Advanced Clinical Practitioner Adult Curriculum

Governance and Strategic Support

The Royal College of Emergency Medicine (RCEM) EM-ACP curriculum provides the framework for Advanced Clinical Practitioners who wish to apply for credential status with the Royal College. The RCEM ACP Curriculum Sub-Committee of the RCEM Education Committee was established in 2021 to refresh the existing curriculum, taking the RCEM medical curriculum and adapting the content for ACPs whilst retaining both the standard and breadth of practice defined in the previous RCEM ACP curriculum published in 2017.

The sub-committee is constituted of Fellows, credentialed ACPs, consultant nurses and paramedics. It has representatives from devolved nations, and ordinary Fellows and ACPs appointed after open application.

A full working draft of the curriculum was available for stakeholder review. This included RCEM committees, others working in Emergency Medicine (EM), the Royal College of Nursing and College of Paramedics, our lay partners through College Council, Health Education England, and NHS employers among others. The RCEM Education Committee gave approval in principle in June 2022 with the final sign off in September 2022.

The curriculum was launched in September 2022 accompanied by a programme of communication, training and engagement with ACPs and their supervisors as well as other interested parties. The RCEM electronic portfolio (RCEM ePortfolio) was adjusted to support implementation of the curriculum.

How to Use This Curriculum

The curriculum is designed to lay out what is required to be a credentialed Advanced Clinical Practitioner seeing adult patients in Emergency Departments in the UK. Henceforth, this document will refer to ACPs in training and preparing for credentialing as tACPs, and ACPs at the point of credentialing as EM-ACPs.

The Purpose Statement outlines why emergency medicine is vital to the patients of the UK and a key element of the National Health Service and why ACPs are an integral part of the Emergency Medicine workforce.

The curriculum also describes the learning opportunities that should be provided to tACPs and how they and their supervisors can use the curriculum to develop their skills.

Generic Professional Capabilities (GPCs) are designed to foster a common set of skills, attitudes and behaviours in the workforce that might be transferrable if needed. These are comparable to the common competences described in the 2017 ACP curriculum and mirror the multi-professional capabilities described in the Multi-Professional Framework for Advanced Clinical Practice in England[1].

The expertise of an EM-ACP working within the NHS involves a wide range of knowledge and technical skills. The breadth of the clinical presentations and pathophysiological processes that need to be known by EM-ACPs are listed as the Clinical Syllabus. Up-to-date knowledge and understanding of the assessment and treatment of patients presenting to the Emergency Department (ED) is a fundamental part of training. Acquiring this knowledge and understanding will be by a combination of private study, departmental and regional teaching, and considerable clinical experience. Evaluation of the acquisition of this knowledge and understanding will be by a framework requiring workplace-based assessment, personal reflection, and evidence of learning, delivering and teaching. This clinical syllabus has been mapped to the 2017 ACP syllabus to demonstrate the correlation and confirm that the breadth of practice is maintained and not expanded.

The Specialty Learning Outcomes (SLOs) outline what an EM-ACP at the point of credentialing will be expected to be able to do, and the level of entrustment – or degree of independence – expected at credentialing. These are linked to the relevant GPCs in each section. Entrustment as a concept in this curriculum is a ‘judgement decision’ based on observation in practice and identifying the level of entrustment that the EM-ACP has reached in each SLO. It should be noted that the level of entrustment for a newly credentialed EM-ACP will be:

• Level 2b for SLOs 1, 2, 3, 4, 7, 8 and 12. Level 2b of entrustment is defined as Supervisor within hospital for queries, able to provide prompt direction or assistance and trainee knows reliably when to ask for help.

• SLO6 has varying levels of entrustment depending on the procedural skill.

• Level 3 for SLOs 9, 10 and 11 reflecting the four pillars of the Multi-Professional Framework for Advanced Clinical Practice already achieved by EM-ACPs. Level 3 is defined as Supervisor ‘on call’ from home for queries, able to provide directions via phone and able to attend the bedside if required to provide direct supervision.

EM-ACP specific ACP Key Capabilities (KCs) are described for each of the SLOs. These are the specific contextualised aspects of the SLOs that are fundamental to the practise of EM in the UK. Key Capabilities form the basis, and are the building blocks, of how the SLOs will be assessed. EM-ACPs wishing to credential are required to demonstrate how they have developed their capability against each of these, seeking and considering feedback in each KC. The Supervisor is required to confirm whether these key capabilities have been achieved or not achieved, contributing to the overall entrustment evaluation for that SLO.

The Descriptors section of each Specialty Learning Outcome (SLO) give examples and further guidance for ACPs and assessors about what is required.

An entrustment decision is made by an individual assessor on each assessment and by the faculty in the faculty group meetings – as a joint decision. This must be documented clearly in the portfolio in the Faculty Educational Governance Statement (FEGS) and referenced in the Educational Supervisor Report (ESR) prior to credentialing.

Utility of assessments and the rationale for the requirement for documented workplace-based assessments for ACPs

Whilst it is recognised that the best use of training opportunities in the workplace for learners is to find areas of challenge and to seek and reflect on feedback from trainers via workplace-based observation, there is a purpose to workplace-based assessments (WPBAs) that is unique to the credentialing process.

Unlike the medical curriculum, where there is a summative assessment in the form of an examination, for EM-ACPs the credentialing process relies on the presentation of sufficient triangulated evidence. The assessment blueprint is therefore prescriptive, in that a fixed minimum number of consultant supervisor workplace-based assessments are required as evidence for credentialing, alongside many other items of evidence. It is also expected that EM-ACPs will have additional assessments completed during their training that will demonstrate the development of increasing independence and capability to support their application for credentialing. It is important for the EM-ACP to show development in all SLOs, and the breadth of evidence required for credentialing for each of the SLOs is laid out in the assessment blueprint and in the ‘other evidence required’ section of this document. The Regulations for Credentialing[1] should be read in conjunction with this curriculum.

