ACP Literature Review

Sorry it’s been a while! In the last couple of years, alongside the disruption and juggling we have all been doing due to Covid-19, I have been steadily working away on my PhD. After a change of supervisors last year I have finished a systematic literature review and have now been working on gaining approval and undertaking my research (more on that in another post!).

I managed to get my systematic literature review accepted for publication, however due to Covid-19 it has never (yet) made it into print. Systematic literature reviews are a snapshot in time and so it is understandable that when there has been a gap in data collection and publication it may not seem as relevant. However they are powerful tools to make sure we don’t repeat ourselves and they can facilitate focus on the areas that have gaps that need addressing. This is certainly why I undertook the review in the way that I did, and it has been really useful in shaping my topic for my research.

I therefore thought it would be helpful to do a series of posts about the findings from my review. I hope this helps others to find a focus for their research in ACP, and please do get in touch if you want to know more detail about the research process, methodology, methods, etc that I used in my review. So watch this space…key themes from a review of existing ACP research regarding the benefits of the role from key stakeholders coming up!


Regulation of ACP- perceptions, evidence and the problems trying to be solved.

I’ve been reading the recent report that was undertaken on behalf of the HCPC regarding the review of whether to provide additional regulation of Advanced Practice for its registrants. The conclusion drawn is “there is no clear evidence, based on the findings of this research, that additional regulation of advanced level practice is needed, or desired, to protect the public”. This is despite the research revealing that 78.2% of participants believed that the HCPC should regulate ACP.  The reason for this juxtaposition of conclusions appears to come down to what has been widely reported regarding ACP; it is diverse, complex, evolving, variable.

Those that reported a support for additional regulation appeared to state the reason for this call was to address the lack of consistency widely experienced in ACP.  Variation in pay, scope of practice, training and support opportunities, education standards, access to ACP roles, as well as a lack of awareness and acceptance of the value of ACPs is undisputed. However, can and should regulation address the ‘problem’ of inconsistency and lack of recognition?

From the evidence I have found, no-one so far has been able to establish whether and what type of regulation would have a positive or negative impact on the development of ACP. Globally different countries are at varying stages of ACP development, including use of a range of regulation (Carney 2016).   The USA is often quoted as the place where ACP first developed at scale, and is known to have widespread regulation in place.  Yet, even here, there is variation between different states and a confusion of different titles and scope of practice (Heale and Reick Buckley, 2015).  There is not therefore a model we could pick off the shelf and apply to the UK, especially considering the particular health system and professional context that operates here.

This begs the question, does regulation assure consistency? If we look at the existing regulation for health care professions we can see that it does not address fully the problems we are trying to solve with ACP. For example, despite all Nurses being regulated, pay varies considerably across different sectors of the health system, with those working in the primary care, independent, or other sectors not falling under the ‘agenda for change’ standard rates of pay for particular types or levels of work. In addition, the HCPC and NMC, as the two largest UK regulatory bodies of health professionals, do not address through their current regulation whether training, support or job opportunities are equally accessible to all. This often depends much more on the resources and opportunities available at a local employer level. 

These regulatory bodies do though provide a role in setting and monitoring the over-arching standards of education in the professions they regulate. It would however, be hard to argue that Health Education England (HEE) and their Centre for Advancing Practice have not already stepped into this role for ACP. The establishment of the Multi-professional framework for advanced clinical practice in England (which mirrors the standards used in the other countries of the UK) has set the bar for expectations of ACP education programmes. The fact that HEE also hold the purse strings for commissioning ACP education means they can monitor and control what education opportunities are available. This, combined with the ACP apprenticeship standards set by the Institute for Apprenticeships and Technical Education (which maps directly to the framework) and monitored by Ofsted , appears to address the issue of knowing what to expect from an ACP education programme. These initiatives are at the early stages of implementation so time will tell if this is successful. As with all new initiatives sufficient time should be allowed for this to be evaluated before a new initiative (such as further regulation) is added.

In these times when we have been so often confronted with our ineptitude in embracing diversity, (e.g. the Black Lives Matter and LTBQI+ campaigns and health inequalities exposed by Covid-19) there is also the risk that our pursuit of homogeneity will exclude some of the ACP population. The NHS people plan notes that we need to encourage and support the development of new ways of working and innovative roles to achieve the objectives of ‘growing for the future’. We have already seen that some professions and clinical specialisms within the ACP community are more readily supported and recognised than others, which is not helped by the existence of credentialing frameworks, education programmes and accreditation processes for some, but not all of the diverse range of advanced clinical practice. Certainly regulation to date has not resolved the public confusion regarding health profession roles, including male nurses and ACPs often been called doctor and female doctors having their professional title used less often than their male counterparts.

The findings of this research is therefore enlightening, as much by what it notes needs to be researched further due to insufficient evidence, as by what it has found. We will await the outcome of the NMC and HCPC reviews for ACP. We can of course expect them to focus on its core purpose as a regulatory body, which is to protect the public and therefore undertake/ omit actions that advance this cause. So far regulatory bodies have noted there is not evidence to say the public are at higher risk by receiving care from ACPs. There is extensive research that has highlighted that the clinical effectiveness outcomes of ACPs compared to other professions (usually medical professionals) is at least as good as, if not better.

