The rise of advanced clinical practitioners (ACPs) within healthcare systems has promised to address some of the most pressing challenges in patient care, from medical workforce shortages to improving service delivery and enhancing patient outcomes. However, despite the role's growing prominence and potential, many ACPs find themselves facing a reality that does not always meet their initial expectations. In the accompanying research article in this edition of the International Journal of Advanced Clinical Practice, Vikki-Jo Scott (2024) addresses a critical issue: What are advanced clinical practitioners' expectations of the benefits of pursuing the role, and are these being realised? This online, cross-sectional study used a sequential, mixed-methods, exploratory design, to identify themes from focus groups to construct a follow-up questionnaire. This investigation into the experiences of a diverse group of UK-based ACPs revealed several important insights into the gaps between what ACPs anticipate when they enter the role and the realities they encounter in practice. This editorial reflects on Scott's findings regarding the broader implications for advanced clinical practice, policy development and workforce development.
The context and evolution of Advanced Clinical Practice
The Multi-professional Framework for Advanced Clinical Practice in England (Health Education England, 2017) offers a comprehensive model for ACP roles, encompassing the four pillars of: clinical practice; education; leadership and management and innovation and research. This framework sets a clear definition and scope for ACPs, aiming to guide healthcare organisations in training, deploying, and supporting these professionals. As Scott notes, advanced practice is not unique to the UK. Countries such as the US and Australia have implemented similar roles to reconfigure healthcare services, often as a response to workforce shortages and rising patient demand. ACPs were positioned as a solution to these challenges, expected to operate at an advanced level of practice, bridging gaps between healthcare teams, delivering high-quality care, and taking on leadership roles. However, the growing disconnect between these expectations and ACPs' lived experiences could threaten the long-term sustainability of the profession.
Key findings from Scott's research
Scott's mixed-methods study gathered insights from UK-based ACPs, identifying five key themes that illustrate the gap between ACPs' expectations and reality: clinical and non-clinical balance; full use of knowledge, skills and experience (KSE); leadership in quality improvement; career progression; and policy, vision and organisational support. These themes provide a comprehensive overview of the challenges facing ACPs, pointing to areas that require urgent attention if the role is to meet its full potential.
Clinical and non-clinical balance
A central finding in Scott's research is the imbalance between clinical and non-clinical duties. ACPs are trained to engage in both patient-facing clinical work and non-clinical activities such as education, leadership and research. However, Scott's study reveals that a majority of ACPs feel their roles are heavily weighted towards clinical work, with little time allocated for non-clinical responsibilities. More than half of the respondents reported that non-clinical time is not routinely scheduled, and many have to undertake such tasks in their own time. This imbalance limits ACPs' ability to fulfil the broader aspects of their role and risks professional burnout. Scott's recommendation to ringfence non-clinical time is crucial if ACPs are to engage in the full spectrum of activities expected of them. Protecting time for leadership, education and research is essential for ACPs to develop their roles and contribute meaningfully to service improvement and innovation.
Use of knowledge, skills and experience
ACPs bring a range of KSE to their roles, often acquired through years of professional practice. Scott's findings suggest that ACPs are not always able to apply this full breadth of expertise in their day-to-day work. Many reported that their roles are constrained to a narrow clinical focus, limiting their ability to draw on their advanced training and specialist knowledge. This underuse is a missed opportunity for both ACPs and healthcare systems. When ACPs are not fully empowered to use their skills, the potential benefits of advanced practice, including improved patient care and service innovation, are significantly diminished. Scott highlights the importance of creating opportunities for ACPs to apply their full KSE.
Leadership in quality improvement
Leadership is a critical expectation for ACPs, who often enter the role with a desire to drive quality improvement and service innovation. Scott's research reveals that many ACPs feel marginalised from leadership opportunities, with limited influence over the direction of services or the decision-making processes. The study notes that leadership in quality improvement is often underdeveloped, with ACPs reporting inconsistent involvement in service redesign and improvement projects. Scott's recommendation for greater support in leadership development is particularly important. ACPs are well-placed to lead initiatives that enhance patient care, streamline service delivery and foster innovation. However, without structured opportunities and support for leadership, ACPs are unable to fulfil this critical aspect of their roles. Scott calls for organisations to provide clear leadership pathways for ACPs, ensuring that they are integrated into decision-making structures and given the authority to shape services.
Career progression
Career progression is another area where expectations often fall short. Scott's study found that while many ACPs see the role as a step forward in their careers, a significant proportion feel ‘stuck’ in their current positions, with few opportunities for further advancement. This stagnation could negatively affect job satisfaction and retention, particularly as many enter the role expecting it to offer long-term career growth. Scott emphasises the need for transparent and structured career planning within healthcare organisations, ensuring that ACPs have realistic expectations about their future prospects and opportunities for progression. This includes providing pathways for both clinical and non-clinical advancement, allowing ACPs to grow in their roles and take on new responsibilities over time.
Organisational policy, vision and support
Scott's research also highlights significant inconsistencies in the organisational support provided to ACPs. While the Multi-professional Framework offers a national standard, the implementation of ACP roles varies widely between organisations. Many ACPs report that their roles are not well understood by colleagues or managers and that they lack the structural support needed to succeed in their positions. This lack of clarity and support undermines the potential of ACPs to contribute effectively to healthcare services. Scott calls for greater standardisation in how ACP roles are implemented across different settings, with clear policies and organisational structures in place to support ACPs in all aspects of their roles. Without this, ACPs risk becoming isolated, unable to fully integrate into healthcare teams or contribute to broader service goals.
Implications for policy and practice
The findings of Scott's research have significant implications for the future of advanced clinical practice. If ACPs are to deliver on the promises of improved patient care, service innovation, and leadership in healthcare, urgent reforms are needed to address the expectation-reality gap. Scott's recommendations provide a roadmap for these reforms, focusing on key areas that require immediate attention.
Conclusions
Scott's research offers a valuable and timely contribution to our understanding of the challenges facing ACPs. The findings underscore the need for systemic changes in how ACP roles are implemented, supported and developed. By addressing the gaps between expectations and reality, healthcare organisations can ensure that ACPs are empowered to fulfil their full potential as clinicians, leaders, educators and innovators. This research makes it clear that this will require a concerted effort from policymakers, educators and healthcare leaders to ensure that ACPs can deliver the transformative impact they are capable of providing. If these challenges are addressed, advanced clinical practice can truly become the cornerstone of 21st century healthcare, offering a sustainable and fulfilling career path for practitioners and improved outcomes for patients.