The Purpose statement of the RCEM ACP Curriculum

The RCEM ACP curriculum has a clear and stated purpose based on the scope of practice of credentialed advanced clinical practitioners in Emergency Departments, and the service, individual patient and population needs. The curriculum defines the capabilities that the EM-ACP is expected to demonstrate for the College to credential the ACP and describes the expected standard and required evidence. The College recognises that many credentialed EM-ACPs, and working ACPs who are yet to credential, are working at a higher standard of entrustment or independence than this curriculum defines in some or all areas of this curriculum. This document focuses on what is required to credential and post credentialing personal development is a matter for individuals and their supervisors and line managers.

The purpose of the RCEM Adult ACP Curriculum is to train ACPs to work in the ED within the multi-disciplinary team, providing urgent and emergency care to all adult undifferentiated patients attending ED nationwide, 24/7, 365 days every year. This includes providing expert clinical care within the multi-professional team for the resuscitation of sick and injured patients. In addition, the EM-ACP will provide care across the full spectrum of acute illness and injury, physical and mental health needs that present to a modern-day ED. They will be able to improve quality, teach and supervise junior colleagues and deliver key administrative tasks. An RCEM credentialed EM-ACP will function as an autonomous practitioner within the adult department, knowing when to ask for help and with the supervisor within the hospital for queries and able to provide prompt direction or assistance.

Since the EM-ACP has already completed a postgraduate course of study at level 7 which encompasses the four pillars of Advanced Practice AND will commonly have had extensive experience as a senior clinician in their base profession, the EM-ACP can reasonably be expected to demonstrate higher autonomy and expertise in the domains of leadership and management, education and research.

EM-ACPs are a fundamental and critical part of the multi-professional workforce that is required to meet the ever-increasing demand on emergency care. It is therefore imperative that the adult curriculum is fulfilled in its entirety to enable the EM-ACP to contribute to the activity within the team.

The aims of the RCEM adult ACP curriculum

This curriculum seeks to provide a clear, flexible training pathway for tACPs training in EM and focusing on adult patients The curriculum articulates the standard required to work as a credentialed EM-ACP seeing adults. It should be read in conjunction with the Regulations for Credentialing[1]. Additional guidance and advice on the credentialing process will be available and updated regularly on the College website.

[1] Regulations for Credentialing

The scope of EM practice

Adult EM-ACPs are required to display a wide range of knowledge, skills, behaviours and attributes reflecting the broad nature of the specialty in practice. By the point of credentialing, adult EM-ACPs will be skilled in caring for adult patients with critical illness, injury, mental health problems, frailty, and many other complex conditions. They will be able to competently complete practical procedures related to the clinical care of such patients, will be expert communicators with strong interpersonal skills, will have strong situational awareness and be adept at the management of potentially highly complex situations. EM-ACPs’ EM-specific clinical skills and knowledge will be developed and evidenced through achievement of 11 adult SLOs.

RCEM Specialty Learning Outcomes for credentialed EM-ACPs

Previous experience before entering the academic and clinical training pathway

The multi-professional advanced practice workforce is a strength of emergency medicine and ACPs are appointed to emergency departments according to the service needs and practitioners experience. Whilst professional training for nursing or paramedic professions provides a foundation most likely to support advanced training, other allied health care professionals and pharmacists also study at advanced practice level and can utilise the curriculum structure, portfolio and assessment tools ​to work towards credentialing. Practitioners from these professions will ​be able to credential against this curriculum on presentation of the required evidence. ​The breadth of previous experience, particularly around procedural skills and case mix will mean that other professions may need additional time to credential.

Entry into the credentialing pathway will be defined locally but it is recommended that a suitable entry point would be 5 years post-registration with a minimum of 3 years emergency/acute care experience and the practitioner working at enhanced practice level. All tACPs and EM-ACPs must be registered with either the NMC, HCPC or GPC. All time periods contained within this document refer to full-time equivalent.

Academic training

EM-ACPs will have undertaken an accredited educational programme in advanced practice (or similar title) and gained a level 7 award (minimum PGDip) with a minimum of 120 credits.  All modules must be at level 7. If the programme is not accredited by HEE, then the EM-ACP must complete the Academic Credentialing Declaration in the RCEM ePortfolio by mapping the learning outcomes of the modules they have undertaken to the learning outcomes required by RCEM. The modules must cover ‘history taking and physical assessment’, and ‘clinical decision making and diagnostics’.

Independent prescribing

Independent non-medical prescribing level 7 must be held at submission for credentialing. The exception to this is where the EM-ACP attained a level 6 NMP certificate before commencement of EM-ACP training and can provide evidence of competence and daily utilisation of prescribing.

Clinical experience within the training pathway to credentialing

The development of capability to entrustment level 2b takes a considerable amount of time. The minimum time that must be completed before submission is three years full time, 30 hours delivery of direct clinical contact per week (pro-rata). Any other activity (non-clinical time) will be additional to this, e.g. time for study, QI, etc.

This clinical contact should be direct clinical care, not supervision or departmental coordination. It will take three years (full time equivalent) to develop the experience, maturity and judgement to perform at the expected level of a credentialed ACP. Documenting progression through the entrustment levels is key to demonstrating the development of the range of capabilities. The tACP will need sufficient patient contact (as evidenced by patient numbers) to cover the breadth of the clinical experience and collect sufficient evidence. Progression must be documented in the Faculty Educational Governance Statement entrustment decisions at the end of each year of training; the EM-ACP must have achieved level 2b in the relevant clinical SLOs (various levels for SLO 6 – procedural skills) and level 3 in the supporting  SLOs  (9, 10, 11) before credentialing.

EM-ACPs can progress to credentialing working part time, providing they have time in clinical practice equivalent to 30 hours a week for three years. However, because evidence submitted must be recent or have appropriate reflection and evidence of continued professional development, there may be challenges for those who work less than full time in a particular SLO or syllabus presentation/condition.

Mandatory consultant supervisor assessments must all be within three years of submission. If these are not within timescale, they will need to be repeated.

Other assessments which are older than three years may be submitted as evidence but reflection on progress since the assessment will be required.

EM-ACPs should be in active practice for the three months immediately prior to submission. The final FEGS and ESR must be completed within the last three months, and both must be based on current capability as observed in the clinical workspace.

The programme does not require any particular sequencing of SLOs although it is recommended that the tACP starts with SLO1 and works through to the later SLOs as confidence and experience grows.