Will they stand firm and say that regulation cannot resolve the ills that are facing ACP? Will the desperate cry for equal recognition and fair access to opportunities force their hand to accept perceptions that regulation can be the knight in shining armour to save the day and be the persuasive evidence to introduce additional regulation for ACP? Will the current government stem the tide of calls for more regulation and intervene on their mission to reduce bureaucracy and de-regulate health professions? We shall see….

You can also read my commentary piece published in the British Journal of Nursing ‘Advanced Clinical Practice: Is it worth the bureaucracy?’


Reflections on Advanced Practice Week

Credentialing, confusion, communication, collaboration, and country lanes.

This month I have been reflecting on the various activities and conversations that happened in the ‘Advanced Practice Week’ that occurred between the 9th-13th November.

This included the Health Education England ‘Advancing Practice-Taking Centre Stage‘ conference, Twitter chats, Facebook queries, and making new connections with people working in this area. There was a lot that provided encouragement about advanced clinical practice.

Consensus on the place of research in ACP was clearly voiced. Supervision as a way to support ACP was welcomed. Some brilliant examples of the positive impact ACPs can make to clinical effectiveness were also shared. (For example Heather Rimmer’s service evaluation of ACP’s experiences of emergency redeployment to intensive care during Covid-19). This appears to show significant progress being made in the world of ACP. The fact that the conference had to close to offering places due to its popularity means that there is a large body of people that are engaged in ‘all things ACP’.

However, there is of course the concern that we are ‘preaching to the converted’. Those that signed up for the conference or got talking on Twitter are people that are already invested or ‘sold’ on the idea of the positive impact that ACPs can provide and are aware of the work that needs to happen to make the most of this body of health professionals. In comparison, it was interesting to see the questions that keep popping up in other forums, (e.g Facebook groups) that are populated by those that maybe on the shop floor of ACP rather than those you will see on more ‘academic or managerial forums (such as national conferences and Twitter feeds). Repeatedly questions continue to arise about what is required to be able to be recognised, gain employment, and be supported in ACP roles. This indicates the answers to these questions are not being clearly communicated or are not yet known.

In a recent on-line workshop that gathered over a thousand responses from ACPs, “concern was expressed that a degree of certainty was needed about the future of advanced clinical practitioners if professionals were to invest their time in developing their skills and qualifications and if employers were to provide their investment and planning.”   From the literature review I have recently conducted, the certainty that is being asked for here is far from being present in the current empirical evidence.  This evidence is dominated by descriptions of ACP and highlights the barriers and diversity of the ‘in practice’ reality of ACP. 

In response to the specific call made in the NHS people plan, there now appears to be a ramping up of the development of ACP credentials. As noted in one of my previous blogs, this may start to fill some gaps in the current situation of some specialisms, professional groups, or fields of practice being left out from the current patchy set of credentials already out there.

And yet… there remains calls of what about me and how far do we go? For example one participant in the ‘Taking Centre Stage’ conference asked “Credentials feels like CPD but also puts people into little boxes with fixed scope. If we have pelvic health where does this stop? Are we going to have one for every system!?”

Does this mean that a whole new industry is being created where every minutiae of clinical practice will need a credential to validate against? How sustainable is that, when we know that part of the role of ACP is to be innovative and to develop practice? The credentials we produce now are unlikely to be fit for the future in the long term. Perpetual writing and re-writing of ACP credentials could become a major industry!

Alternatively having just broad credentials to cover the main fields of practice might give the majority a place to call home. However, it is unlikely to fully reflect the complexity, intersectionality and diverse community that is ACP. This will always leave someone out that doesn’t quite fit, and will not provide the detail of knowledge, skills, capabilities, and competencies that are required to do that ACP role, in that service, in that place at that time. For this, the situatedness or localisation of ACP (as discussed by DeBont et al) remains a clear feature, and one that will need addressing at a level much closer to home between ACPs and the people they work with than a nationally produced credential could ever achieve.

And yet… people continue to ask but what about this route, or do I need to get that piece of paper, or follow that process to be able to work and be a valid ACP.

This is compounded by the different bodies that appear to be offering a route to recognition, and trying to demonstrate that their one is the best way to go. It was encouraging to hear of the promises being made regarding collaboration between these bodies to try to reach agreement about transferability. (The idea being that if you have completed a process through one, like the RCN credentialing process, this would also be recognised by the other, like the Health Education England’s accreditation, and won’t be superseded by a change made by a regulatory body such as the HCPC). However, so far nothing definite has been confirmed. The concern therefore remains that each body, who have their own personal interests (such as control of ownership of setting standards, and retaining a funding pipeline to support their work), do not really have the commitment to come to an equitable solution to this, and we may have put the cart before the horse.

So has the call for certainty to allow people to make the right decisions about their development in ACP been addressed? I think it is too early to say; there is more work to be done. My advice, to anyone that asks, is therefore to tread carefully. Look at all the options, scan the horizon, get objective advice, and weigh up the alternatives that work best for you within the resources and constraints you have. (i.e. it’s not so simple, it’s more like a network of country lanes to navigate than a nice, straight, fast, 4 lane motorway!)


