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Studies Regarding NP Practice

Rural Health Services Review Final Report: Understanding the concerns and challenges of Albertans who live in rural and remote communities.

Alberta Health. (2015). Rural Health Services Review Final Report: Understanding the concerns and challenges of Albertans who live in rural and remote communities.  Retrieved from

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Key Points Regarding NP Practice in Alberta: 

  • Recommendation in Primary Care: “Allocate funding to models of remuneration that support team-based primary health care, and enable the recruitment and deployment of other providers such as nurse practitioners, midwives and physician assistants in rural Alberta.” -pg 10
  • “The Committee certainly also heard that it could not be only about physicians—that it was about recruiting and retaining providers across the professions. Many communities expressed the desire to attract and recruit NPs in particular, noting that barriers to the use of these providers needed to be removed.” -pg24
  • Recommendation regarding Recruitment and Retention: “Re-define the mandate of the rural physician action plan (RPAP) to include province wide support and coordination for recruiting all health care providers including nurse practitioners, physician assistants, midwives, nurses, physicians and allied health providers to rural Alberta. Set specific accountabilities and performance targets for community engagement and assistance with recruitment efforts.” -pg 26
  • Recommendation regarding Recruitment and Retention: “Establish appropriate funding mechanisms and infrastructure for nurse practitioners, physician assistants, midwives and allied health providers in rural Alberta.” pg-26

Understanding Nurse Practitioner Autonomy

Weiland, S. A. (2015). Understanding nurse practitioner autonomy. Journal of the American Association of Nurse Practitioners, 27(2), 95-104.

Purpose: This Gadamerian hermeneutic study was undertaken to understand
the meaning of autonomy as interpreted by nurse practitioners (NPs) through
their lived experiences of everyday practice in primary health care.
Data sources: A purposive sample of nine NPs practicing in primary health
care was used. Network sampling achieved a broad swath of primary care NPs
and practice settings. Data were collected by face-to-face interviews. Because NP
autonomy is concerned with gender and marginalization, Gilligan’s feminist perspective
was utilized during interpretive analysis.
Conclusions: Having Genuine NP Practice was the major theme, reflecting the
participants’ overall meaning of their autonomy. Practicing alone with the patient
provided the context within which participants shaped the meaning of Having
Genuine NP Practice. Having Genuine NP Practice had four subthemes: relationships,
self-reliance, self-empowerment, and defending the NP role.
Implications for practice: The understanding of Having Genuine NP Practice
will enable NPs to articulate their autonomy clearly and better influence
healthcare reform. Implications for advanced practice nursing education include
integrating findings into classroom discussion to prompt self-reflection of what
autonomy means and socialization to the NP role.

The enemy within: Power and politics in the transition to nurse practitioner

MacLellan, L., Levett-Jones, T., & Higgins, I. (2016). The enemy within: Power and politics in the transition to nurse practitioner. NursingPlus Open, 2, 1-7.



The period of transition from registered nurse to nurse practitioner is often challenging. While adjusting to their autonomous role, nurse practitioners need to create and define a distinct role for themselves within practice contexts that may be unfamiliar, sometimes unwelcoming and inhospitable. During this time of transition, nurses need well developed negotiation skills and personal attributes including resilience, tenacity, fortitude and determination.

Purpose of the research

The purpose of the research reported in this paper was to explore the transition experiences of 10 newly endorsed nurse practitioners in Australia during their first year of practice. This paper focuses on power, control and political manoeuvring that negatively impacted the ׳nurse practitioners׳ transition. A qualitative approach using a modified version of Carspecken׳s five stage critical ethnography, informed by focused ethnography, was the methodology selected for this study. Methods included observations of practice, journaling, face to face and phone interviews which were recorded, transcribed and analysed thematically.


“The enemy within” emerged as a dominant theme highlighting issues of power, powerlessness and politics dominating the participant׳s experiences. Power struggles amongst nurses, both overt and covert, and the deliberate misuse of power were frequently encountered. Many of the participants felt powerless and ill-prepared to negotiate the challenging situations in which they found themselves. Many lacked the skills needed to address the negative behaviours they experienced.


This paper reports on the experiences of 10 newly endorsed nurse practitioners during their transition to the nurse practitioner role. The impact of the political climate at the time of this study had an undeniable influence on many of the participants׳ transition experiences. Competition for the limited numbers of designated nurse practitioner positions led to hostility between senior nurses and, in some contexts, a jostling for power, control, prestige and position. Rather than camaraderie, cooperation and collaboration, many of the participants described feeling besieged, undermined and alienated. The new nurse practitioners felt isolated, unwelcomed and unsupported. Several felt burnt out and abandoned their aspirations to be become a nurse practitioner. They left and returned to practice as a registered nurse.

