Advanced clinical practitioners (ACPs) practice within a dynamic field characterised by high levels of autonomy, advanced clinical skills and critical decisionmaking responsibilities (Crouch et al, 2024). As advancing practice continues to gain recognition and prominence in healthcare systems worldwide, it is increasingly important to advance research, one of the four pillars of advancing practice (Health Education England (HEE), 2017). Fostering philosophical perspectives is vital for ACPs, as it promotes critical reflection, strengthens clinical decision making, enables holistic care and sparks innovation (Wilson et al, 2015). Furthermore, such perspectives facilitate a strong professional identity and role clarity (Webb, 2017). This process promotes self-awareness, aligns practitioners' values with their professional roles and clarifies their purpose within the healthcare system. As practitioners critically evaluate their practice through the lens of different philosophical perspectives, they gain empowerment, confidence and recognition of professional boundaries (Alsararatee, 2024). Integrating personal beliefs with professional identity enhances authenticity and coherence, ultimately contributing to a strong sense of professional identity and role clarity among practitioners. This article provides a comprehensive examination of ontological and epistemological approaches relevant to advanced clinical practice. Central to this exploration is how ACPs conceptualise, generate, interpret and apply knowledge in clinical settings.
Ontological foundations for advanced clinical practitioners
Ontology, the branch of philosophy dealing with the nature of existence, provides the conceptual framework for understanding reality and the nature of being (Berryman, 2019). Within the realm of advancing practice, practitioners encounter diverse ontological perspectives that shape their understanding of health, illness and the patient-clinician relationship (Nasution, 2018). Various philosophical perspectives offer clear ontological frameworks to comprehend reality and existence (Abadia and Porr, 2021). Positivism, rooted in empirical evidence and objective truths, has a strong and established presence in healthcare systems (Maksimovic and Evtimov, 2023). It heavily influences the accepted hierarchy of evidence, with systematic reviews and randomised controlled trials often placed at the pinnacle. While this approach has undoubtedly contributed to advancements in evidence-based practice, ACPs should also be mindful of its potential limitations. An over-reliance on positivist approaches can sometimes inadvertently minimise the value of qualitative research methods and the rich insights they can provide into patients' subjective experiences and the complexities of clinical practice. In contrast, post-positivism acknowledges the role of human interpretation and the fallibility of objective knowledge (Tripathi et al, 2024), encouraging ACPs to critically engage with research findings and consider multiple perspectives. Interpretivism and constructivism highlight the subjective nature of reality, urging ACPs to prioritise patient-centred care and qualitative research methods to uncover the contextual nuances of clinical practice (Clark, 2018). Additionally, pragmatism advocates for the integration of diverse ontological perspectives, empowering ACPs to leverage both quantitative and qualitative approaches in pursuit of pragmatic solutions to clinical challenges (Kelly and Cordeiro, 2020).
However, critical realist ontology suggests that realities are socially constructed entities subject to constant internal influence, urging ACPs to critically assess prevailing assumptions about health and illness within societal frameworks.
Epistemological foundations for advanced clinical practitioners
Epistemology, the branch of philosophy concerned with the nature and scope of knowledge, examines how knowledge is acquired, justified and applied (Scudellari et al, 2018). Different epistemological perspectives shape the ways in which ACPs and researchers approach the generation and interpretation of knowledge (Wyer and Loughlin, 2020). There are five epistemological paradigms that offer distinct perspectives on how knowledge is acquired, justified and applied. Positivism advocates for the use of empirical evidence and scientific methods to establish objective truths (Park et al, 2020). Positivist approaches in advanced clinical practice prioritise randomised controlled trials and systematic reviews as the gold standard for evidence-based practice. Post-positivism extends beyond positivism by recognising the limitations of objective knowledge and the influence of human subjectivity on the research process (Nasution, 2018). It acknowledges that while scientific inquiry is inherently influenced by the researcher's biases and perspectives. Post-positivism emphasises the importance of critical thinking and reflexivity in research, recognising that knowledge is provisional and subject to revision based on new evidence and interpretations. However, interpretivism/constructivism emphasises the subjective interpretation of phenomena and the importance of understanding context and meaning in research and practice (Ataro, 2019). It values qualitative research methods such as interviews, focus groups and ethnography. Interpretivist perspectives in advanced clinical practice seek to explore the complexities of clinical practice from multiple perspectives. Pragmatism acknowledges the practical utility of knowledge and focuses on the application of theories and concepts to real-world problems (Kelly and Cordeiro, 2020). It emphasises the importance of incorporating multiple perspectives and methodologies to address complex issues in healthcare. From a critical realist epistemological perspective, reality and knowledge are viewed as socially constructed and influenced by power dynamics inherent in society, empowering ACPs to challenge dominant knowledge structures and advocate for more inclusive and equitable healthcare practices.