ACP- Bureaucratic Blockages?

In my last blog post I asked what next? Well its been a bit busy since then in the ACP education world with the doors opening for Universities to apply for accreditation of their ACP programmes and the freshly published People Plan making specific reference to CPD and ACP. One of the largest regulators of health care professionals in the UK (the HCPC) has signalled their intention to look again at the evidence for potential regulation of ACP. And we’ve also had NHS workers (including ACPs) excluded from the pay rises given to other public workers in the aftermath of the C-19 crisis. The people plan notes as one of its key messages that bureaucracy falling away in this time has helped people to feel empowered to do what is needed. So is this context reflective of the ACP experience? Have bureaucratic blockages been removed to allow ACP to be implemented effectively? I’m not sure it has.

In my last post I gave an example of how I witnessed first hand an ACP work really effectively and in more extensive and expert ways than even she realised. However I am not sure if this was because the barriers that may have previously been in her way had thoughtfully and systematically been removed due to policy change. Was it just necessity as there was no-one there to tell her otherwise, and would her position and scope of practice that she was ‘awarded’ in this time be sustained? I would like to think so.

Covid-19 has forced, nudged, or more generously, allowed us to operate in different ways than we had before. But the hard work now may be to effectively evaluate whether this was a positive change, and if so how this can be sustained.

I’ve been reading a lot of research on ACP, where….

1. we know what benefit ACPs can bring

2. we know the principles of how to effectively implement ACPs

3. we also know the barriers that prevent ACPs working well

….but…….the barriers are still there and there is still evidence of ACPs being prevented from achieving their full potential.

The principle of removing barriers, (particularly bureaucratic ones which arguably are there not for any sound justification) is a good one. In ACP this could be ensuring people have equal and easy access to CPD, supervision and protected time for training. It could be ensuring people that may stand in the way of ACP development, potentially out of an undue sense of needing to protect a profession are ‘enlightened’ to the merits of supporting ACP development. It could also be making sure people are given the recognition and remit to do the work they have the knowledge and skills to do by creating jobs, teams, clinical pathways to allow this to happen. This all sounds good, right, what’s needed.

What I’m not sure of is how some of the recent changes in policy, context or practice help us to get there.

Equal, easy access to CPD with protected time for training requires backfill, as the People Plan highlights. Do we have the skilled workforce and the money currently to do facilitate this? A large amount of the media such as the recent RCN report of staff shortages questions this. My own experience is that working through NHSP to continue to support colleagues in ITU past the peak of Covid, has been stopped due to financial concerns of agency staff costs. But this is still whilst they are facing staff shortages due to sickness, sheilding or self-isolation, and the ‘normal’ work of ITU ramps again.

Ensuring colleagues understand the merits of ACP and the full scope they can offer so they become a facilitator rather than a barrier may go either way. It could be that the crisis way of working has opened people’s eyes and with renewed vigour we can embed more formally the ACP role in our services. Or it could be that as things return back to more routine work, the ‘re-deployed’ are returned back to their original boxes.

Recognition can happen in many ways. A clap on a Thursday was nice whilst it lasted but appears to have turned sour and momentary, spurring many on to campaign for such gestures to turn into something of more solid value. Will the accreditation of ACP programmes provide that recognition? From someone going through the paperwork required for this process, I am conflicted as to whether this is just another bureaucratic barrier for ACPs to pass through or whether it may actually remove a barrier by facilitating national recognition against a set of ‘guaranteed’ standards. The HCPC makes the promise that any measures taken as a result of their current investigations regarding additional regulation of ACP “should enable, and never restrict or serve as a barrier, to effective development of registrants advancing their practice.” Will this translate into creation of more ACP jobs?

The people plan refers to 400 extra ACPs in training but not whether this will translate into new positions and whether that is enough for what is needed and to recognise the potentially large number of people that are/ can work at ACP level?

So I’m left feeling there’s lots of aspiration here. We have the basis on knowing what ACPs are and what they can offer. We also know the things that may help or hinder that progress. But is this just full of promises without the opportunity and right ingredients to make it happen? As with many right now I waver between optimism and pessimism but ultimately a lot of hope that there is enough energy left for us to overcome the barriers, bureaucratic or not.


Advanced Clinical Practice- where next?

I want to start this latest blog post with an apology for the hiatus. As many of us have got used to hearing over the last few months a little thing called Covid got in the way a bit! I ended my last post with the question ACP-where next? So I thought it would be helpful to say what I’ve been up to since the last post and where I think this leads us to next.

Back at the end of March the opportunity for me to return to clinical practice as a Critical Care Nurse presented itself in the form of the ‘Covid crisis’. Whilst this meant that I was somewhat distracted from my plans for this blog it did afford me a unique insight to witness first hand ACPs in action. For me, this provided perfect illustration of what I’ve been reading, learning and thinking about ACP.