The Potential for Nurse Practitioners in Health Care Reform

Archibald, M. M., & Fraser, K. (2013). The potential for nurse practitioners in health care reform. Journal of Professional Nursing, 29(5), 270-275.


In Canada, health care reform is underway to address escalating costs, access and quality of care issues, and existing personnel shortages in various health disciplines. One response of the nursing profession to these stimuli has been the development of the advanced practice nurse, namely, the nurse practitioner (NP). NPs are in an excellent position to address current shortcomings through increasing points of access to the health care system, providing an emphasis on education and disease prevention, and delivering high-quality, cost-effective care in a multitude of practice settings. With an emphasis on the social determinants of health, NPs are in a prime position to provide care to underserved and vulnerable populations across Canada. Despite the potential for NPs to be instrumental in health care reform, there is a lack of support and regulation necessary for their optimal use. Barriers to mobilizing NPs in Canada exist and impede the integration of NPs into the Canadian health care system, which has both quality of care and social justice implications.

Nurse Practitioners, Canaries in the Mine of Primary Care Reform

Contandriopoulos, D., Brousselle, A., Breton, M., Sangster-Gormley, E., Kilpatrick, K., Dubois, C. A., … & Perroux, M. (2016). Nurse practitioners, canaries in the mine of primary care reform. Health Policy.

A strong and effective primary care capacity has been demonstrated to be crucial for controlling costs, improving outcomes, and ultimately enhancing the performance and sustainability of healthcare systems. However, current challenges are such that the future of primary care is unlikely to be an extension of the current dominant model. Profound environmental challenges are accumulating and are likely to drive significant transformation in the field. In this article we build upon the concept of “disruptive innovations” to analyze data from two separate research projects conducted in Quebec (Canada). Results from both projects suggest that introducing nurse practitioners into primary care teams has the potential to disrupt the status quo. We propose three scenarios for the future of primary care and for nurse practitioners’ potential contribution to reforming primary care delivery models. In conclusion, we suggest that, like the canary in the coal mine, nurse practitioners’ place in primary care will be an indicator of the extent to which healthcare system reforms have actually occurred.

Nurse Practitioner Care Improves Renal Outcome in Patients with CKD

Peeters, M. J., van Zuilen, A. D., van den Brand, J. A., Bots, M. L., van Buren, M., ten Dam, M. A., … & van de Ven, P. J. (2014). Nurse practitioner care improves renal outcome in patients with CKD. Journal of the American Society of Nephrology, 25(2), 390-398.

Treatment goals for patients with CKD are often unrealized for many reasons, but support by nurse practitioners may improve risk factor levels in these patients. Here, we analyzed renal endpoints of the Multifactorial Approach and Superior Treatment Efficacy in Renal Patients with the Aid of Nurse Practitioners (MASTERPLAN) study after extended follow-up to determine whether strict implementation of current CKD guidelines through the aid of nurse practitioners improves renal outcome. In total, 788 patients with moderate to severe CKD were randomized to receive nurse practitioner support added to physician care (intervention group) or physician care alone (control group). Median follow-up was 5.7 years. Renal outcome was a secondary endpoint of the MASTERPLAN study. We used a composite renal endpoint of death, ESRD, and 50% increase in serum creatinine. Event rates were compared with adjustment for baseline serum creatinine concentration and changes in estimated GFR were determined. During the randomized phase, there were small but significant differences between the groups in BP, proteinuria, LDL cholesterol, and use of aspirin, statins, active vitamin D, and antihypertensive medications, in favor of the intervention group. The intervention reduced the incidence of the composite renal endpoint by 20% (hazard ratio, 0.80; 95% confidence interval, 0.66 to 0.98; P=0.03). In the intervention group, the decrease in estimated GFR was 0.45 ml/min per 1.73 m2 per year less than in the control group (P=0.01). In conclusion, additional support by nurse practitioners attenuated the decline of kidney function and improved renal outcome in patients with CKD.

Cost-effectiveness of Nurse Practitioner/Community Health Worker Care to Reduce Cardiovascular Health Disparities

Allen, J. K., Himmelfarb, C. R. D., Szanton, S. L., & Frick, K. D. (2014). Cost-effectiveness of nurse practitioner/community health worker care to reduce cardiovascular health disparities. The Journal of cardiovascular nursing, 29(4), 308.

Findings: Comprehensive management of cardiovascular risk factors by NP/CHW teams that includes lifestyle counseling, drug prescription and titration and promotion of compliance is a cost-effective strategy to reduce cardiovascular risk and thereby address health disparities in underserved, minority populations. Chronic illness care in medically underserved patients with CVD or at high risk for CVD is complex. These data add to the body of evidence that specially trained nurse-led teams are efficacious strategies to improve management. A sizeable body of research reinforces that patient care outcomes are similar and sometimes better when patients are managed by NP’s as primary care providers as compared to physicians. As the costs of health care for chronic diseases continues to increase, NPs are in pivotal positions to address the need for safe, effective, patient-centered, efficient, and equitable health care.