For tACPs wishing to credential in both the adult and children’s curriculum, it is anticipated that the ACP will require a minimum of 4 years, 30 hours clinical content per week (or pro-rata). Given the magnitude of the evidence required, it may be appropriate to credential in adults first and subsequently in children at a later date. This may also allow focused experience in one area or another which can support the learning process. The regulations deal with the issue of complementary evidence in adult and children’s portfolio to minimise duplication.

Regulation and professional skills

Professional regulation

Advanced Clinical Practitioners will always be accountable to their respective regulatory body (HCPC, NMC or GPC), whatever the level or context of their capabilities (HEE, 2017[1]). EM-ACPs should ensure that they always practice within their own scope of practice and according to the Standards of Proficiency relevant to their regulatory body.

Advanced clinical practice defines a level of practice, not only in the clinical domain but across the 4 pillars of advanced practice, which also include leadership and management, education, and research and quality improvement (defined by HEE, National Leadership and Innovation Agency for Healthcare – NHS Wales, NHS Education for Scotland). Coupled with the General Professional Capabilities (GPCs) and respective professional codes, this provides a robust framework of professional accountability and practice.

The EM-ACP should note that the decisions relating to scope of practice in any given institution is a matter for the institution and not the Royal College of Emergency Medicine.

The domains within the General Medical Council’s Generic Professional Capabilities Framework[2] are incorporated into the RCEM EM-ACP curriculum. This is to maintain synergy with the professional skills defined by the General Medical Council for doctors. They strongly align with advanced practice frameworks used in the UK nations and mirror competences within many HEI Master’s level awards in advanced clinical practice.

[2] Generic Professional Capabilities Framework

Introduction

There are eleven RCEM Adult ACP Specialty Learning Outcomes, seven of which are patient-facing relating directly to patient care or activity in the clinical workplace. These are the Clinical SLOs.

The remaining four relate to supporting activities that take place away from the ED clinical areas but are also essential to the development of the credentialed ACP in EM.  These are the Supporting SLOs.

The RCEM Adult ACP SLOs are listed below. The tACP at the point of credentialing should have reached entrustment level 2b in the clinical SLOs (except where specified in SLO6) with demonstrable evidence for all the key capabilities described. They should be able to:

• take on all but the most difficult and complex cases and know when to ask for support from others
• provide support and supervision for junior colleagues within their scope of practice
• contribute to the senior multi-disciplinary leadership team in the department.

SLO 6: Deliver key procedural skills

The approach to SLO 6 differs from that of the other SLOs. There is a recognition that EM-ACPs will be required to undertake a range of procedures to patients in all areas of the ED and of variable acuity.

Foundation procedures Foundation procedures are those that would be familiar ​and commonly used in everyday practice for an experienced ED practitioner who is about to embark on Adult ACP training and ​would therefore need a simple sign off by the ACP educational supervisor. Those ​practitioners moving from other ​ clinical areas ​where they are not commonly using these skills will need to demonstrate ​documented competence of ​each of  these foundation skills. ​This would normally take three months to complete and should be the focus of development in the initial phase of ACP training as they are the basic skills on which the EM-ACP builds to acquire core and additional skill. These ​foundation skills can be assessed by trained assessors suitable for each procedure (e.g. practice educator). All tACPs, ​regardless of background, will need to evidence continued practice and competence.

Core procedural skills are those which an EM-ACP, upon credentialing, must be able to complete safely and independently, regardless of the area they work in. Assessment will be by consultant DOPS, except for those marked * which may be by a trained assessor.

Additional procedural skills cover those skills which some ACPs may carry out in their practice but, for others, may not be routinely carried out in their area of work or at their level of training. The ACP Educational Supervisor (in conjunction with local faculty) must define which procedures must be achieved by DOPS and can be carried out safely and independently by the tACP, and which may be covered by CbD (plus sim DOPS if required). Post-credentialing, the Adult EM-ACP may continue to develop their practice and obtain independence in additional procedures via further assessment and assignment of entrustment levels.

On credentialing, the following entrustment levels must be reached:

• Foundation procedures: Level 4
• Core procedural skills: Level 3
• Additional procedural skills: Level 2b for those which are expected to be carried out in practice, Level 1 for those which are not carried out by the ACP themselves

Clinical Syllabus

The RCEM EM-ACP curriculum, being outcome based, is structured around the actions that a credentialed EM-ACP needs to be able to do. Underpinning these actions is the clinical knowledge that informs them.

The breadth of that clinical knowledge is described below in the Clinical Syllabus. It defines the scope of presentations or clinical conditions that an EM-ACP may encounter in the workplace, and therefore need to know about. These lists are to be used to give a context to the Programme of Learning (see section 4) that supports the delivery of the curriculum. tACPs are expected to develop their knowledge base in each of these presentations or conditions. This might be done in formal teaching, self-directed learning and use of online resources

This knowledge is not assessed in an examination, unlike medical trainees. Therefore, there is an imperative to ensure the EM-ACP has had adequate experience and they have the underlying knowledge base (including basic sciences) to support their clinical work in all areas of the clinical syllabus.

tACPs are expected to collect evidence to support their credentialing against all elements of the syllabus. These may be reflective notes, case studies, attendance at training days, eLearning certificates, assessments for development and, where mandated, consultant supervisor assessments. EM-ACPs will be expected to know about relevant basic sciences as well as relevant epidemiology, differential diagnoses, investigation and management of these conditions.

The clinical syllabus is included in the ePortfolio for the tACP to collect evidence and evaluate their experience, tracking their breadth of capability. The ACP Educational Supervisor will be required to confirm that all presentations and conditions have been covered with sufficient experience by the tACP. This is part of the final sign-off for credentialing and the tACP and ACP Educational Supervisor should discuss the syllabus and review evidence regularly to ensure the breadth is covered.

Learning and teaching

The organisation and delivery of EM-ACP training is currently a local Trust responsibility. The Royal College of Emergency Medicine recommends collaboration within regions and networks for formal teaching opportunities as well as shared events with medical trainees where possible.  Regions in England will benefit from liaison with their Regional Advanced Practice Faculty Lead. Throughout the UK, a number of Emergency Medicine Schools have identified an ACP TPD to lead on this work.

