In the mixed method systematic literature review I undertook, 44 papers met the criteria for inclusion. The aim of the review was to understand what the evidence base is for claims made regarding the beneficial impact of ACP for key stakeholders in this field and discover where there are gaps in evidence for future research.
The purpose of this research was not to assess the evidence base for clinical effectiveness of ACP or benefit to the patient. From an initial search of literature it is evident that studies on clinical outcomes, (including patient satisfaction), had been conducted, often within closely defined specialist areas. These studies consistently noted at least equivalent or a positive impact of ACP on clinical effectiveness. There is consequently a limited gap in knowledge regarding clinical effectiveness and positive impact on patients of ACP that needs to be addressed whereas other potential benefits or positive impact for stakeholders of ACP is less clear.
One of the first features of existing literature regarding the benefits of ACP I found, was that there exists a large amount of opinion, discussion, or editorial based discourse on ACP and that practice, policy, or theoretical literature dominates over primary research.
In addition a large number of papers were excluded from my review due to not fitting the ‘ACP’ criteria I had set using the Multi-Professional Framework for Advanced Clinical Practice in England as a reference point. This confirms the much-cited issue that ACP definitions, scope, and the titles used, are multi-variate and may be confusing. Papers that were excluded focused on either;
- other types of training or education (e.g. pre-registration health care profession training rather than ACP),
- a particular clinical specialty (not the advanced practice that may be present within that specialty),
- specific sub-types of professional training or enhanced or specialist practice which may form a clinical part of ACP but is not ACP in its entirety (e.g. endoscopy, primary care nursing, or non-medical prescribing).
- Other job roles or stages of career, (such as pre-registration students, clinical educators, consultants or clinical specialists).
Using critical evaluation of the research I found there were a range of methods being used in ACP research. Use of a quantitative method was the least frequent and there were no randomized controlled trials within the literature found in this search. The quality varied across the range of methodologies; there was not a particular methodology that had a generally higher or lower quality than the others, with strengths and weaknesses being found across the full the range of methodologies employed. Use of a protocol or a clear plan of how the research would be conducted provides example of the variety of quality of evidence available, regardless of the methodology.
Discussion of the rationale behind the methodological choices made and how this addressed their stated aim was not always explored in the research identified. Often this was discussed in an implicit rather than explicit way, leading to assumptions being made about why the researchers may have chosen one method over another. There was a lack of longitudinal research found in this literature review, particularly since key developments in ACP have occurred, and this exposes potential opportunities for future research.
Small sample size, or a sample that captures only one particular element of the broader ACP community is a common feature in the primary research. This is acknowledged by some (but not all) when exposing bias, drawing conclusions, or setting out the rationale for undertaking this research. Some research has attempted to capture a more general theme, concept, or experience related to ACP. These typically had a larger sample size. However, it would be wrong to assume that the conclusions from these studies can be applied to all particular types, contexts, professional groups, or clinical specialities in ACP, which we know is incredibly diverse.
Whilst no date limits were placed on the literature search to ensure that any relevant insights could be gained from the historical context and longitudinal research, it should be noted that the current context of ACP may differ from the previously less evolved nature of this field of healthcare. 11 papers were published in the last 5 years, 25 in the last decade, and 19 that were 10 years or older. ACP is currently getting increased attention and there are several new initiatives and policy changes with new research and knowledge that is emerging. Only 6 papers had been published since the introduction of the Multi-professional framework for Advanced Practice; the potential impact and benefits of this may not yet have been realised or studied.
The critical evaluation of the literature in this systematic review therefore provides an emphasis on needing to take a cautious approach when selecting and relying upon existing research to establish the benefits of ACP.