Introduction

The concept of advanced healthcare practice (AHCP) was first introduced in Western countries by the nursing profession in the 1960s (Hulse, 2022) to meet the needs of underserved rural populations better (Hibbert et al., 2017). Now firmly established as a key strategy in accommodating the increasing demands and complexity of patient populations (Lawler et al., 2020), AHCP has been linked to improved patient outcomes, facilitation of interprofessional practice and enhanced clinician work satisfaction (HEE, 2017; Hulse, 2022). These benefits have prompted healthcare professions outside of nursing to develop AHCP roles. Such roles have been labelled using various titles, including advanced practitioner, clinical specialist, advanced clinical practitioner, and clinicians with expanded scope, as well as by specific professional designations, such as Nurse Practitioner (Evans et al., 2020a, 2020b; Hulse, 2022; Leslie et al., 2021).

In 2017, Health Education England (HEE), a public body coordinating and supporting healthcare education and training, published a multi-professional framework for AHCP (HEE, 2017) that provided one of the first multi-profession definitions of AHCP. AHCP was defined as being:

… delivered by experienced, registered health and care practitioners. It is a level of practice characterized by a high degree of autonomy and complex decision-making. This is underpinned by a master level award or equivalent that encompasses the four pillars of clinical practice, leadership and management, education, and research, with demonstration of core capabilities and area of specific clinical competence.

(HEE, 2017, pg. 8).

Among healthcare providers, competency has been defined as “an observable ability of a health professional, integrating multiple components, such as knowledge, skills, values and attitude” (Frank et al., 2010, pg. 641). While the terms competency and capability have been used interchangeably in relevant literature, in this review the term competency will be used to encompass the concept of core capabilities and skills. Competency is an integral concept in understanding competency-based education, proposed as an alternative to process-based education in the 1970’s. Seeking to ensure that graduates are adequately prepared to meet the needs of a given population, competency-based education considers the desired outcomes of training with a focus on both the needs of the learner and patient (Frank et al., 2010; Schumacher et al., 2024). Therefore, just as AHCP roles have emerged to meet population and healthcare needs, so too, has competency-based education (Frank et al., 2010; HEE, 2017). Assessment within competency-based education is guided by the attainment, maintenance, and enhancement of competencies as a measurement unit (Schumacher et al., 2024). This lends itself to assessment of learners at various levels of practice. To develop and implement defined AHCP roles, there must first be an overarching understanding of the competency of practice.

The development of HEE’s multi-professional framework was a critical step in promoting competency-based education for the implementation of AHCP. This framework is specific to England, yet multi-professional AHCP has not been clearly defined internationally (Evans et al., 2020a, 2020b; Lawler et al., 2020; Leslie et al., 2021). Furthermore, a recent scoping review examined the implementation of AHCP in the United Kingdom (UK) following the publication of the HEE framework and found that ongoing ambiguity in competency and educational requirements of AHCP has hindered its successful implementation (Evans et al., 2020a, 2020b). Similarly, a recent case study comparing scope of practice policy and regulation in the UK, United States, Canada, and Australia found poor agreement on the education requirements, accreditation, and competency of those in relevant roles (Leslie et al., 2021). This lack of mutual understanding around AHCP competency has resulted in disagreements around roles, scope of practice, underutilization of skills sets and limited integration of AHCP roles in the workplace (Lawler et al., 2020; Leslie et al., 2021).

Although the concept of AHCP competency has been examined in both primary and secondary literature, current considerations are limited to single professions or specific roles, and little is known about competencies across AHCP and how these competencies relate to the four pillars outlined by the HEE framework (Leslie et al., 2021). Developing a broader understanding of existing competencies and whether they map to the four established pillars will continue to inform the development of competency-based educational curricula, enhance team-based care and contribute to health systems planning (Evans et al., 2020a, 2020b; Frank et al., 2010). Addressing this knowledge gap will help further support the operationalization of multi-profession AHCP and information to help inform AHCP educational curricula.

Objectives

  1. 1.

    To determine which professions, have core competencies for graduates of AHCP degree-granting programs.

  2. 2.

    To identify competencies across AHCP.

  3. 3.