After 18 years away from the ‘front-line’ of clinical practice I found myself working one day with a critical care nurse, (I’ll call her ‘Amy’), that had been in the midst of her ACP training when C-19 hit. What I witnessed was a true epitome of the 4 pillars of ACP in action (clinical practice, education, leadership and research).

She became an excellent educator to the (obviously nervous) redeployed staff; something she would never have thought she would need to do so extensively. Staff frequently looked to her to provide leadership in unfamiliar, unprecedented, and scary times. She expertly provided this with clear and supportive instructions and decisions. In coffee room debates of ‘what’s new about Covid-19’ she often was able to refer to an evidence base to support what she was saying, to dispel myths, and propose areas that were uncertain and would likely feature in future research or evidence to come out of this time.

However she also talked to me about her worry that her training had been suspended and that she was trying to think of different ways to meet the (highly demanding) list of clinical competency assessments required. Being in critical care she is in one of the few groups where a set of credentials have been set down to be able to be recognised and practice as an ACP in this field (FICM).

What struck me was that she was so focussed on the clinical competencies and so nervous about getting these right, and was worried about missing opportunities to practice and be assessed in them, that she was perhaps ignoring how she was brilliantly demonstrating what it means to be the true embodiment of an ACP!

I just wanted to say don’t worry, those clinical tasks will come, there will be opportunity for that, and over time new ones will be needed and other ones assigned to the discard pile. What you are doing now is astounding development as an ACP with knowledge, skills and experience that will last you a life time.

We also talked about the potential barriers the future holds for her to utilise the full range of her ACP role. During this time I have also been completing a scoping review of the evidence of the benefits of ACP education, and unfortunately this is a fear that has got significant foundation to it. Clinical practice tends to dominate ACP work and factors such as the way in which ACP roles are organised and developed, and the willingness of colleagues to relinquish tasks and offer autonomy to ACPs can restrict their practice.

This experience and my findings from the scoping review are leading me to think more than ever ‘what’s next for ACP?’

What is clear is that we do not need to repeat the multitude of studies that defines or sets out the potential scope of ACP. The barriers and facilitators to effective development and implementation of ACP are well known. The positive impact that ACPs can have on clinical effectiveness outcomes, including patient satisfaction and measures such as reduced waiting times has been evidenced. The impact on costs depends on whether ACPs are being used to substitute for others (usually Doctors) or provide a supplementary service and ‘add value’, which has often not been measured over long enough to really evaluate the impact. (The OECD working paper on Nursing in Advanced Roles provides a useful summary and exploration of these themes).

What is less clear is where people like the ACP trainee I worked with are heading next. Will they be able to realise the various benefits that I talked about in my first blog post, such as remedying staff shortages, or providing a satisfying career development route for our most skilled, experienced and advanced practitioners in health care?

The recent on-line HEE Advanced Practice workshop held to gather experiences of ACP in this pandemic may help to signal what we can expect from ACPs in such times or in the ‘new normal’ we are all adapting to.

Now the first peak of C-19 appears to have subsided in my part of the world, I am turning my attention back to my research and work as an educator in ACP.

I am still not sure what is next for ACPs, but believe from my research, work, and experiences so far that attention needs to be paid to evidencing the purported benefits of ACPs for those that are interested in/ being encouraged to follow this career route. If people like Amy are to fully realise her potential and the health service is to benefit fully from people like her we need to assure her that she is following the right path. So this questions… is ACP the way to go?…I’ll leave that question to explored in a future blog.

Domination of Clinical Practice in ACP

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_

Substitution/ Supplementation in ACP

A major feature I found in my systematic literature review regarding the benefits of Advanced Clinical Practice related to whether the definition, nomenclature, and scope of the ACP role is a substitution or a supplementation.

This is where ACPs are either employed to take on the work normally or previously performed by others (e.g. junior doctors) thus “freeing them up to concentrate on other elements of care” (McDonnell et al., 2014, p. 794), or if they hold their own case load within a service which may previously have not existed or was fragmented across a number of services or role holders (e.g. outreach or care co-ordinators). This can be categorised as role extension (substitution) or role expansion (supplementation).

Substitution/ supplementation is a common feature in terms of the impetus for development and thereby the definition and scope that is afforded to ACPs. Several authors noted that a main driver for development of ACP roles has been due to a shortage of doctors or where policy change, such as the imposition of a restriction on junior doctors hours, or a requirement to reduce waiting lists has affected the supply of medical professionals. 

A significant number of ACP roles, at least in their development and early stages of implementation, have been aimed at substitution.  However, there is evidence that whilst the impetus may have been to address the shortage of doctors, there had actually been no reduction in the number of medical posts. This may be due to increasing demands on the service, but also the reluctance of medical staff to accept ACPs had the skills to cover them, (a commonly identified barrier to ACP).

There is also evidence that whilst substitution often has provided an impetus for creating ACP roles, once in place ACPs are then well positioned to develop supplementary or ‘added value’ services and drive the evolution of these roles. These new services are aimed at promoting high quality care or responding to changing demands on health care systems, and filling gaps in services that need addressing. This could be described as a type of re-engineering that shifts the focus to patient centred rather than profession centered services and care, using case management and multi-disciplinary approaches.

