Abstract
Background The introduction of advanced practitioners (APs) is one approach to addressing health and care workforce shortages, with around 6000 APs working in primary care in England. There is variation in implementation, regulation, and scope of the role, and limited knowledge on implications of their implementation on workforce organisation, staff, and patients. There is a pressing need for research to understand what works in advanced practice implementation, for whom and in which contexts.
Aim To understand the contexts and mechanisms that influence key outcomes in the implementation of multiprofessional advanced practice in primary care in England and develop recommendations to support workforce development.
Design & setting A realist evaluation using mixed methods across four work packages in primary care in England, incorporating research with advanced practice workforce leads, APs, key primary care staff (clinical and management), and patients and carers.
Method The following approaches will be taken: (i) semi-structured interviews with advanced practice workforce leads in England to inform the development of an initial programme theory (IPT) (n = 15); (ii) online survey of APs in England to refine IPT (n>300); (iii) case studies in five GP practices in England, interviewing staff members (n = 10), conducting interviews or focus groups with patients (n = 5), and gathering documentary data (to test and modify the IPT); (iv) stakeholder workshops to share findings and develop policy and practice recommendations.
Conclusion Findings will be used to inform recommendations for the implementation of advanced practice in primary care, to support workforce development, enhance patient experience, and improve health outcomes.
How this fits in
Advanced practitioners are one strategy to address the primary care workforce crisis. They come from a range of professional backgrounds (for example, nurses, midwives, allied health professionals, and pharmacists). Variations in how advanced practice roles are implemented and supported have led to role ambiguity among colleagues and patients, and variations in job satisfaction. This study will use realist methods across several work packages to understand the mechanisms that influence key outcomes, in a range of contexts. Findings will inform a framework for best practice for supporting advanced practice in primary care, to improve role clarity and retention, alongside guidance to improve understanding of advanced practice roles using inclusive designs for patients and carers.
Introduction
Advanced practitioners (APs) have been introduced as one strategy to address the workforce crisis,1 where the decrease in GPs adds significant pressure on primary care in the UK and globally.2–5 Approximately 6000 APs work in primary care in England;6 most from nursing but almost one-third from other health professions,7 including pharmacy and allied health professions (AHPs). APs undergo training (at post-registration master’s level or equivalent) to assess, diagnose, and treat patients.7 They practice with a high degree of autonomy and responsibility for complex decision making.8
AP roles are not collectively regulated in the UK and the multidisciplinary nature of advanced practice brings variation in the planning, implementation, regulation, and scope of the role. APs in primary care have been evaluated positively,9,10 are accepted by colleagues, and make important contributions to patient care.9,11–13 However, they face a number of challenges including the following: role ambiguity; variations in job satisfaction; variations in pay, employment contract, and job security; barriers to secondary care referral processes; isolation and lack of belonging; inadequate resources for training, supervision, continuing professional development (CPD), and research-informed practice;9,11,12,14–16 and a lack of routes for career progression.17 These challenges generate problems in recruitment and retention of APs.18 Further, this variation and ambiguity brings confusion about role expectations for employers, colleagues, and patients. Intra-professional and inter-professional tensions resulting from boundary blurring have also made transition from nurse, pharmacist, and AHP to AP in primary care sometimes difficult to achieve.18,19
Prior research on advanced practice has predominantly focused on nurses.18 There is a need to explore the experiences of APs from other disciplines,20 as well as the views of managers, policymakers, patients, and other health professionals;21 and the impact of advanced practice on inter-professional team functioning, working conditions, and workload.9
The proposed study will use realist methods22 to understand the contexts (including different models) of primary care advanced practice and the mechanisms that influence key outcomes (such as workforce retention and patient experience). We will develop recommendations to inform strategies to enhance primary care workforce development and contribute to delivering better patient outcomes.
Method
A realist evaluation22,23 allows researchers to specify what works for whom in what context by understanding the mechanisms through which outcomes are enacted, and the conditions that allow those mechanisms to be triggered. This evaluation will include four work packages (WPs) to develop and refine programme theories.24 WPs will be undertaken sequentially so that results from earlier WPs can inform later WPs (see Figure 1).
