperial College NHS Trust and progressed from staff nurse to charge nurse, senior charge nurse, to surgical and ENT matron. He is a certified Advanced Practitioner (MSc), Independent Prescriber (v300), and Senior Fellow with AdvanceHE. Barry is a Commissioning Editor for the British Journal of Nursing, and a Consultant Editor for the International Journal for Advancing Practice.
Ian Peate is Visiting Professor of Nursing at St George's University of London and Kingston University London; Visiting Professor, Northumbria University; Senior Clinical Fellow, University of Hertfordshire; Professorial Fellow, University of Roehampton; Editor-in-Chief of the British Journal of Nursing, Consultant Editor of the Journal of Paramedic Practice, and Consultant Editor of the International Journal of Advancing Practice.
Sadie Diamond-Fox is an Advanced Critical Care Practitioner (FICM member) at Newcastle upon Tyne Hospitals and Strategic Lead for Advanced Practice Programmes, Assistant Professor in Advanced Critical Care Practice (Fellow - HEA) and a PhD Candidate ('ImpACCPt' Study) at Northumbria University, UK. She is also a Training Programme Director for Critical Care within Health Education England's Advancing Practice Faculty in the North East & Yorkshire, UK and an Honorary Assistant Professor in Advanced Clinical Practice at Nottingham University, UK and External Examiner for Advanced Clinical Practice programmes at Southampton University. Sadie is also a council member and education committee member of the Intensive Care Society.
Barry Hill is an Associate Professor of Nursing Science and Critical Care at Northumbria University, UK. Barry has been a Registered Nurse for almost 20 years and is skilled in clinical settings and Higher Education in the area of acute and critical care, and advanced practice. He worked in general, cardiac and neuro trauma Intensive Care Units at Imperial College NHS Trust and progressed from staff nurse to charge nurse, senior charge nurse, to surgical and ENT matron. He is a certified Advanced Practitioner (MSc), Independent Prescriber (v300), and Senior Fellow with AdvanceHE. Barry is a Commissioning Editor for the British Journal of Nursing, and a Consultant Editor for the International Journal for Advancing Practice.