Delamaire and Lafortune (2010) draw attention to hierarchical and non-hierarchical forms of ACP where the degrees to which ACPs are substituting and are supervised by doctors may have an impact on the extent they are able to operate as autonomous practitioners. The extent of autonomy further influences how much ACPs draw, to a lesser or greater extent, on their own professional background, theoretical frameworks, knowledge and skills rather than purely using the ‘medical model’. This has an impact on whether re-engineering of services which involves innovative ideas about changing professional roles and shifts the focus to patient centred care can take place. The evidence from my literature review demonstrated that where substitution is in place this can lead to fragmentation of care , lack of clarity and autonomy in roles and lines of responsibility, and can trigger others feeling disempowered or may risk the loss of skills of those substituted over time.

An example of this is my experience of when Critical Care Outreach roles were first implemented. A key aspect to the success of their role was to upskill and support ward based staff. They were not there just to swoop in when a patient is deteriorating to provide medical interventions and swoop out again when they are stable without providing safety netting, advice, training, and support to staff close to the patient to continue their care and avoid further episodes of deterioration, (as perhaps had happened previously when relying purely on resuscitation teams to deal with potentially terminal crisis events). This led to the concept of ‘Critical Care Without Walls’ where advanced practitioners were specifically employed to bridge the gap between the geographic location of the patient and the critical care unit to provide coordination and continuity of care for the deteriorating and recovering critically ill patient.

This brings us back to the topic of localisation in ACP and how the local relationships, practice, attitudes, and policies plays a crucial role of reallocation of tasks (i.e. in substitution roles). Case studies and narratives from ACPs experiences reveal that “legally assigned clinical activities sometimes cannot be carried out due to restrictive local arrangements” and this can lead to ACPs not being able to practice their full scope of competence (De Bont et al., 2016, p. 8).  This view is supported by a number of authors in noting that where ACPs were bought in to ‘fill gaps’ their scope of practice becomes limited to clinical tasks.  This can impact on costs, and the measurable outcomes achieved by ACPs.

Delamaire and Lafortune (2010) note that where the ACP role is used as a substitution for others, it has been shown to be equivalent to or produce a reduction in costs (although commonly the full costs have not been included such as costs of education). Where ACPs are used to provide a supplementary or ‘adding value’ service, costs are shown to increase, (but again commonly the long-term costs have not been fully evaluated such as effects on preventing future hospitalisation or enhancing continuity of care).  

However, this broad assumption relies on a number of factors which may tip the scale of cost evaluation either way. For example, ACPs may be paid less than doctors (depending on their grade) but may also provide an enhanced or ‘added value’ service which allows them to spend a greater amount of time with patients. This may still require some supervision from doctors for this ‘added value service’ and, over time, may cost the equivalent or more than the ‘standard’, time-restricted, service that would have been delivered if ACPs had not replaced doctors in this part of the clinical pathway. This, combined with variety of education routes (and thereby costs to supply training and education to ACPs) makes drawing any broad conclusions about cost of ACP in the UK difficult.

It would of course be perverse to want cost reduction to be the only or primary outcome measure in healthcare, where positive clinical outcomes are the more desirable, standard, and required outcome measure that is expected.

From the evaluation of literature, it can be argued that substitution roles are not well placed to facilitate the full remit of ACP and to maximise the benefit that can be gained from effective employment of these roles which requires that this includes, but also goes beyond, operation of clinical tasks. We may need to accept that substitution has often been a starting point, but supplementation and adding value should always be the goal. If this can be baked in from the beginning of ACP role development the opportunity to “harness the brilliance” of ACPs can be achieved. [Quote from Deborah Harding at the 2022 Centre for Advancing Practice ‘Empowering People, Transforming Care’ conference].


De Bont, A., Van Exel, J., Coretti, S., Güldem Ökem, Z., Janssen, M., Lofthus Hope, K., Ludwicki, T., Zander, B., Zvonickova, M., Bond, C. and Wallenburg, I. (2016) ‘Reconfiguring health workforce: a case-based comparative study explaining the increasingly diverse professional roles in Europe’, 16, pp. 1-14.

Delamaire, M.-L. and Lafortune, G. (2010) ‘Nurses in Advanced Roles: A Description and Evaluation of Experiences in 12 Developed Countries’.

McDonnell, A., Goodwin, E., Kennedy, F., Hawley, K., Gerrish, K., Smith, C. and (2014) ‘An evaluation of the implementation of Advanced Nurse Practitioner (ANP) roles in an acute hospital setting’, 71, pp. 789-799.

Advanced Clinical Practice; Patient Outcomes & Clinical Effectiveness

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.


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/

ACP Education pathways, regulation & education methodologies

In this blog I will explore the key themes I identified in my systematic literature review on the benefits of the Advanced Clinical Practice for key stakeholders in relation to education and regulation.