Integration of ontological and epistemological approaches in advanced clinical practice
Recognising the interplay between ontological and epistemological perspectives is essential for navigating the complexities of advanced clinical practice. Ontology can help define the research framework, while epistemology can determine the research question (Al-Ababneh, 2020). Integration of diverse philosophical perspectives allows practitioners to approach clinical challenges from multiple angles. By integrating ontological and epistemological approaches, advanced clinical practitioners can adopt a multidimensional lens through which they view patient care. For instance, an interpretivist approach to chronic pain management is grounded in the ontological belief that pain is a complex, subjective experience uniquely shaped by an individual's context. An epistemological standpoint values knowledge gained through deep exploration of the patient's lived experience, their narrative of suffering and the personal meanings they attach to their condition. Through in-depth interviews and phenomenological analysis, practitioners gain insight into the patient's unique understanding of pain. This knowledge then informs all aspects of care, including understanding treatment preferences, tailoring communication and fostering shared decision making that aligns with the patient's values and context.
Moreover, the integration of ontological and epistemological perspectives can inform clinical decision making and practice guidelines (Thomas et al, 2020). By synthesising evidence from both quantitative (informed by positivist epistemology) and qualitative research (informed by interpretivist epistemology), ACPs can develop more nuanced and contextually relevant interventions. Challenges may arise in reconciling conflicting ontological and epistemological frameworks, particularly in interdisciplinary settings where practitioners with different philosophical orientations collaborate. However, embracing pluralism and reflexivity can facilitate dialogue and collaboration among practitioners and researchers. By fostering an environment of open-mindedness and intellectual curiosity, advanced clinical practice can harness the strengths of diverse philosophical approaches while mitigating potential conflicts. To understand the ontological and epistemological approaches through an ACP's perspective and how it impacts the four pillars of advancing practice, consider the case of a patient who presented to emergency care with breathlessness (Table 1). Table 2 summarises the research paradigms and their influence on four pillars of advanced practice and patient care.
| Ontology | Epistemology | Pillar | Explanation |
|---|---|---|---|
| Realism | Positivism | Clinical practice | Recognising breathlessness as an objective physiological phenomenon, using empirical evidence for objective assessment and management |
| Realism | Positivism | Leadership | Applying evidence-based approaches for effective breathlessness management |
| Realism | Positivism | Education | Educating with evidence-based methods to ensure accurate understanding and management |
| Realism | Positivism | Research | Conducting studies using empirical evidence to advance evidence-based practice |
| Constructionism | Interpretivism | Clinical practice | Recognising breathlessness as a socially constructed phenomenon, with an emphasis on understanding the patient's subjective experiences to provide personalised care |
| Constructionism | Interpretivism | Leadership | Leading teams by recognising diverse patient experiences and fostering empathetic communication for collaborative care |
| Constructionism | Interpretivism | Education | Educating by acknowledging patient perspectives and tailoring educational approaches |
| Constructionism | Interpretivism | Research | Integrating qualitative methods to understand social aspects of breathlessness, informing patient-centred care |
| Phenomenology | Interpretivism | Clinical practice | Exploring patients' lived experiences of breathlessness, guiding empathetic and patient-centred care approaches |
| Phenomenology | Interpretivism | Leadership | Leading with an understanding of patients' breathlessness experiences, promoting patient-centred care practices |
| Phenomenology | Interpretivism | Education | Educating by exploring the essence of patients' experiences of breathlessness to provide more meaningful and personalised education |
| Phenomenology | Interpretivism | Research | Using qualitative methods to explore subjective experiences, contributing to deeper understanding and care approaches |
| Realism | Critical realism | Clinical practice | Acknowledging the objective reality of breathlessness while considering its complex interplay with social and psychological factors |
| Realism | Critical realism | Leadership | Leading with a holistic understanding of breathlessness, addressing physiological, social and psychological aspects for comprehensive care |
| Realism | Critical realism | Education | Providing comprehensive understanding of breathlessness, addressing both objective and subjective dimensions |
| Realism | Critical realism | Research | Integrating quantitative and qualitative methods to address complexity of breathlessness for evidence-based practice |
| Research paradigm | Ontology | Epistemology | Impact on the four pillars | Application to the breathless patient |
|---|---|---|---|---|
