This is the International Journal for Advancing Practice, but what actually does ‘advancing practice’ mean for the advancing practice community and beyond? Does it refer to the advancement or progression of practice, or does it refer to a linear approach, such as a continuum for attaining progressively higher levels of practice for registrant healthcare professionals?
Both these conceptualisations of the term advancing practice have relevance. The concept of the ‘continuum of advancing practice’ is of most relevance to the advancing practice community as it is used to describe the levels of practice along which health and care professionals from multi-professional registrant backgrounds can progress during their careers. However, alongside the continuum, advancing practice is also about health and care professionals progressing their practice to enable them to provide optimised care to patients.
What levels of practice comprise the continuum of advancing practice? These are the ‘enhanced’, ‘advanced’ and ‘consultant’ levels of practice. These levels of practice are steps on a career and workforce development pathway that starts from qualification and registration as a health and care professional. Practitioners then progressively gain the education, training and experience required to develop their knowledge, understanding and skills in roles which have a significant and positive impact on care for people, their families and carers.
In the context of the nursing, midwifery, allied health and pharmacy professions, working within the continuum of advancing practice normally refers to the approach taken for conceptualising the expert activities of health and care professionals who are mostly working directly with patients, their families and carers in clinical practice in patient-focused roles. Health and care professionals working fully in other roles, such as academics, senior leaders, managers and policy makers, will often exemplify advancing practice in either leadership and management, education, research or policy development, but not necessarily clinical practice, as they are not usually responsible for directly caring for patients. An exception would be professionals who combine their main role with clinical practice, such as clinical academics or advanced practice leads.
Enhanced level practice refers to the expertise of highly experienced and knowledgeable health and care professionals. Practitioners at this level manage specific aspects of care within a defined context, which may, at times, include whole episodes of care, depending on the nature of the service provided. In contrast, advanced practitioners oversee entire episodes of care, from initial presentation to conclusion, within complex environments. They navigate uncertainty, assess varying levels of risk, and hold accountability for their decisions.
The ‘principles of enhanced level practice’ (Health Education England, 2023) explains about enhanced level practice and the contribution made by those working in these roles towards improving services. Health and care professionals in enhanced level practice roles typically do not have job titles that include ‘enhanced’. Instead, enhanced level practice is recognised as the expertise and progression of experienced registrants working beyond their initial registration, rather than as a specifically designated role such as ‘enhanced clinical practitioner’.
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, encompassing all four pillars of advanced practice: clinical practice, leadership and management, education and research.
Advanced practice embodies the ability to manage care in partnership with individuals, families and carers. It includes the analysis and synthesis of complex problems, and management of clinical risk and uncertainty across a range of settings, enabling innovative solutions to expedite access to care, optimise people's experiences and improve outcomes. The consensus framework for advanced level practice in England is the multi-professional framework for advanced clinical practice in England (Health Education England, 2017). Similar consensus frameworks correspondingly exist for advanced practice across the other nations of the UK (Barratt, 2024). In contrast to enhanced level practice, advanced practice roles often, though not exclusively, integrate the word ‘advanced’ into job titles to recognise the engagement of the post-holders in advanced level practice.
Consultant level practice is an expert level of practice that builds on the enhanced and advanced levels of practice. Consultant level practitioners are strategic and clinical leaders of health and care systems. While advanced practitioners will have the ability to manage and take responsibility for the whole episode of a person's care, the consultant level practitioner will be able to use their expertise across care pathways and systems in ways that have maximum impact on practice, services, communities and populations, while enabling sustainable workforce capacity and capability.
The Centre for Advancing Practice's (2023a) multi-professional consultant level practice capability and impact framework sets out the capabilities that underpin consultant-level practice. It also indicates how practitioners can build on their existing practice attainment to develop into consultant-level roles, along the continuum of advancing practice (Centre for Advancing Practice, 2023b). As with enhanced and advanced practice roles, consultant-level practice is a multi-professional opportunity. However, maintaining distinct professional identities in consultant practice role titles is normally essential. This clarity ensures that patients, carers and families can easily recognise who is leading, delivering and evaluating services in collaboration with them (Crouch et al, 2024).
Entry level practice precedes the continuum of advancing practice, which refers to the level of practice that registered healthcare professionals are prepared for on completion of their initial training as nurses, midwives, allied health professionals or pharmacists. Advancing practice development is a post-registration activity that requires, at a minimum, progression beyond the newly qualified, preceptorship or foundation periods of entry-level practice. This progression allows registrants to gain experience before preparing for enhanced or advanced-level practice. Consultant level practice is typically only relevant to experienced practitioners, and those engaging in consultant level practice will have accrued significant experience as a health and care professional.
Progression from entry level practice into the levels of the continuum of advancing practice is not necessarily a linear path. Many experienced practitioners will proceed to enhanced-level practice roles and continue in those roles as the focus of their career development. Conversely, other experienced practitioners may move from an enhanced level practice role on to advanced level practice preparation.
Other experienced practitioners may move from working at the level of practice their initial registrant training has prepared them for into advanced practice trainee roles that subsequently enable them to work as advanced practitioners. In contrast, progression to consultant level practice is normally contingent on gaining significant experience in a discrete speciality area of practice, at either enhanced or advanced-level practice.
The continuum of advancing practice does not directly relate to all groups of healthcare professionals that come under statutory regulation, such as pharmacy technicians, nursing associates and other associate professions.
For these different types of healthcare professionals to progress along the continuum of advancing practice, they would first need to attain registration in their respective affiliated registrant profession.
For example, pharmacy technicians would need to additionally train and gain registration as a pharmacist by completing a full-time MPharm degree and a foundation training year to become a registered pharmacist. The nursing associate role provides a progression route to becoming a registered nurse, as preceding nursing associate training can count towards a shortened nursing degree or degree-level nurse apprenticeship.
There is a clear need for highly experienced registered health and care professionals, educated and trained at an advancing level of practice, whether that be enhanced, advanced or consultant practice. Progression along the continuum of advancing practice is not about creating a generic health and care professional (Barratt, 2022). Each clinician's distinct professional identity as a registered health and care professional—whether a nurse, midwife, allied health professional, or pharmacist—is fundamental to their practice. This identity enables them to operate at enhanced, advanced or consultant levels within their specific scope of practice, across various services and professional contexts.
While advancing practice offers positive career development opportunities for health and care professionals, the ultimate aim of engagement with the continuum of advancing practice is to expedite access to care and improve experiences and outcomes for patients and their careers and families across all health and care settings.