15 of the 26 papers that had a theme of education within them, noted that there are a variety of education pathways ACPs have taken to be working in their current role, including formal, and ‘non-formal’ training, UG, PG, and Doctoral study.  This concurs with the results of my recent survey as part of recruitment to my latest research project where 41% had achieved an academic qualification in ACP, 23% had received on the job training and only 4% had undertaken a credentialing programme. This variation has been identified as a potential barrier to effective implementation of ACP; creating confusion and lack of a clear career pathway for ACPs and their employers, and is linked by some authors to the lack of regulation structures for ACP.

There appears to be agreement that regulation may be a way to reduce variation and confusion over career pathways for ACPs. It is suggested that in countries where there is less developed regulation, the presence of barriers are higher. However the data to corroborate this statement is not presented in the research, only data that confirms that variation exists is presented.  Conversely, others point to the lack of regulation in the UK as facilitating adaptation to the scope of practice which enables ACP roles to be effectively implemented at a local level. However again, this was not directly measured in the research data presented.  I found limited evidence of directly researching different types of regulation and the impact this has on effective ACP, other than evidence based upon self-report surveys of a subset of organisations linked to nursing only organisations in some countries.  The literature I found presents what regulation is present, but does not measure which may be more or less effective, particularly in the diverse, contemporaneous, UK ACP context.

Thus far regulatory bodies appear to have rejected the idea of adding a new level or type of regulation for their ACP members because of the belief that their regulation already covers practitioners to develop along a continuum, including advanced practice.  This stance was endorsed by the Council for Healthcare Regulatory Excellence in 2009. The Nursing and Midwifery Council’s (NMC) review in 2019 however noted the repeated calls for regulation of ACP and highlighted an opportunity to draw together the “patchwork of education” and rationalise it under the leadership of the regulator. (Noting that a new standard for post-registration education in SCPHN and SPQ, has now been produced, NMC, 2022). The work conducted by Leary et al 2017 which more broadly looked at titles used within nursing found proliferation, inconsistency, and poor clarity which they concluded could be attributed, at least in part, to lack of regulation. 

However, ACP is multi-professional and there continues to be no national regulation of ACP . The somewhat newer introduction of ‘credentialling’ as an effort toward standardisation, remains patchy.  There is insufficient longitudinal evidence found in my review that directly assesses whether regulation is a barrier or facilitator specifically of ACP, or what types and degrees of regulation may be more or less effective in realising the benefits of ACP.  Further research that particularly focuses on the impact of changes to regulation or standardisation of ACP may provide evidence to support or reject changes to regulation. (For example research that investigates the impact of the work being undertaken by the Centre for Advancing Practice and ACP accreditation by Health Education England (2022), or the independent research conducted by Hardy et al 2021 to explore issues of ACP regulation in the allied health professions as part of a review by the Health and Care Professions Council).  

Similarly evidence has not been established that one form of education and training better equips the ACP for their role. It is proposed however that the form of training and education undertaken by ACPs may have an influence on their ability to provide, & support others in providing, evidence based practice, critical thinking, decision making and professional identity, and leadership. There is a self-reported perception that certain types of training/ education preparation (Masters study) provides personal benefits including opportunities for service improvement and that it enhances confidence, autonomy, and external authority. There is broad consensus that ACP preparation should be at Masters level, although there is also recognition that in the UK a number of routes continue to exist.

Hughes et al. (2017) included a Training Needs Analysis in their study of pharmacist ACPs in which 4 main themes were identified as needed to carry out the ACP role;

  • clinical examination and assessment,
  • diagnostic skills,
  • medical management and treatment, and
  • specialist training course components (e.g. radiology or minor injuries). 

Whilst the Hughes et al. (2017) study focussed on assessing if ACPs could effectively manage a clinical case load within an emergency department, it is interesting to note that other aspects of training such as in leadership, policy development, or research and evidence based practice were not identified as significant or valued by ACPs in this study. This is contrary to the position of requiring a Masters level qualification noted by many of the papers, and one that does not align to the Multi-Professional framework which necessarily entails training in a broader range of knowledge and skills than those focussed purely on clinical practice.

Some types of education methods within ACP training programmes have been tested for their effectivity on achieving their stated aims or purpose, (including simulated video OSCEs, coaching, gamification, action learning sets). There was potential for bias in these studies, and it was noted that there exists variation in the quality of ACP training and education programmes, (particularly in relation to their relevance for specific fields of clinical practice). However, in general, these were seen as useful and effective education strategies for ACP. The use of distance learning and alternative forms of delivery are recommended for further investigation in relation to their effectiveness as more ‘traditional’ options can be costly, inconvenient, and not sustainable. The wide uptake and cultural shift in utilising technology and other forms of education delivery and interaction in the Covid-19 pandemic presents a good opportunity for this to be investigated. Evidence is though limited in terms of measuring long term outcomes and application of ACP education approaches to contemporary contexts in which ACPs practice.

So the key themes here seem to be variation, a desire for standardisation, and uncertainty as to how best to address this, especially noting the need to address the four pillars of ACP, and the diverse range of ways and fields in which ACPs practice.


