Within my systematic literature review on the benefits of Advanced Clinical Practice, I noted there was consensus on the definition of ACP, and this broadly reflected the ‘four pillars’ of clinical practice, leadership & management, education, and research. However, I also found that whilst there is a consensus that ACP reflects the 4 pillars, it is clear that in practice the ‘clinical’ element dominates in terms of priority given, workload allocation, or the value it is held in. In a period of time where industrial action is on the rise and is drawing attention to the prioritisation and value that is attributed to certain aspects of work or particular roles through pay, contract arrangements, and workload, this seems a good time to reflect on this particular topic from my research in relation to ACPs.
The studies I found provide some evidence for the other 3 pillars being part of the role of ACP in the reality of practice, but these are seen, prioritised, and valued to a lesser degree. These studies noted that the focus on clinical practice is seen as a motivational factor for why practitioners choose to undertake this role as they want to remain to be seen as clinicians and be responsible for delivering clinical activity. This may provide endorsement for clinical practice being given priority over other aspects of the role.
The extent to which the dominance of clinical practice occurs was linked within the literature to known barriers of ACP. For example, Elliott et al. (2016) noted that ‘large clinical caseload’ was the most frequently reported barrier to effective implementation of ACP roles. Across the literature I found that increasing clinical caseloads was reported as impacting on the time available and opportunities for ACPs to research, take on leadership activities, engage in networking, or move forward with practice development. This resulted in a lack of visibility of ACPs as leaders. (Noting that nurses makes up the largest proportion of ACPs and thus limits the opportunities particularly for nurses to be seen as leaders in their organisation).
Heavy workload was cited by participants in ACP studies as the reason they did not have the time to keep up-to-date with research; this echoes the finding that clinical workload takes priority over other parts of the role. This included opportunity for undertaking continuing professional development and that research had to be undertaken outside of work time, and this may cause stress and potential burn-out. The Read et al. (2001) work on a variety of innovative roles, including ACPs, also note the potential for personal detriment due to excessive clinical workloads, which further compromises the ability to undertake other aspects of the role (e.g. training, audit, research). In their study over 75% reported working in excess of their contracted hours. Whilst this study is now over 20 years old, the headlines we are seeing currently about health care professionals becoming personally impacted by clinical workloads, burnt out, and leaving the NHS or health care altogether, appears to suggest this problem has not gone away.
The McConnell et al. (2013) study found Emergency Nurse Practitioners (a sub set of ACPs) estimated >80% of their time was spent on the clinical aspects of their role with only 2.5% and 2.6% being spent on leadership and research. In addition none of the participants reported ”involvement in any organisational decision-making, legislative or policy making activities”(McConnell et al., 2013, p. 79). It is therefore hard to see how they are fulfilling the full scope of the ACP role, particularly around expectations of leadership and service improvement at an organisational level.
In other studies, I found the focus on clinical practice is more nuanced. There was confirmation that much of the activity is in response to acute clinical need and staff shortages, but that, where possible, the emphasis is on supporting, educating and enabling other staff to undertake the direct patient care activities (such as taking blood gases or inserting cannulas). This is echoed in discussion of future developments of ACP roles in that, if they were allowed to draw back from clinical activities the teaching and management aspects of the role would likely be developed further.
In summary, we know that ACP is not just about clinical practice, but that this often dominates the role. Clinical practice demands are limiting the extent to which we can make the most of ACP talent. From the evidence I have reviewed, this damages the potential to achieve the aspirations of the NHS People Plan, including to utilise development of ACP roles as a way to expand and develop the NHS workforce, (NHS 2022, page 42). If we do want to ACP to succeed, this particular aspect of ensuring all four pillars are entwined and given space in the work that ACPs do, will need particular attention.
Elliott N, Begley C, Sheaf G, Higgins A. 2016. Barriers and enablers to advanced practitioners’ ability to enact their leadership role: A scoping review. International J. Nurs Stud. 60:24-45.
NHS 2020. ‘We are the NHS: People Plan 2020/21, Action for us All’. [cited 2022 November 25] Available from https://www.england.nhs.uk/ournhspeople/
McConnell D, Slevin OD, McIlfatrick SJ. 2013. Emergency nurse practitioners’ perceptions of their role and scope of practice: Is it advanced practice? Int Emerg Nurs. 21(2):76-83.
Read S, Llyod Jones M, Collins K, McDonnell A, Jones R, Doyal L, Cameron A, Masterson A, Dowling S, Vaughan B, Furlong S, Scholes J. 2001. Exploring New Roles in Practice (ENRiP) Final Report. ENRiP Team July [cited 2020 May 18] Available from https://www.academia.edu/3270447/Exploring_New_Roles_in_Practice_ENRiP_