Progression

Progression through the RCEM ACP curriculum will be determined by the local faculty. The College strongly recommends a process for independent review of progression of the tACP similar to the ARCP process for medical trainees. This annual review allows the local organisation to plan and to provide additional support if required. Whilst there is no formal requirement within credentialing for an outcome to be stated from such a process, a document summarising the progress made in the last 12 months is expected within the portfolio.

The minimum requirement for credentialing is three of each of the following at yearly intervals:

• Educational Supervisor Report (ESR) confirming the progress being made on evidence collection, entrustment decisions, coverage of the syllabus and breadth of knowledge
• Faculty Educational Governance Statement (FEGS)
• Multi-Source Feedback (MSF) for each year of training (minimum of three in total) with appropriate numbers of consultant faculty contributions.

The training environment

This curriculum should be used to help design training programmes locally that ensure all tACPs can develop their capabilities in a variety of settings and situations. It is designed to ensure that there is flexibility in training, meeting service needs as well as supporting each individual tACP’s learning and development plan. The standards that apply to medical training are relevant for this ACP programme and follow the HEE Quality Framework[1]:

Theme 1: Learning environment and culture

S1.1 The learning environment is safe for patients and supportive for learners and educators. The culture is caring, compassionate and provides a good standard of care and experience for patients, carers and families. tACPs are provided with opportunities to deliver care to patients in their role in an appropriately supervised environment.

S1.2 The learning environment and organisational culture values and supports education and training, so that learners are able to achieve the learning outcomes required by their curriculum. tACPs are enabled to access assessments and receive constructive feedback on their progression.

Theme 2: Educational governance and leadership

S2.1 The educational governance system continuously improves the quality and outcomes of education and training by measuring performance against the standards, demonstrating accountability and responding when standards are not being met. The training programme for tACPs is incorporated into the departmental programme with regular review of the tACP progress and access to learning.

S2.2 The educational and clinical governance systems are integrated, allowing organisations to address concerns about patient safety, the standard of care, and the standard of education and training. tACPs are encouraged to participate in local faculty group meetings as well as clinical governance meetings and are enabled to contribute to initiatives around safety and quality.

S2.3 The educational governance system makes sure that education and training is fair and is based on the principles of equality and diversity. All relevant staff are enabled to develop themselves and apply for ACP training.

Theme 3: Supporting learners

S3.1 Learners receive educational and pastoral support to be able to achieve the learning outcomes required by their curriculum. tACPs have named clinical and educational supervisors who meet the required RCEM standards.

Theme 4: Supporting educators

S4.1 Educators are selected, inducted, trained, and appraised to reflect their education and training responsibilities. ACP Educational Supervisors are expected to have attended the RCEM specific training if they are to sign off the credentialing application.

S4.2 Educators receive the support, resources and time to meet their education and training responsibilities. ACP supervisors should receive appropriate time (0.25 PA per ACP) in their job plan for educational supervision.

Theme 5: Delivering programmes and curricula

S5.1 Local training providers seek to develop new and innovative methods of education delivery including multi-professional approaches

S5.2 Timetables, rotas and workload enable the tACP to meet curriculum requirements including sufficient non-clinical time to meet the ACP key capabilities in the supporting SLOs

Theme 6: Developing a sustainable workforce

S6.1 Employers work across networks to ensure the curriculum can be delivered at the breadth and depth required

S6.2 Programmes provide information and advice to support career planning decisions including new and innovative ways of working

Teaching and learning methods

The curriculum can be delivered through a variety of learning situations:

Clinical experience should be used as an opportunity to undertake WPBAs and reflection. Every patient seen in the ED or urgent treatment centre, SDEC unit, CDU or acute assessment unit provides a learning opportunity which will be enhanced by following the patient through the course of their illness. The experience of the evolution of patients’ problems over time is a critical part of both the diagnostic process as well as management. Patients seen should provide the basis for critical reading and reflection on clinical problems. Every time a tACP observes another clinician seeing a patient or their relatives there is an opportunity for learning. To ensure patient safety, tACPs should be appropriately supervised for their level of capability and entrustment.

Learning with peers: working alongside, discussion cases, small group teaching.

Simulation: as some presentations and procedures are relatively infrequent, simulation is a valuable tool to allow learning opportunities and also for the formative assessment of competence.

Simulation used for assessment:  Where a summative DOPS for a procedure is required, this must be with a real patient other than for those indicated in SLO6.  Where a simulation scenario is used for a clinical presentation assessment, only the tACP ‘leading’ the scenario can be summatively assessed, although other participants may have formative assessment and feedback recorded, both for clinical and non-technical skills.

Courses (external or internal)

• Mandatory life support courses: ALS, ATLS/ETC and Paediatric Basic Life Support (Trust)
• Management and leadership
• Vascular access
• Human factors
• Critical thinking
• Paediatric sedation
• Procedural skills including emergency thoracotomy, emergency caesarean section, surgical airway
• Resuscitation team leadership
• Dealing with challenging situations in the workplace.

A programme of regular teaching sessions to cohorts of medical trainees or tACPs (organised in each hospital or across a region) designed to cover aspects of the curriculum:

• Case presentations
• M&M meetings
• Journal clubs
• Research and audit projects
• Lectures and small group teaching
• Clinical skills – use of simulation
• Critical appraisal exercises
• Joint specialty meetings
• Life support courses
• Participation in management meetings
• Delivering teaching to peers, or junior colleagues/other professionals.

Independent self-directed learning

• RCEMLearning: content mapped to the Clinical Syllabus and SLOs and maintenance of personal portfolio (self-assessment, reflective learning, personal development plan)
• Other eLearning sources as relevant
• Reading journals
• Working towards personal learning goals beyond the essential core curriculum.

Governance activity: audit, quality improvement and research projects within job planned protected non-clinical time

The purpose of assessment

The purpose of the RCEM ACP Programme of Assessment fall into three broad categories:

Assurance:

• demonstrate EM-ACPs are competent across the breadth of the curriculum having acquired the knowledge and skills at the required standard
• mandatory workplace-based assessment as evidence that tACPs are meeting the curriculum standards during the training programme.

Regulating progression and targeting remediation:

• assess tACPs’ actual performance in the workplace
• inform the progression meeting and identify any requirements for targeted or additional training or experience where necessary
• identify performance concerns and ultimately tACPs who should be advised to consider changes of career direction.