Council for Healthcare Regulatory Excellence (2009) “Advanced Practice: Report to the Four UK Health Department” [cited 19th February 2020] Available from https://www.professionalstandards.org.uk/docs/default-source/publications/advice-to-ministers/advanced-practice-2009.pdf?sfvrsn=38c67f20_6

Hardy M, Snaith B, Edwards L, Baxter J, Millington P, Harris M, 2021.  Advanced Practice: Research Report. Health and Care Professions Council [cited 2021 January 27] Available from https://www.hcpc-uk.org/cy-gb/adnoddau/policy/advanced-practice-full-research-report/

Health Education England, (2022). ‘Programme Accreditation’. [cited 2022 November 4] Available from https://advanced-practice.hee.nhs.uk/our-work/programme-accreditation/

Hughes, E., Terry, D., Huynh, C., Petridis, K., Aiello, M., Mazard, L., Ubhi, H., Terry, A., Wilson, K. and Sinclair, A. (2017) ‘Future enhanced clinical role of pharmacists in Emergency Departments in England: multi-site observational evaluation’, Int J Clin Pharm, 39(4), pp. 960-968.

Leary A, Maclaine A, Trevatt P, Radford M, Punshon G, 2017.  Variation in job titles in the nursing workforce. J Clin Nurs. 26:4945-4950

Nursing and Midwifery Council (2019) ‘Evaluation of post-registration standards of proficiency for specialist community public health nurses and the standards for specialist education and practice standards’.  [cited 2020 February 19] Available from https://www.nmc.org.uk/globalassets/sitedocuments/education-programme/evaluation-post-registration-scphn-and-spq-standards.pdf

Nursing and Midwifery Council (2022) ‘Part 3- Standards for Post-Registration Programmes’. [cited 2022 November 4 ] Available from https://www.nmc.org.uk/standards/standards-for-post-registration/standards-for-post-registration-programmes/

Barriers/ Facilitators of Advanced Clinical Practice

Over half of the papers included findings from my literature review on the benefits of ACP related to the identification of barriers or facilitators of implementing effective advanced clinical practice or advanced clinical practitioner roles.

Several of the papers focussed research on a specific context (e.g. specialty, geographic area or professional group), however the findings identified potential barriers/ facilitators that could be applied in other contexts where ACP occurs or is being developed or introduced. The range and currency of many of the papers appears to also provide consensus that despite knowing about the barriers to effective implementation of ACP, they are still prevalent, and the facilitators are often not considered when planning development of an ACP role. 

The barriers and facilitators of ACP broadly fit under the themes below:

  • Access to training and education
  • Support from others for role expansion
  • Organisational structure, policy and protocols

Access to training & education

Some of the literature highlights the ‘adhoc’ way in which ACP roles have developed and that this has created a “confusing overlap” in many areas. The literature also makes claim that a lack of consistency in training and education (both in what is offered and how it is accessed) has hindered efforts to make full use of ACPs in health care. 

A number of papers also highlight that there is a need for sufficient availability of appropriate interprofessional and financially viable education and training to provide the skills necessary to fill ACP posts. Without this it acts as a barrier to development and implementation of effective ACPs. 

Inadequate protected time for education is commonly identified as a barrier and is often related to one of the other major findings of my literature review; that clinical practice dominates the role and the time allocated to duties/ tasks within this role. It was commonly reported that clinical demands took priority and that opportunities for development and education were missed if a clinical task was needed. 

Support from others for role expansion

In a range of studies medical staff were the major professional group that had a significant impact on the development, implementation, level of autonomy, management, and operation of the ACP role.  There is discussion in the literature of the need to ‘win round’ physicians if the role was to be considered as a worthwhile endeavour, to remove anxiety of ACPs ‘taking over’ and undermining their role, and to attract the funding and managerial or organisational structures to facilitate the role. 

Where support was not in place ACPs often found they were unable to operate the full extent of the role and utilise the knowledge, experience, and skills they had gained. Significantly this was correlated with a lack of engagement in managerial or leadership functions of the role, including development of policy.

The perception and understanding of the role, particularly by physicians and employers, was discussed as having a major influence on how, what, and where ACP roles were developed.  This reflects the ‘localisation’ of ACP, which, as noted in my previous blog post, has an impact on the definition, nomenclature, and scope of ACPs. This occurs even in situations where specific policy or protocols were in place to ensure consistency.

Personal relationships can be key and may require a long time to build up; ‘trust’ is required between professions to allow the sharing, re-allocation or shaping of health care services, roles, and tasks.  The personal attributes of the ACP also has an impact here, with perceptions of ACPs that hold desirable attributes such as confidence being more likely to gain trust. The presence of a role model, mentor or support from senior managers, combined with opportunities to receive feedback or engage with a peer network were powerful enablers of the role.  

However, the reliance on support from others makes the ACP role precarious. It requires professional relationships built up over time and if a supportive member of staff leaves, the ACP role may not be able to continue to develop or operate as it had done before.

Organisational structure, policy and protocols

Familiarity within an organisation and ‘localisation’ extends even in situations where national, professional, or organisational level policy is in place. Local arrangements may restrict ACPs from undertaking their full range of the role and the skills they hold. This includes protocols that define the path of clinical intervention, including what tasks are undertaken by whom, which may limit the development of these roles and ‘lock’ people into their current employer.