    To examine how identified competencies map to the four pillars of AHCP. (HEE, 2017).

Methods and methodology

An umbrella review was conducted to provide an overview of existing systematic and secondary reviews (Aromataris et al., 2014a, b). Umbrella reviews offer the ability to broadly examine a topic of interest and determine if there is general consensus within the literature examining similar review questions (Aromataris et al., 2014a, b). The methodology for this review was based on the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis (Aromataris et al., 2024. A study protocol was developed a priori and made available on Open Science Framework (Kenyon et al., 2022). Following the development of the protocol, changes were made to the wording of the review objectives to improve their clarity. A second quality appraisal tool was also identified and used to assess the methodological quality of the included reviews.

Eligibility criteria

Inclusion and exclusion criteria were identified using the PEO Model (Aromataris & Munn, 2020) for clinical questions and can be found in Table 1.

Table 1 Inclusion and exclusion criteria for selected studies (Gavarkovs et al., 2022)
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Search strategy

The search strategy was developed and executed in consultation with an Information and Research Librarian. This was conducted in three phases. In the first phase, initial key words were identified in a preliminary search using CINAHL and Google Scholar. Relevant keywords were then categorized for the Population, Exposure and Outcome model described by JBI (Aromataris & Munn, 2020). Search terms were entered into CINAHL, Scopus, Medline (OVID), Embase (OVID), and ERIC (OVID) using Boolean operators and truncation to ensure the search was adequately comprehensive. Any results not in English or French were excluded. A grey literature search was completed by entering the keywords identified in the preliminary search into an advanced Google search. The first two hundred returned results were screened for inclusion. Additionally, a hand search from personal files was conducted reviewing articles and their reference lists. The details of the final search are listed in Appendix A.

Study selection

All yielded studies were exported to Mendeley for citation management and to Covidence (https://www.covidence.org) for citation screening and the removal of duplicates. The screening was completed by E.K., S.D., R.E., D.L., and B.S. and occurred in two steps: title and abstract screening followed by full-text review. Two independent reviewers chosen by Covidence conducted all screening based on the identified inclusion and exclusion criteria, with disagreements resolved by a third independent reviewer. Reasons for exclusion at full text stage were recorded.

Data extraction

Data extraction from included studies was completed using a modified version of the JBI Extraction Form for Review for Systematic Reviews and Research Synthesis (Aromataris & Munn, 2020). As recommended, this tool was reviewed by the authors and amended by consensus before beginning data extraction (Aromataris & Munn, 2020). Amendments allowed for the addition of data extraction fields for target data as specified in the PEO Model. This included data fields to capture the profession a review pertained to, identified competencies and if reference was made to the HEE multi-professional framework. The amended version of this tool can be found in Appendix B. Consistent use of the tool was ensured by predetermining definitions for all data extraction fields and by piloting the tool using one randomly selected study from those included. Data extraction was completed in duplicate by two independent reviewers (S.D., R.E., E.K., D.L., B.S.) using Covidence. A third independent reviewer resolved conflicts.

Data analysis and synthesis

Data was analyzed using directed content analysis; a deductive qualitative approach described by Mayring (2000). Using previously established research and theories to define categories and subcategories, the authors organized extracted data for analysis according to the steps outlined by Mayring (2000). HEE’s four pillars of AHCP were used to define codes to which competencies retrieved from the literature were mapped. Findings were then summarized in a heat map indicating which HEE pillars and competencies were described within the retrieved reviews and their frequency. Abbreviated versions of the competencies listed in the HEE multi-professional framework have been used in the heat map. These abbreviations had been previously established in the work of Fennelly et al. (2020) (Appendix C).

Mapping was completed by two independent reviewers (S.D., R.E., D.L., S.B.) with conflicts resolved by a third independent reviewer. Reviewers were permitted to assign multiple codes to a single competency. Consistency in coding was achieved by reviewing the use of codes between raters at three points during analysis: after 50 competencies had been coded, on completion of coding by independent reviewers and on completion of consensus (Mayring, 2000).