Fostering self-regulated learners:

• enhance learning by providing formative assessment, enabling tACPs to receive immediate feedback, understand their own performance and identify areas for development
• drive learning and enhance the training process by making it clear what is required of tACPs and motivating them to ensure they receive suitable training and experience
• identify and encourage excellence.

Types of assessment

The credentialed EM-ACP, by presenting a comprehensive suite of evidence, demonstrates their development into a reflective practitioner, committed to lifelong learning as well as meeting the required standards. The inclusion of assessments from the beginning of training helps to demonstrate the journey to capability. It is recognised that assessments completed in the first year or two of training will not meet the entrustment level required but will allow feedback to the tACP on how they can continue to develop their capability to reach that level. Therefore, it is expected that there will be a considerable number of formative type assessments, not meant to confirm capability but to enable ongoing development.

The mandatory consultant supervisor assessments (or by trained assessors in some cases) are expected to demonstrate the required entrustment level at the point of submission; the tACP is expected to select the most appropriate assessment as per the requirements below.

• The mandated assessments, demonstrating appropriate capability and entrustment has been reached, must be completed by an experienced supervisor – in most cases an Emergency Medicine Consultant
• The remaining assessments can be completed by a range of supervisors including senior EM trainees and Trust doctors (ST4 equivalent and above), consultant and credentialed ACPs and other practitioners. These assessments are designed to foster self-regulated learners.

Panel-based judgements

Faculty Educational Governance Statements (FEGS) provide regular, panel-based, information-rich, individualised judgements that inform each tACP’s progression. The faculty will consider the tACP’s workplace performance and provide a summative recommendation about whether a tACP has met the standard in the SLOs relevant to their experience as a tACP. This information is combined with other evidence in an Educational Supervisor Report (ESR) that is completed each year in preparation for credentialing.  It is envisaged that the ESR is written by the ACP Educational Supervisor having reviewed the evidence collected and offering a judgement on progress and the standard reached, including the WPBAs and MSF, case load, critical incidents, reflections, logbooks, etc.  These ESRs are reviewed at credentialing to ensure a progression and any suggestions on additional focus or activity are followed by the tACP.

The ACP credentialing assessment blueprint

The table below shows the mandatory assessments required for credentialing. There is no requirement for any assessment to be completed in a specific year of training although evidence older than five years is not appropriate.  Any mandatory assessment must be within three years of submission, exceptionally a mandatory assessment that is older can be accepted but must be accompanied by suitable reflection on the individual’s development of capability since the assessment. A mandatory assessment submitted for credentialing must demonstrate the relevant level of entrustment has been met. An assessment completed at the beginning of training is unlikely to demonstrate the appropriate entrustment level has been achieved.

In addition to the mandatory assessments, a considerable amount of other evidence must be presented, including assessments where the relevant entrustment level is not met but which may provide an indication of the development of capability (formative). All sections of the clinical syllabus must have some evidence. In addition to the 48 mandatory consultant/named assessor assessments (listed below), it is expected that the clinical syllabus will have a minimum of 30 additional assessments, with the rest covered by eLearning and other evidence. This is the minimum number of assessments and many tACPs will find additional assessments helpful.

Within the syllabus, the resus domain must have an assessment for each of the eight clinical presentations, i.e. three further assessments in addition to the five listed below. These can be at entrustment level 2a. The additional three do not need to be by a consultant assessor.

Entrustment Decisions

The transition to a credentialed EM-ACP is an important time. Not only does it signify the ACP is able to provide a defined standard of care, but it also conveys that the ACP is able to take on some responsibilities and a higher degree of independence.  The judgement of the entrustment level requires a clear working knowledge of what the level means and the ability to predict how the ACP will respond when given a higher complexity of cases or additional clinical responsibility.

Key features of good judgement-based assessment are asking the right people and asking the right questions. The FEG panels are composed of staff who know the tACP well and know the responsibilities of the job well. Critically, the judgements are framed in terms of entrustment and independence. This aligns with the natural decision-making heuristics of clinician supervisors, and there is good empirical evidence that such ‘construct aligned’ judgements are significantly more dependable that judgements framed in terms of experience in the job or merit, e.g. poor, satisfactory, or good.

The RCEM entrustment scale for EM-ACPs is shown in the table below:

The expectation of tACPs in each SLO are shown below. It should be noted that for credentialing, the EM-ACP is expected to reach entrustment level 2b in the clinical SLOs, although it is recognised that in the supporting SLOs the EM-ACP will be at entrustment level 3. A newly credentialed EM-ACP is not expected to be operating at entrustment level 4 in any SLO.

What is it?

This is a statement that summarises the collated views of the training faculty about the progress of a tACP and, specifically at the point of credentialing, their suitability for the award of the credential.

This judgement is based on the observation of the tACP in the workplace, on feedback from staff and patients and what faculty members have learned about the tACP’s performance from WPBAs (individual WPBAs and reflections need not be reviewed by the training faculty at each FEG meeting, but they are available for review if the faculty judges that they need more data to make their judgement). Within this statement, the strengths of the tACP are also summarised, as well as areas to develop, thus giving the opportunity to reflect and encourage excellence. The FEG panel can also offer suggestions as to how the tACP might address any on-going training needs, potentially making the FEGS an ‘adaptive’ or individualised assessment.

The decision made by the faculty on the progress towards independence is seen as a benefit locally in supporting the tACP as they make progress on the training pathway. The clear descriptions of what is required should benefit both the tACP and the local department.

How is it done?

The FEGS can be completed in different ways according to local arrangements. However, the key feature of the FEGS is that it includes the views of the right people, i.e. those who know the tACP and know the responsibilities of the job. It must represent the collated views of the training faculty as to whether they believe a tACP has met the requirement for practice in each of the relevant SLOs at the level of independence required in their job role. The decision will relate to the Key Capabilities for each SLO that are relevant to the tACP’s stage of training.

When is it done?

For tACPs a FEGS is required for each year of practice, culminating in submission for credentialing. The final FEGS should be completed within 3 months of the submission date. A minimum of 3 FEGS, each spaced approximately 12 months apart, is mandated for credentialing.