The impetus for the development of the role is seen as significant in providing the organisational structure in which ACPs operate and it is highlighted that when ACPs have been bought in to ‘fill the gaps’, this can impact the scope of their role. For example, advances in medical knowledge, clinical interventions, and technological advancement, especially in management of chronic illness, may create a need for roles that organise the various aspects of care required in this complex context. ACPs as a ‘generic’ rather than a specialist role can “fill up the space between the specialised practitioners, guiding the patient through the treatment trajectory”.  De Bont et al. (2016, p. 11). In this organisational structure the ACP can therefore be seen as adding value in terms of promoting continuity of care through complex systems, services, and disease trajectories. 

Funding mechanisms that support particular organisational structures (such as group GP practices and sharing of ACPs) may also provide an impetus (or disincentive) to support the ACP role. On a more functional level, the lack of access to administrative support funding, and resources for data management may affect the fulfilment of the role, particularly in leadership aspects. This also links to a lack of authority and position within an organisation because ACPs often sit outside of traditional hierarchical and committee structures, which impedes their influence on strategic decision making.

The need for clear communication of role definitions, job descriptions, and boundaries to reach consensus on expectations and facilitate transition into ACP roles is highlighted. The lack of clear agreement and communication of the career pathway for ACPs within the current or traditional organisational structure is noted as a potential barrier, with the risk that ACP is seen as a ‘dead end job’ or a ‘career cul-de-sac’. The lack of engagement with, or opportunity for non-clinical aspects of the role (leadership, education, research) may reinforce this, with few options for these health professionals in an organisation to progress in a clinically dominated career. Although the more recent development of the framework for consultant level practice may prove to overcome this to some extent (if similar barriers and facilitators as experienced within ACP are addressed).


There is broad consensus on the barriers and facilitators that by their presence/ absence affect full realisation of the potential benefits of ACPs, effective implementation, or measurable positive impact on outcomes. If we want ACP to be successful we do therefore need to address these, share best practice, and not repeat mistakes of the past.

Reference: de Bont A, van Exel J, Coretti S, Ökem ZG, Janssen M, Hope KL, Ludwicki T, Zander, B, Zvonickova M, Bond C, Wallenburg. 2016. Reconfiguring health workforce: a case-based comparative study explaining the increasingly diverse professional roles in Europe. BMC Health Services Res. 16:637.

Definitions of ACP, nomenclature & scope

Defining what we mean by ACP seems a good place to start when looking at existing evidence regarding ACP. In my systematic literature 30 out of the 44 papers included findings related to the definition of ACP, nomenclature used when referring to ACP roles and titles, and the scope of the ACP role or practice.  All noted that there continues to be a proliferation of nomenclature/ titles used to describe ACP and ACP roles.  However, what emerges is a broad consensus on the definition, conceptual models, and features of Advanced Clinical Practice across different professional, clinical speciality, health service and geographical contexts. 

These commonly reflect the 4 pillars, (Research, Education, Leadership and Clinical Practice), knowledge, skills and attributes, (capabilities including education and experience) and context (workforce and governance and accountability) as set out in the Multi-Professional Framework for ACP in England.

Some alternative conceptual models are presented which provide a ‘finer-grading’ of the definition and scope of ACP which do reflect the existing ‘4 pillar’ framework but also draw particular attention to aspects, such as the administration features of the role, that may not be as overtly described elsewhere. Other models proposed give some variation from the more simplified ‘4 pillars’ framework which can be seen as a set of tasks to ‘tick off’ to fit the definition of an ACP. These include recognition of the integrated subroles, skills and processes, contextual pre-requisites and outcomes of ACP and the significance of autonomy and clinical expertise as central attributes. Alternatively a continuum of predominately clinical orientation to predominately managerial orientation for innovative nursing roles is proposed, with ACPs working at some point on this continuum. However, this can often overlap with other roles (such as clinical nurse specialists) and so is not clearly defined.

Some papers focussed on developing a snapshot of the current status of ACP. These tended to only provide a picture of ACP within a sub-set under the broader definition of ACP by focussing on:

  • a particular profession, (although research that focussed on or included professions other than nursing was rare; only 9 out of the 44 papers included non-nurses in their sample). 
  • geographical area or particular service
  • clinical specialty
  • one of the 4 pillars of ACP

From the papers I reviewed the scope of ACPs does vary to some extent and this is influenced by a number of factors including the original purpose for developing the role, regulation boundaries on scope, education preparation, organisational context in which the ACP operates, origins or purpose of the role and personal attributes of role holders. This leads to ‘localisation’ of ACP which then impacts on the ‘professional jurisdiction’ and scope of practice for ACPs.

International comparative studies highlight that despite the varied definitions, nomenclature, scope and regulation globally, ACP continues to be increasing and developing in a range of health care settings.

In conclusion existing research shows that ACP is diverse and growing. The definition of ACP broadly coalesces around the four pillars of clinical practice, education, leadership/ management and research. However there is a powerful element of localisation in the way ACP is operationalised and experienced.

Features of existing ACP research.

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.