Clinical supervision during the integration of Advanced Clinical Practitioners into General Practice teams: a realist evaluation.

Problem

NHS policy is to support the provision of General Practice (GP) services through the introduction of non-medical advanced clinical practice (ACP) roles. Understanding what mechanisms enable them to support the principals of high-quality generalist care remains a key research gap. An important part of their development is supported through clinical supervision by experienced GPs to help their successful adaptation to a new role and context. This challenge is more acute in deprived communities where there is a greater amount of multi-morbidity in the population. Studies have also shown that GP services serving these more deprived communities rely more on non-medical ACP roles than others do.This study aims to identify the key contexts and mechanisms that support this new workforce to deliver equitable high quality primary health care.

Approach

A realist evaluation of clinical supervision during the integration of new non-medical advanced clinical practitioners into general practice teams. An initial programme theory was developed through public and stakeholder engagement and published literature. Fifty-four candidate context-mechanism-outcome configurations (CMOCs) were identified. Paired, realist semi-structured interviews were undertaken with 13 ACPs working in general practice (within three years of starting their new roles) and 12 of their supervising GPs. Purposeful sampling ensure half of participants were from practices serving communities in the most deprived quintile by IMD score. Interviews were transcribed and analysed using NViVo with independent verification of codes by CB and SA. A combination of deductive and inductive analysis was used to both test candidate CMOCs and recognise demi-regularities suggesting new CMOCs. Refinement and modification of the initial programme theory is in process with ongoing patient and practitioner engagement.

Findings

Ongoing analysis of the interview transcripts will be presented with the important contexts and mechanisms supporting both desired and undesired outcomes: key contextual aspects relate to practitioner background, supervisor training and team structure, key mechanisms relate to confidence, trust, and professional development. Findings are set against mid-range educational theories such as entrustable professional activities, reflective practice and a supervision alliance.

Consequences

The findings of this study will contribute to the evidence for a principles-based approach to the clinical supervision of this new primary care workforce. Purposeful sampling ensures that findings are derived from, and relevant to, the experience of practitioners delivering care to the most deprived communities. NHS policy makes understanding the key mechanisms within clinical supervision that support the integration of these practitioners and the delivery of sustainable, high-quality generalist care critical in maintaining primary care.