Methodological quality appraisal

It was initially proposed that methodological quality of the included reviews would be appraised using the JBI (Joanna Briggs Institute) Critical Appraisal Checklist for Systematic Reviews and Research Syntheses (Aromataris et al., 2024). This tool consists of an 11-question checklist that prompts the user to select “yes,” “no,” “unclear,” or “not applicable,” as well as an overall appraisal rating of “include,” “exclude,” or “seek further info.” After study selection, most included reviews utilized qualitative study designs and presented their findings narratively rather than quantitatively. The Scale for the Assessment of Narrative Review Articles (SANRA) (Baethge et al., 2019) was identified to appraise narrative-type studies, defined as “any attempt to summarize the literature in a way which is not explicitly systematic, where the minimum requirement for the term systematic related to the method of the literature search” (Baethge et al., 2019). The SANRA is a 6-item scale that includes anchored definitions for each item. Each item is rated as a 0, 1 or a 2 with a total score < 4 indicating very poor quality (Baethge et al., 2019). Quality assessments using both the JBI checklist and SANRA were completed by two independent reviewers (S.D., R.E., D.L., S.B.), with conflicts being resolved by a third independent reviewer. Findings of the methodological quality appraisal were not used to determine inclusion, rather to provide comment on the overall quality of the included literature.

Results

Studies

The final search was completed between November 2022 and January 2023 with 3460 articles retrieved from databases. After removal of duplicates, 2102 articles underwent title and abstract screening and subsequently 97 underwent full-text screening. Following full text screening, 33 articles were excluded as they did not determine competencies, 21 articles were not secondary reviews or research syntheses, 19 did not examine master level or degree granting programs, 6 were published in languages other than English or French, 4 did not pertain to governed professions, and 1 full text was not available despite two attempts to contact the author. Three additional articles were identified from the grey literature. Seventeen reviews were included. A PRISMA diagram outlining study selection can be found in Fig. 1.

Fig. 1
figure 1

PRISMA Diagram of AHCP Competencies (Haddaway et al., 2022)

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Characteristics of included reviews

Included reviews were published between 2004 and 2023 with countries of origin including the United States, the United Kingdom, Canada, Australia, the Netherlands, Switzerland, Germany, Spain, Singapore, Thailand, and China. One review was published in French. Nine reviews were literature reviews; four were scoping reviews, and two were integrative reviews in addition to both a single narrative review and a Ph.D. thesis. Of the included studies, 71% (n = 12/17) examined competencies of advanced practice nursing, while the remainder examined advanced practice physiotherapy (n = 3/17), midwifery (n = 1/17), and pharmacy (n = 1/17). Characteristics of all included reviews can be found in Table 2.

Table 2 Descriptive characteristics of included reviews
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Methodological quality

When methodological quality was evaluated using the JBI checklist, six studies met at least eight of the 11 criteria, five met at least six criteria and six met five or fewer criteria. When evaluated using the SANRA, 12 reviews scored nine or more, four scored at least five and one scored less than four. Those studies that met a higher number of criteria or scored higher are suggested to be of higher methodological quality. Quality appraisal suggests that, although the quality of the data was rated more favorably when using the SANRA compared to the JBI checklist, the quality of the data is moderate to high. The JBI tool commonly identified studies failing to critically appraise data and determine risk for publication bias, whereas the SANRA tool commonly identified studies failing to state specific research questions or adequately describe the search strategy. These findings reflect the differences in content validity of the two tools (Aromataris & Munn, 2020; Baethge et al., 2019; Sadoyu et al., 2022). Scoring of methodological quality can be found in Table 2.

Identified competencies based on profession

The included reviews identified 620 individual competencies. Most of the retrieved competencies were from nursing (62%, n = 387/620) and physiotherapy studies (10%, n = 62/620). The competencies retrieved from the pharmacy (5%, n = 33/620) and midwifery (< 1%, n = 4/620) were limited in number, and each retrieved from a single review. Several of the reviews reported lists of competencies across multiple professions and geographical regions (Fennelly et al., 2020; Tawiah, 2022), but did not specify which professions or region each competency was sourced from. This accounted for 20% (n = 123/620) of the retrieved competencies. Within nursing literature, a unique pattern was identified. Six of the studies examining AHCP nursing competencies cited consensus statements and policy documents published by national governing bodies, professional associations, and regulators (Bender, 2014; Chan et al., 2020; Egerod et al., 2021; Elliott & Walden, 2015; Fennelly et al., 2020; Heinen et al., 2019). These citations were not identified in studies from other professions.