Other evidence required

Reflective practice

tACPs are expected to provide reflection on each item of evidence and, in addition, to provide evidence of reflective practice. Reflection should analyse their own capability – not just a description of the activity, but how the evidence demonstrates the development of their capability and progression to independent practice in that SLO. At each sign-off for key capabilities, the tACP is expected to reflect on why and how they have reached the relevant level of entrustment.

Engagement in training is very important and a marker of an ACP who is seeking to develop beyond their current capabilities is a key principle that underpins the ethos of assessment in the workplace.

In addition, the tACP is expected to reflect on eLearning, e.g. how this affects their daily practice; evidence of learning and a planned change in behaviour is expected. Reflection on teaching attended and delivered, meetings attended, projects undertaken, is all part of the valuable evidence that is expected.

Procedural log

In addition to the mandatory DOPS that are required, it is recommended that tACPs complete a reflective practice log within the portfolio demonstrating both experience and familiarity with procedures. These can also be used in reflective practice.

Other evidence

All sections of the clinical syllabus should have evidence against them. Where relevant, this may be a mandatory item or formative WPBAs, eLearning, teaching delivered, case reports, conference elements, etc. For the clinical syllabus one item of evidence may cover several elements of one section of the syllabus.

Patient log

In order to gain experience sufficient to develop the standard of competence required, it is expected that the EM-ACP has had direct contact with a significant number of patients with a sufficient breadth of practice. A patient log is required which demonstrates the breadth of conditions managed, and an adequate number where the EM-ACP has been the primary clinician caring for the patient. Guidance on the presentation of the patient log is available on the RCEM website. As the curriculum is competence/capability based, adequate experience and patient contact must be demonstrated.

It is recommended that the EM-ACP has a case mix that is made up of 20% resus cases, with 50% of the remaining cases being ones that are referred for ongoing or expert opinion. This provides evidence that the EM-ACP has been working in a multi-disciplinary team and can engage with other specialties for the benefit of patients.

If it recommended that the EM-ACP will have seen a minimum of 2100 adult patients by the end of the three-year minimum (whole time equivalent) training. This would likely be represented by around 700 adult patient contacts in the first year, rising to 1000 as the ACP gets more proficient. It is recognised that the more experienced ACP may see less patients themselves as they are supervising others; an explanation for this would be expected in the ACP’s reflection and from the supervisor.

Supervision and feedback

Access to high quality, supportive and constructive feedback is essential for the professional development of the tACP. Personal reflection is an important part of the feedback process and exploration of that reflection with the trainer should ideally be a two-way dialogue.

Effective feedback is known to enhance learning and combining self-reflection with feedback promotes deeper learning.

All elements of work in training must be supervised with the level of supervision depending on the experience of the tACP, case mix and workload. The duties, working hours and supervision of tACPs must be consistent with the delivery of high-quality, safe patient care.

Initially there should be close supervision of the tACP with opportunities to discuss each case if required. As training progresses, the tACP is expected to work with increasing independence, consistent with safe and effective care for the patient. It is important to establish that the tACP’s knowledge, skills, behaviours and professional conduct are developing appropriately.

The College recommends that Educational Supervisors should be allocated at least 0.25 educational PAs (1 hour) per week per tACP in order to deliver this standard of supervision.

ACP Educational Supervisors must have attended the RCEM training for ACP supervisors. Whilst Paediatricians who are working primarily as PEM consultants in a paediatric emergency department may apply to be an ACP Educational Supervisor for tACPs in the Children’s department, this is unlikely to be required for adult-only tACPs. Paediatrician ACP Educational Supervisors must be Members of the RCPCH and attend the RCEM ACP supervisor training.

In addition, the College recommends Consultant Practitioners and Senior ACPs acting as Clinical Supervisors should also be allocated 1 hour per week, per tACP. This is to support the professional development of the tACP as they transition to autonomous practitioners working in the medical model.

Facilities

Each department must ensure tACPs have access to:

• on-line learning facilities and libraries
• an adequate induction to local policies, procedures and arrangements in the same way as junior doctors undergo local induction
• electronic patient records (EPR) on the same basis as medical staff to allow the tACP to record their clinical findings. They should be allocated the role on the electronic patient record (EPR) consistent with their training level.
• adequate accommodation for themselves and their trainers in which to prepare their audit, teaching, or quality management work
• a private area where confidential activities such as assessment, appraisal, counselling and mentoring can occur
• a secure storage facility for confidential training records
• a reference library where tACPs have ready access to bench books (or electronic equivalent) and where they can access information at any time
• IT equipment such that they can carry out basic tasks on computer including the preparation of audio-visual presentations. Access to the internet is recognised as an essential adjunct to learning.
• a suitably equipped teaching area and access to local training suitable for tACPs – this may be provided by integration with the FY2 or core ACCS EM training
• a private study area
• an appropriate rest area whilst on duty.

Trainee ACPs will always have a named Educational Supervisor and Clinical Supervisor responsible for overseeing their education.

At least one individual involved in assessing trainee and established ACPs within the local ED must have completed the mandatory RCEM ACP supervisor training. Dates are advertised on the RCEM website.

ACP Educational Supervisor

A Fellow of the Royal College of Emergency Medicine and a substantive consultant in Emergency Medicine who is selected and appropriately trained, meeting the GMC framework standards, and who is responsible for the overall supervision and management of a tACP’s educational progress during training. The ACP Educational Supervisor is responsible for completing the Educational Supervisor Report (ESR) and Faculty Educational Governance Statement (FEGS) each year. The ACP educational supervisor must have attended the RCEM supervisor training a year before credentialing sign off for the ACP, and preferably in the tACP’s first year of training.

The ACP Educational Supervisor has responsibility for confirming that the evidence required for credentialing is present and clearly visible and that, in their opinion, the tACP is ready for credentialing. They are expected to review the whole portfolio and to complete the sign-off of the portfolio to confirm they believe the evidence is complete.

This will also require them to have spoken to the entire faculty involved in training the tACP and to ensure that the standard of performance expected is understood and maintained, particularly during the tACP assessments.

The ACP Educational Supervisor has responsibility for the safety of the patients and the tACP. Therefore, the Educational Supervisor should discuss issues of clinical governance risk management and any report of untoward clinical incidents involving the tACP. The Educational Supervisor should be contacted if there are any concerns identified by any member of the extended faculty and clinical team regarding their tACP.