| Positivism | Objective reality exists independently of the observer | Knowledge is gained through empirical observation and experimentation, and seeks to establish causal relationships | Clinical practice: prioritises evidence-based guidelines, standardised assessment tools and quantitative research. Leadership: supports data-driven decision making and quality improvement initiatives. Education: emphasises mastery of core knowledge and skills through standardised curricula | Focuses on physiological measurements (eg blood pressure, oxygen saturation), reliance on diagnostic algorithms, seeking a definitive diagnosis through tests and imaging |
| Post-positivism | Acknowledges a single reality but recognises limitations of human observation and the potential for bias | Knowledge is provisional and subject to revision based on new evidence. Emphasises critical evaluation of research findings | Clinical practice: Encourages critical appraisal of evidence and consideration of context beyond strict guidelines. Leadership: promotes reflective practice and openness to new models of care. |
A similar approach to positivism, but with greater consideration of the patient's history, environmental factors and potential limitations of diagnostic tests |
| Interpretivism/constructivism | Reality is socially constructed and subjective | Knowledge is co-created through interaction and emphasises individual experiences and meanings | Clinical practice: emphasises patient-centred care, qualitative research to understand lived experiences and shared decision making. Leadership: promotes inclusive leadership models and diversity in perspectives. Education: uses case studies, simulations and reflective exercises. Research: emphasises qualitative methods like interviews, focus groups and ethnography | Explore the patient's experience of breathlessness, its impact on their life, their understanding of the condition and their anxieties or fears |
| Pragmatism | Focuses on the practical implications of knowledge, prioritising solutions rather than strictly defining reality | Knowledge is derived from experience and experimentation, valuing what works best in a given context | Clinical practice: fosters adaptability, practical problem solving and openness to innovative approaches. Leadership: encourages flexibility and responsiveness to changing contexts. Education: emphasises problem-based learning and clinical reasoning. Research: prioritises applied research with an emphasis on implementation | Prioritises the rapid assessment and stabilisation of the patient, using the most effective interventions available and adapting treatment based on the patient's response |
| Critical realism | Reality exists independently of human perception but is shaped by social, historical and power structures | Knowledge is socially constructed and fallible. Prioritises research that uncovers and addresses power imbalances | Clinical practice: highlights social determinants of health, and advocates for health equity. Leadership: promotes transformative leadership that challenges systemic inequalities. Education: addresses critical consciousness and social justice perspectives. Research: uses critical theory frameworks and participatory research methods | Considers socioeconomic factors contributing to the patient's condition (eg housing, pollution, access to care) and advocates for systemic changes to address health inequalities |
Application of ontological and epistemological approaches in research and practice
The choice of ontological and epistemological perspectives influences the design, conduct and interpretation of research studies in advanced practice (Thomas et al, 2020). ACPs can apply philosophical principles to inform clinical decision making, patient care and professional development. In research, the application of ontological and epistemological approaches can lead to rigorous study designs and meaningful findings. By aligning research methods with philosophical perspectives, practitioners can ensure that their studies are methodologically sound and theoretically grounded. A study on patient satisfaction with telemedicine might use a phenomenological approach to explore subjective experiences while also incorporating positivist measures for objective clinical outcomes. ACPs can apply ontological and epistemological principles to inform their clinical decision making and patient-care strategies. By critically evaluating the assumptions underlying different approaches to care, ACPs can develop a more nuanced understanding of the benefits and limitations of various interventions. Strategies for navigating the complexities of ontological and epistemological diversity in advanced practice include interdisciplinary collaboration, critical reflection and ongoing dialogue among stakeholders. By engaging in reflexivity and continuously questioning underlying assumptions, ACPs and researchers can enrich their understanding of clinical phenomena and enhance the quality of care provided to patients.
Conclusions
Understanding the ontological and epistemological foundations in research is essential for advancing clinical practice, research and education in healthcare. By embracing diverse philosophical perspectives, ACPs and researchers can enrich their understanding of clinical phenomena and enhance the quality of care provided to patients. Continued exploration and dialogue surrounding ontological and epistemological issues in advanced practice will contribute to the ongoing development and refinement of the field, ultimately benefiting patients, ACPs and healthcare systems alike.