Data synthesis and analysis of the competencies

585 of the 620 retrieved competencies (94%) mapped to the four pillars. Thirty-five of the retrieved competencies were coded as other (6%), indicating that they did not map to the competencies.

A heat map of the retrieved competencies can be found in Fig. 2. Most retrieved competencies were found to map to the clinical practice pillar, accounting for 41% of all assigned codes. Leadership and management were the next most frequently represented pillar (27%),

Fig. 2
figure 2

Heat map—Competencies in relation to advance practice pillars. *Pillars and competencies coded most frequently are depicted in red while those coded least frequently are coded in green

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Data analysis demonstrated that some competencies were described more frequently within the included reviews than others. The most mapped competencies were found within the Clinical Practice Pillar. The most frequently described competencies in order were “clinical reasoning and decision making,” "effective communication” and “assessment methods”. Within the Leadership & Management pillar the fourth overall highest competency was “negotiate scope of practice.” The fifth most common competency was “subject-specific competencies” which is also found within the clinical practice pillar. The competencies associated with the pillars of education (16%) and research (16%) were significantly less, with the combined number of competencies coded to both pillars being less than the number used for the clinical practice pillar alone.

Discussion

Professions that have defined core competencies of AHCP

This review determined that four professions have sought to determine competencies of degree granting AHCP programs. Many of the competencies retrieved by the search originated from nursing literature. This is not surprising as nursing was one of the first professions to establish an advanced practice role (Hulse, 2022). Within the included reviews, it became evident that the nursing profession has determined internationally accepted definitions of profession specific AHCP, and related competencies as well as expanded on their understanding of AHCP for specialized roles and practice settings, such as genetics (Lea et al., 2005), family practice (Schlunegger et al., 2023) and geriatric medicine (Goldberg et al., 2016). Given the successful establishment and implementation of AHCP nursing competencies, there may be key strategies for other professions that are working to establish and regulate advanced practice roles and educational programs.

Among reviews examining the nursing profession, there is evidence of cooperative and collaborative efforts among member organizations, professional associations, and regulatory groups to ensure consensus around capabilities, role definition, nomenclature and policy (Bender, 2014; Chan et al., 2020; Egerod et al., 2021; Elliott & Walden, 2015; Fennelly et al., 2020; Heinen et al., 2019). This comprehensive approach was not observed among reviews of other professions that have more recently begun to implement advanced practice roles, such as physiotherapy (Fennelly et al., 2020; Harding et al., 2015; Tawiah, 2022), pharmacy and midwifery (Goemaes et al., 2016; Harding et al., 2015; Meadows et al., 2004). Unclear definitions of role, role awareness and disagreements around scope have been identified in the literature as barriers to successfully determining competencies and implementing AHCP (Evans et al., 2020a, 2020b; Lawler et al., 2020). Therefore, it appears that collaborative efforts between these stakeholders may be essential in determining core competencies and establishing and regulating educational programs.

Competencies

The distribution of retrieved competencies under the pillars was not uniform,. The most frequent competency for AHCP was found under the “Clinical Practice” pillar. It has been suggested that teachings of competencies related to clinical practice likely underpin skills of the other pillars, such as education and research (Utley et al., 2017). It must be considered that the findings of this review may highlight potential overlap between teachings of clinical reasoning and technical skills, as evidenced by “subject-specific competencies” being found to be the fifth most common competency. Retrieved competencies found to map to this competency included nurse practitioners' assessment and management of geriatric populations (Fennelly et al., 2020). These represent competencies that are specific to professional roles and practice settings rather than those common to AHCP and were often discussed in the literature in a manner that did not make mention of competencies relating to the other pillars, such as education and research. This indicates that the current curriculum and evaluations of candidates in AHCP educational programs may focus on developing clinical skills to the exclusion of the competencies of the other three pillars. This is reflected in a cross-sectional survey of policymakers and clinicians at various levels of practice, which suggests that, although most clinicians consider the four pillars of AHCP important, knowledge of the HEE framework was minimal and competencies within the clinical practice pillar were consistently prioritized in their training (Fothergill et al., 2022).