Other consultants in EM may act as educational supervisor and have oversight of educational progression for the early years. However only an approved ACP educational supervisor can perform final sign off and complete FEGS and ESRs.

Clinical Supervisor

A trainer, usually a consultant but may be a consultant practitioner or senior advanced clinical practitioner, who is selected and appropriately trained to be responsible for overseeing a specified tACP’s clinical work and for providing constructive feedback during their training. The Clinical Supervisor must be familiar with the assessment tools, the standard required, and have undergone training for their role. This may be a consultant in another specialty who will also have undergone training to the GMC framework.

Assessors

Assessors may be medical doctors, or advanced clinical practitioners or other senior healthcare professionals. All assessors need to be aware of the standards required and have been trained in assessment. Assessors must be competent themselves in the area being assessed.

It should be noted that all mandatory consultant assessments must be completed by a substantive consultant in the appropriate specialty. In the majority of cases this will be a Fellow of the Royal College of Emergency Medicine.

It is essential that training in assessment is provided for trainers and ACPs in order to ensure that there is complete understanding of the assessment system, assessment methods, their purposes and use. Training will ensure a shared understanding and a consistency in the use of WPBAs and the application of standards. Opportunities for feedback to tACPs about their performance will arise through the use of the workplace-based assessments, regular appraisal meetings with supervisors, other meetings and discussions with supervisors and colleagues, and feedback from progression meetings where relevant within a local programme.

Responsibility of the tACP

All tACPs should make the safety of patients their first priority. Furthermore, tACPs should not be practising in clinical scenarios which are beyond their experiences and competences without supervision. tACPs should actively devise individual learning goals in discussion with their trainers and should subsequently identify the appropriate opportunities to achieve said learning goals. tACPs will need to plan their WPBAs accordingly to enable their WPBAs to collectively provide a picture of their development during training. tACPs should actively seek guidance from their trainers in order to identify the appropriate learning opportunities and plan the appropriate frequencies and types of WPBAs according to their individual learning needs.

It is the responsibility of tACPs to seek feedback following learning opportunities and WPBAs. tACPs should self-reflect and self-evaluate regularly with the aid of feedback. Furthermore, tACPs should formulate action plans with further learning goals in discussion with their trainers.

Appraisal

A formal process of discussion and review underpins training. This process ensures adequate supervision during training, provides continuity and is one of the main ways of providing feedback to tACPs. All educational meetings should be recorded in the ePortfolio for the purposes of credentialing. Whilst these meetings relate specifically to the progress made in the tACP training programme, it is acknowledged that the tACP’s line manager may need to be involved and/or kept informed of this process.

These educational meetings may be in addition to the Personal Development Review (PDR) process that is a local professional requirement. Ideally the process would be in parallel or in conjunction.

tACPs will be undertaking an academic level 7 programme in Advanced Practice in conjunction with completing this curriculum. It is therefore advised that educational meetings involve feedback from their HEI clinical practice tutor. In this way, themes and work plans across both the ACP curriculum and the Master’s programme can be drawn together to ensure a robust and effective plan for the year ahead can be developed.

The tACP, HEI clinical practice tutor and the Educational Supervisor should have a meeting at the beginning of each year. They should review the tACP’s progress thus far, agree learning objectives for the next year and identify learning opportunities.  A personal development plan should be developed that highlights the experience needed, the evidence that will be gathered and any focused learning required.

Intended use of curriculum by trainers and ACPs

ACP Educational Supervisors and tACPs will be expected to have a good knowledge of the curriculum and should use it as a guide for their training programme and ACP discussions.  The evidence collected by the tACP must demonstrate the depth, breadth and scope of practice and evidence that the tACP is working across all areas.

Each tACP will engage with the curriculum by maintaining their ePortfolio (hosted on the Kaizen platform). The tACP will use the curriculum to develop personal learning objectives and reflect on learning experiences.

The College recommends using the curriculum proactively, both to confirm coverage and identify areas to be covered by new evidence. This ensures more thoughtful learning and ensures cases are valuable learning experiences. The curriculum is also key to the planning of tutorials and assessments.

Currency

Established EM-ACPs will need to provide evidence that covers the entire curriculum. Naturally, some evidence may be retrospective. However, such evidence must be within five years with the majority within three years, and in the case of older evidence, there must be reflection on how their practice has developed since the evidence was collected.

Experienced EM-ACPs may use evidence of their teaching to cover the curriculum. However, there must be evidence of clinical contact for the majority of the presentations, and a suitable case mix and appropriate workload as evidence of that clinical experience.

It should be noted that, given the requirement to use RCEM forms for consultant assessments, and the time limit on currency of evidence, it will take time for established ACPs to ensure the full range of required evidence is collected and appropriate. Revisiting previously demonstrated competences requires appropriate reflection on the personal development and progression since that evidence was first collected.

Recording progress in the ePortfolio

Upon becoming a member of RCEM, tACPs will be given access to the ePortfolio. The ePortfolio allows evidence to be built up to inform decisions on a tACP’s progress and provides tools to support the tACP’s education and development.

The tACP’s responsibilities are to:

• Keep their ePortfolio up-to-date
• Request assessments (WPBAs, MSF) and ensure they are recorded
• Maintain their personal development plan
• Record their reflections on learning and record their progress through the curriculum.

The supervisor’s responsibilities are to:

• Provide guidance on the standard required
• Provide feedback to enable the tACP to meet that standard and to continue to develop professionally
• Communicate with the entire faculty to provide comprehensive feedback to the tACP
• Highlight areas of deficiency and make recommendations for improvement
• Agree the personal development plan and learning objectives for each year
• Regularly review the portfolio to ensure progress is being made
• Complete an Educational Supervisor Report (ESR) each year
• Complete some WPBAs
• Contribute to the MSF
• Ensure the FEGS entrustment decisions are recorded.

Continuing Professional Development (CPD) and revalidation

In line with professional requirements, all tACPs and established ACPs should engage in CPD and maintain a portfolio to ensure they meet the requirements for professional revalidation.