The figure presents the timeline for the REMAP project, a realist evaluation of multiprofessional advanced practice in primary care. Across the top, five connected blue arrows show the project phases from left to right: setup during months 1–4; work package 1 during months 5–9; work package 2 during months 10–15; work package 3 during months 15–30; and work package 4 during months 29–34. A light-blue panel beneath each arrow describes the corresponding activities and outputs.The setup phase covers recruitment and approvals. The planned activities are to recruit two research associates, finalise the protocol, apply for ethical approval, and develop an accessible project website to which outputs can be added. The outputs are information sheets, consent forms, ethical approval, and the study website.Work package 1 consists of interviews with advanced practitioner leads across England. Advanced practitioner leads are to be recruited through integrated care boards and professional colleges. Data will be collected from 15–20 participants and analysed. The findings will be used to develop an initial programme theory that will inform work packages 2 and 3. The outputs are an academic paper, a lay summary for the patient and public involvement and engagement steering group, and a policy briefing.Work package 2 consists of a survey of advanced practitioners across England. The activities are survey development, recruitment through NHS England, data collection from more than 300 participants, data analysis, and refinement of the initial programme theory. The outputs are an academic paper, a lay summary for the patient and public involvement and engagement steering group, and a policy briefing.Work package 3 consists of case studies in general practice surgeries. Data collection will take place in five cases in the North of England. Interviews or focus groups will involve a maximum of 75 participants. The work package also includes documentary analysis and testing and modification of the initial programme theory. The outputs are an academic paper, a lay summary for the patient and public involvement and engagement steering group, and a policy briefing.Work package 4 consists of stakeholder workshops. Data will be collected through one online workshop and one in-person workshop, involving 12–16 participants. The activities also include modification of the initial programme theory, co-production of recommendations, and relationship building. The outputs are a stakeholder event involving 50 participants, a final report, public and policy summary reports, video animations, and conference presentations.The overall sequence moves from establishing the study and obtaining approvals to collecting qualitative data from advanced practitioner leads, conducting a national survey, undertaking case studies in general practice surgeries, and holding stakeholder workshops. Development, refinement, testing, and modification of the initial programme theory link the four work packages. AP means advanced practitioner, ICB means integrated care board, NHSE means NHS England, PPIE means patient and public involvement and engagement, IPT means initial programme theory, WP means work package, and GP means general practice.
WP1: interviews with regional and national AP workforce leads
Aim, design, and setting
WP1 aims to identify specific contexts that impact on advanced practice outcomes, and explore how these contexts shape specific mechanisms,25 informing the initial programme theory (IPT). The findings will also enable us to inform the survey design and identify issues to explore in the case study site selection.
WP1 will utilise semi-structured interviews with regional and national AP workforce leads using a topic guide informed by the literature, and stakeholder engagement, and framed by the Consolidated Framework for Implementation Research (CFIR). It will elicit contexts and mechanisms to develop context–mechanism–outcome configurations (CMOCs). The topic guide will explore decision making about AP training and recruitment, any prioritisation of the professional backgrounds of APs, and the impact of APs on workload planning, appointment accessibility, the interface between primary and secondary care, and patient experience. Interviews are expected to last up to 1 hour and will be audio-recorded, transcribed verbatim using a professional transcriber, and anonymised.
Data collection will be undertaken remotely, online, or by telephone. Therefore, researchers will be based in their usual workplaces and participants may also be in their place of work.
Sampling and recruitment
We will sample advanced practice workforce leads from integrated care boards (ICBs), training hubs (THs), and professional bodies (such as royal colleges) across England, ensuring representation of the different AP professions in English primary care (n = 15–20). We will recruit through our existing networks, including our ICB stakeholders.
Analysis
An iterative approach will be taken to use the data gathered within WP1 to develop the CMOCs to build an IPT for later WPs to test and refine. Data will be analysed thematically26 using realist principles as a theoretical guide.22,27 Data will be coded using NVivo (version 14), and main themes generated jointly across the research team. These will be used to develop the IPT using the following four steps: (a) category identification; (b) elaboration of CMOCs; (c) demi-regularities identification; and (d) generative mechanism refinement.
WP2: survey of advanced practitioners
Aim, design, and setting
The aim of WP2 is to refine the IPT developed in WP1.24 WP2 will involve a survey of APs that responds to the findings from WP1 but also allows space for potential new CMOCs. The survey will be administered remotely using Qualtrics, via email. Researchers will consequently be in their usual place of work, while participants could respond from anywhere across England with suitable internet access.
Sampling and recruitment
Participants will self-identify as an AP in line with the definition provided by NHS England:8‘Advanced practice is delivered by accomplished registered health and care professionals. It is a level of practice characterised by a high degree of autonomy and designated responsibility for complex decision making. This is underpinned by a post-registration master’s level award or equivalent undertaken by an experienced practitioner that encompasses all four pillars of clinical practice, leadership and management, education, and research.’ We hope to achieve a response of more than 300 APs from primary care across England. Cascading of study information for recruitment will be supported by the NHS England Centre for Advancing Practice and its network of regional faculties for advancing practice, ICBs, professional forums, and practice networks. An email with a link to the survey will be sent to the mailing lists, with reminders at 3 weeks and 6 weeks. Participants will be offered a CPD certificate for taking part in research and the opportunity to enter a prize draw or give the prize to charity.
