It is fitting that at the end of this year’s advanced practice week, that I am focussing on the topic of clinical effectiveness and patient outcomes; arguably the most important aspect of ACP.
In my systematic literature review I had in fact specifically excluded this from the search criteria as the purpose of this research was not to assess the evidence base for clinical effectiveness of ACP or benefit to the patient. This may seem perverse to exclude the most important stakeholders (service users) from this review. However from initial searches it was evident that, (necessarily to ensure validity), studies that focus on clinical outcomes including patient satisfaction were within closely defined specialist areas. In addition these studies consistently note at least equivalent or a positive impact of ACP on clinical effectiveness. The benefits to patients can be argued to already be clear from existing evidence, and research should always focus on addressing gaps in knowledge.
However, the research found in my systematic review often measured this as part of a broader focus. All papers that referred to patient outcomes confirmed that ACPs in a range of contexts have been shown to have at least similar if not better outcomes in terms of clinical effectiveness when compared to other professions or types of service such as diagnosis, reducing waiting times, improved access to services, continuity of care, treatment management and patient satisfaction. For example, reports included a perceived positive impact on patient experience, enhanced continuity of care from admission to discharge, improved patient safety, and the reassurance, confidence, and patient dignity that is provided by ACPs to those under their care.
The limitations of the research noted by the authors of these papers does though draw attention to any broader conclusions being drawn beyond the specific context in which these outcomes and measures have been evaluated. For example, the research I found commonly focussed on a particular profession, within a particular speciality, in a particular hospital, during a particular time period. This shows us how it can be done but is limited in offering external validity, (so cannot necessarily to be transferred or replicated elsewhere). It can also be noted that few studies have been undertaken longitudinally, with many stopping at pilot stage. This misses opportunity to assess impact on patient care outcomes (such as the trajectory of chronic disease) over a longer period of time.
It is also difficult to separate out the unique contribution that ACPs have made to these outcomes as they are often operating within multi-professional teams or as part of a complex set of services where other changes or developments have been made at the same time. This can of course then risk the patient care provided by advanced practitioners being overlooked or invisible (Dowling et al. 2013, p. 135).
There were also examples of where the impact of ACPs on patient outcomes and clinical effectiveness measures appeared to have been affected by the presence/ absence of barriers/ facilitators of ACP, (which I have discussed in a previous blog post).
‘True’ measures of impact on clinical effectiveness are therefore likely to be highly context specific and obscured by other factors. This, combined with the absence of formal structured and consistent audit and longitudinal measurement of outcomes of ACP makes the evidence of definitive clinical effectiveness of ACP context specific.
So what do I think this means for the evidence base of clinical effectiveness of ACP?
Well that, the impact is felt and experienced locally, and perhaps most powerfully at a person centered level. Where we do continue to seek out ways in which to evidence the significant contributions ACPs make to patient outcomes, researchers should note that the methodology and methods chosen will always need to pay careful attention to the diverse and context bound nature of Advanced Practice. Future research should also include taking a ‘long view’ now that ACPs are becoming well established.
The wealth of existing evidence that consistently notes at least equivalent or a positive impact of ACP on clinical effectiveness, should help us to move on from this question of whether ACPs are worth investing in. This was again clearly evident at the Health Education England 2022 Centre for Advancing Practice conference which presented an incredible array of impactful work that is being done by ACPs.
We should therefore now focus on how this powerful, diverse, and adaptable resource can be best employed and supported to address population health needs at a local, bespoke, and personal level.
References
Dowling, M., Beauchesne, M., Farrelly, F., Murphy, K. and (2013) ‘Advanced practice nursing: A concept analysis’, 19, pp. 131-140.
Health Education England, Centre for Advancing Practice Conference 2022, ‘Empowering People, Transforming Care’ https://heeadvancingpracticeconference.co.uk/
VJs Advanced Clinical Practice Blog 