It should be noted that professional revalidation is required for the whole scope of practice but is not affected by credentialing. Revalidation will be with the relevant regulator of the individual practitioner. Evidence collected for revalidation may be useful for credentialing and vice versa but will require reflection on how it contributes to the evidence for credentialing.

Equality and diversity

The Royal College of Emergency Medicine complies, and ensures compliance, with the requirements of equality and diversity legislation set out in the Equality Act 2010.

The College believes that equality of opportunity is fundamental to the many and varied ways in which individuals become involved with the College, either as members of staff and Officers; as advisers from the medical profession; as members of the Colleges’ professional bodies or as ACPs and credentialing applicants.

Assessment methods

Acute Care Assessment Tool (ACAT) assesses the capability of a tACP across a range of patients over a period of time – typically 1-2 hours.  The tool looks at clinical assessment, investigation and management of patients, patient safety, clinical judgement and time management.  The ACAT can be linked to a number of clinical syllabus items and is usually either focused on the clinical KCs in SLO1 or SLOs 3 and 4. This tool also assesses SLOs 2 and 7.

Case Based Discussion (CbD): assesses the performance of a tACP in their management of a patient to provide an indication of competence in areas such as clinical reasoning, decision-making and application of knowledge in relation to patient care. It also serves as a method to document conversations about, and presentations of, cases by tACPs. The CbD should focus on a written record such as a patient’s written case notes. The CbD tool can be used for summative or formative assessment.

Direct observation of procedural skills (DOPS): assessment tool designed to evaluate the performance of a tACP in undertaking a practical procedure, against a structured checklist. The trainee receives immediate feedback to identify strengths and areas for development.

Extended Supervised Learning Event (ESLE): an extended event of observation in the workplace across cases. It covers interactions, decision making, management and leadership, as well as the tACP’s individual caseload. It is therefore an assessment of the non-technical supporting SLOs (2,7,8,9,12) although the clinical patient characteristics may meet SLO 1,3 and 4 KCs. The event will characteristically be three hours in length, with around two hours of observation followed by one hour of feedback. The tACP will be observed during their usual work on shift, but the consultant observer will be supernumerary, i.e. not in the clinical numbers. tACPs are given a rating aligned to independence in each domain observed by the consultant supervisor. The purpose of doing so is to provide expert opinion on development against expectation and to generate learning outcomes for further work in the ED and future ESLEs.

Leadership assessment tool: designed to provide feedback and development of leadership skills as per the RCEM Leadership framework

Management assessment forms: a range of forms looking at specific management activities designed to provide feedback and development of management capabilities

Mini-clinical evaluation exercise (Mini-CEX): evaluates a clinical encounter with a patient to provide an indication of competence in skills essential for good clinical care such as history taking, examination and clinical reasoning. The tACP receives immediate feedback to aid learning. The Mini-CEX can be used at any time and in any setting when there is a tACP and patient interaction and an assessor is available. The Mini-CEX can be used in a summative or formative manner.

Multi-source feedback (MSF): method of assessing generic skills such as communication, leadership, team working, reliability etc. This provides objective systematic collection and feedback of performance data on a tACP, derived from a minimum of 12 colleagues, which should include 2 consultants, line manager, senior nursing/AHP staff, junior doctors, junior nurses and support staff.

Quality Improvement Assessment Tool (QIAT): designed to assess a tACP’s competence in completing a quality improvement project. The QIAT requires 3 main areas of content: a report of the project itself, an account of working with others, and reflection on leadership and learning.

Teaching Observation: designed to provide structured, formative feedback to tACPs on teaching competence. The Teaching Observation can be based on any formal teaching by the tACP, which has been observed by the assessor. The process should be trainee-led (identifying appropriate teaching sessions and assessors).

Ruth Brown, Chair of the RCEM ACP Curriculum Sub-committee and ACP Credentialing Sub-Committee, EM Consultant and Associate Postgraduate Dean HEE London
Amy Cawthorne, ACP Forum Regional Representative (North), Lead Adult ED ACP and credentialed ACP, Leeds Teaching Hospitals NHS Trust
Robert Crouch OBE, Consultant Nurse and Honorary Professor of Emergency Care, University Hospital Southampton NHS Foundation Trust
Emma Farrow, EM Consultant, North Cumbria Integrated Care NHS Foundation Trust
Els Freshwater, Consultant Paramedic, Lead Advanced Clinical Practitioner and credentialed EM ACP, University Hospital Southampton NHS Foundation Trust
Wayne Hamer, EM Consultant and Joint ACP Clinical Lead, Leeds Teaching Hospitals NHS Trust
Michael Harrison, EM Consultant and Joint ACP Clinical Lead, Leeds Teaching Hospitals NHS Trust
Ellen Jones, EM Consultant, Heart of England NHS Foundation Trust.
Ashleigh Lowther, ACP Forum Chair (from 2022), credentialed EM ACP, University Hospitals Plymouth NHS Trust
Simon Mckay, EM Consultant, Blackpool Teaching Hospitals NHS Trust
Marianne Mackenzie-Brown, credentialed EM ACP
Dolly McPherson, credentialed ACP, University Hospital Southampton NHS Foundation Trust
Maya Naravi, Chair of the RCEM Training Standards Committee and EM Consultant, Bradford Teaching Hospitals NHS Trust
Robert Pinate, Consultant Nurse, University College London Hospitals NHS Foundation Trust, and Clinical Associate, NHSEI Emergency Care Improvement Support Team
Wendy Preston, Head of Nursing Practice, Royal College of Nursing
Pete Sago, credentialed EM ACP, East Suffolk and North Essex NHS Foundation Trust
Tony Stone, Head of Clinical Development for Emergency and Critical Care, College of Paramedics
Jacqueline Thompson, Nurse Consultant Frailty and Elderly Care, North Cumbria Integrated Care NHS Foundation Trust, and Royal College of Nursing representative
Olivia Wilson, ACP Forum Chair (2019-2022), credentialed EM ACP, Belfast Health and Social Care Trust

Romana Moss, Deputy Chief Executive
Elizabeth Goldsmith, Associate Director of Training and International
Lee Sullivan, Training Manager
Nick Powe, Project Manager
Rachel Boothby, Training Officer
Tahirih Doncaster, Training Officer
Sabrina Bodigoi, ePortfolio and Curriculum Officer