Analysis
Survey data analysis will be predominantly descriptive to understand APs’ professional backgrounds, professional identities, levels and scope of practice, experiences of support, and career intentions. The survey will also be used to test and modify the IPT. Data will be analysed with SPSS (version 29). Where possible, comparative statistics will be used to look at the differences between those of differing professional backgrounds. Analysis of validated scales will be undertaken in accordance with published guidance.
WP3: case studies in GP surgeries
Aim, design, and setting
WP3 aims to further refine the IPT. It will consist of case studies of five GP surgeries in the North of England to allow for in-depth exploration of complex issues.28 Each site will be visited by a member of the research team to provide information about the study and invite eligible participants. The case studies will include interviews with key staff members (n = 10) such as APs from a range of professional backgrounds, GPs, practice managers, and practice nurses, and interviews and focus groups with patients and carers (n = 5). Face-to-face and online interview options will be given for convenience, accessibility, and privacy.
Sampling
We will use a sampling frame developed in WP1 and WP2 to purposively select cases, ensuring variation across integrated care system (ICS) regions, rural and urban locations, deprivation measures, team configurations, and the inclusion of underserved groups. Sampling will be based on data from National Institute for Health and Care Research (NIHR) delivery network databases. We will also purposively sample within the cases, aiming for demographic variation of participants, adopting strategies to promote inclusive recruitment.29 Staff will be offered backfill funding to compensate for their time and patients and carers will be offered a voucher for taking part.
Analysis
Analysis will be iterative and will follow procedures similar to those described by Gilmore et al. 30 Cases will initially be analysed separately before a final cross-case synthesis stage. Case studies will contribute to the final CMOCs and will be analysed using NVivo (version plus 14). The analysis process will include the following: preparing the data; identifying individual CMOCs; refining CMOCs in each case study; synthesising the analysis across case studies; and creating a final modified programme theory of advanced practice in primary care.
WP4: stakeholder workshops and dissemination event
In WP4 we will present the CMOCs used to inform the emerging programme theory to our stakeholders through one online and one in-person workshop. The aim is to share our findings and develop recommendations for policy and practice. Workshop feedback will be discussed within the research team and used to sense-check the programme theory and develop recommendations for practice and policy.
Participant inclusion
Table 1 summarises the inclusion and exclusion parameters for participation in each WP.
Ethical considerations and data governance
For each WP, participants will receive an information sheet and have the opportunity to ask questions about the research before participating. Written informed consent will be taken from each participant using Qualtrics before participation in WP1, WP2, and WP3. As WP4 is stakeholder engagement, participants will not be required to sign a consent form. Participants will be made aware of their right to cease participation and withdraw their data. All data will be processed in line with General Data Protection Regulation requirements and adhering to a comprehensive data management plan, ensuring confidentiality and secure storage.
Study oversight groups
Three study management groups were established during the project’s initial stages:
1) steering group to meet twice a year to provide overall supervision for the project on behalf of the sponsor and the funder, and ensure it meets rigorous standards;
2) advisory group to meet annually to provide context and guidance to the project team on behalf of key national stakeholders on issues such as policy developments and support targeted dissemination; and
3) patient and public involvement and engagement (PPIE) group to meet every 4 months to inform project design, and provide feedback on data analysis and the production of materials for dissemination.
Discussion
This research will address a gap in current evidence on the implementation of multiprofessional advanced practice in primary care. It will use a realist evaluation approach and mixed methods across four WPs to understand the mechanisms through which advanced practice can be applied effectively in different contexts to support workforce development and patient care. It will produce recommendations to enhance workforce development, patient experience, and outcomes. The strength of a realist approach is that it allows the research to go beyond a focus on ‘what works’ to understand how things work under particular conditions. Its multi-stage and mixed-methods nature also allow for iterative development and refinement of programme theories, increasing the rigour of the research and robustness of associated recommendations.
Notes
Funding
This study is funded by the NIHR Health and Social Care Delivery Research (169270). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
Ethical approval
WP1 and WP2 ethical approval has been granted by the University of Sheffield research ethics committee (REC) (ref. 071021) and the Health Research Authority (HRA) (ref: 25/HRA/4779). We will seek approval for WP3 from the NHS REC at a later stage.
Provenance
Freely submitted; externally peer reviewed.
Data
The datasets generated and/or analysed during this study are in the form of anonymised interview transcripts, focus group transcripts, and survey data. These data are not publicly available but are held on a University of Sheffield secure server and the University's repository, ORDA, in line with study ethical approval. Anonymised transcripts and the quantitative survey data are available from the corresponding author on reasonable request. Requests will require a protocol, research ethics committee approval, and will be pending a data sharing agreement.
Acknowledgements
We are very grateful for feedback and guidance from our steering committee, advisory board and PPIE group.
Competing interests
The authors declare that no competing interests exist.
- Received December 12, 2025.
- Accepted December 22, 2025.
- Copyright © 2026, The Authors
This article is Open Access: CC BY license (https://creativecommons.org/licenses/by/4.0/)
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