To ensure that AHCP educational programs equip graduates to achieve the competency required to practice at the advanced level, curricula should consider mapping of program competencies across all four pillars. The development of such curricula, however, must also consider how to best ensure that candidates are proficient in the seamless application of multiple competencies in a holistic manner to manage complex and multi-faceted care environments. Therefore, although helpful in developing an overarching understanding of the current landscape of AHCP, consideration of competencies using only commonality may limit contextual understanding in an educational environment. This may be achieved in educational settings by considering the intention of the HEE multi-professional framework (2017) to be used alongside profession-specific national frameworks, such as that developed for AHCP nursing in England (HEE, 2020) to develop competency-based curricula. Using both frameworks allows for profession-specific competencies to be further defined while also ensuring that curricula map across pillars of AHCP, thus avoiding prioritization of only clinical skills.

Alignment with the four pillars of AHCP

This review found that, although only four of the included reviews mentioned HEE’s multi-professional framework (2017), there was a strong alignment between the competencies retrieved from the literature and the competencies of the four pillars of AHCP. Therefore, the findings of this review suggest that HEE’s multi-professional framework describes the competencies common to AHCP both internationally and across professions. This suggests the potential of this framework to be considered as a guiding document for mapping educational curricula internationally to ensure alignment with advanced-level training requirements. (Fothergill et al., 2022). A small number of retrieved competencies (6%) did not map to the four pillars. Two themes were evident within these unmapped competencies: cultural sensitivity and business management skills. The finding of competencies that do not map to the existing framework suggests that future research may be warranted to determine if such competencies are integral to AHCP and to determine if existing frameworks may need to be reviewed and updated to ensure that they are contemporary and continue to reflect the needs of the dynamic healthcare systems.

Strengths and limitations

This was the first large-scale international review of AHCP across professions and practice settings. This review utilized an umbrella review methodology, which permitted a systematic evaluation of the current body of literature and directions for future research. Screening and data analysis procedures were undertaken using two independent reviewers with a third to resolve conflicts, which along with the inclusion of a quality appraisal, strengthened the methodology of this review. This study has some potential limitations. The results of this review are limited to master and doctoral level educational programs and only captured data from professions which have examined AHCP with secondary research, therefore; results may not be inclusive of countries or professions with established or emerging advanced roles that are developed through experiential or diploma/certificate programs. Lastly, both the JBI checklist and SANRA lacked defined cut-off scores, limiting their ability to compare the methodological quality of the included studies (Sadoyu et al., 2022).

Future recommendations

Further research is needed to determine the essential competencies of AHCP of professions and countries with newly established or emerging AHCP roles. Research with a focus on the development and assessment of competencies of leadership and management, education, and research is also needed as the current body of research focuses heavily on competencies related to the pillar of clinical practice (Evans et al., 2020a, 2020b; Fothergill et al., 2022). This may be achieved through the development of profession-specific national frameworks to be used in conjunction with the HEE multi-professional framework (HEE, 2017).

Conclusions

The benefit of AHCP roles to patient outcomes and healthcare systems as a whole has been well substantiated in the literature (Evans et al., 2020a, 2020b; Evans et al., 2020a, 2020b; Fothergill et al., 2022; Hulse, 2022; Kleinpell et al., 2022), yet confusion remains regarding educational requirements, role delineation and the competency of those occupying AHCP roles (Evans et al., 2020a, 2020b; Lawler et al., 2020; Leslie et al., 2021). This review demonstrated that competencies of AHCP across different professions are consistent with the four pillars of HEE’s multi-professional framework (2017). The distribution of described competencies, however, is not equal across pillars, professions, or geographical regions, which may provide direction for further research. Therefore, the HEE multi-professional framework (HEE, 2017) may be useful as a guiding document in the design and evaluation of AHCP, although additional work is needed to establish profession-specific national frameworks and to ensure that competencies are developed across all four pillars.