The Quality and Effectiveness of Care Provided by Nurse Practitioners

Stanik-Hutt, J., Newhouse, R. P., White, K. M., Johantgen, M., Bass, E. B., Zangaro, G., … & Weiner, J. P. (2013). The quality and effectiveness of care provided by nurse practitioners. The Journal for Nurse Practitioners, 9(8), 492-500.

Evidence regarding the impact of nurse practitioners (NPs) compared to physicians (MDs) on health care quality, safety, and effectiveness was systematically reviewed. Data from 37 of 27,993 articles published from 1990-2009 were summarized into 11 aggregated outcomes. Outcomes for NPs compared to MDs (or teams without NPs) are comparable or better for all 11 outcomes reviewed. A high level of evidence indicated better serum lipid levels in patients cared for by NPs in primary care settings. A high level of evidence also indicated that patient outcomes on satisfaction with care, health status, functional status, number of emergency department visits and hospitalizations, blood glucose, blood pressure, and mortality are similar for NPs and MDs.

Cost-effectiveness of Nurse Practitioners in Primary and Specialised Ambulatory Care: Systematic Review

Martin-Misener, R., Harbman, P., Donald, F., Reid, K., Kilpatrick, K., Carter, N., … & DiCenso, A. (2015). Cost-effectiveness of nurse practitioners in primary and specialised ambulatory care: systematic review. BMJ open, 5(6), e007167.

Objective To determine the cost-effectiveness of nurse practitioners delivering primary and specialised ambulatory care.

Design A systematic review of randomised controlled trials reported since 1980.

Data sources 10 electronic bibliographic databases, handsearches, contact with authors, bibliographies and websites.

Included studies Randomised controlled trials that evaluated nurse practitioners in alternative and complementary ambulatory care roles and reported health system outcomes.

Results 11 trials were included. In four trials of alternative provider ambulatory primary care roles, nurse practitioners were equivalent to physicians in all but seven patient outcomes favouring nurse practitioner care and in all but four health system outcomes, one favouring nurse practitioner care and three favouring physician care. In a meta-analysis of two studies (2689 patients) with minimal heterogeneity and high-quality evidence, nurse practitioner care resulted in lower mean health services costs per consultation (mean difference: −€6.41; 95% CI −€9.28 to −€3.55; p<0.0001) (2006 euros). In two trials of alternative provider specialised ambulatory care roles, nurse practitioners were equivalent to physicians in all but three patient outcomes and one health system outcome favouring nurse practitioner care. In five trials of complementary provider specialised ambulatory care roles, 16 patient/provider outcomes favouring nurse practitioner plus usual care, and 16 were equivalent. Two health system outcomes favoured nurse practitioner plus usual care, four favoured usual care and 14 were equivalent. Four studies of complementary specialised ambulatory care compared costs, but only one assessed costs and outcomes jointly.

Conclusions Nurse practitioners in alternative provider ambulatory primary care roles have equivalent or better patient outcomes than comparators and are potentially cost-saving. Evidence for their cost-effectiveness in alternative provider specialised ambulatory care roles is promising, but limited by the few studies. While some evidence indicates nurse practitioners in complementary specialised ambulatory care roles improve patient outcomes, their cost-effectiveness requires further study.

The Value of Full Practice Authority for Pennsylvania’s Nurse Practitioners

Bailey, J. P., & Jaep, K. (2015). The Value of Full Practice Authority for Pennsylvania’s Nurse Practitioners: Technical Appendix.

Conclusion: Existing studies suggest that granting Pennsylvania’s nurse practitioners Full Practice Authority could potentially benefit Pennsylvanians by increasing access to comparable or better health care at lower costs. Research demonstrates reform would save Pennsylvanians at least $6.4 billion in the next ten years, increase the number of NPs statewide by 13%, and improve the statewide quality of primary care.


Economic Benefits of Less Restrictive  Regulation of Advanced Practice  Registered Nurses in North Carolina:  An Analysis of Local and Statewide Effects  on Business Activity

Conover, C., & Richards, R. (2015). Economic benefits of less restrictive regulation of advanced practice nurses in North Carolina. Nursing outlook,63(5), 585-592.

The practical implication is that we have a high degree of confidence that the impacts of less restrictive regulation of APRNs will be at least as large as described in the lower-bound estimates in this report. We have provided our rationale for why it is appropriate to view the entire increase in APRN utilization resulting from less restrictive regulation as being financed through an injection of external federal funds. Hence, the EIA assessment provided in Section III is a valid means of assessing the impact of that supply increase on the North Carolina economy. Thus, less restrictive regulation of APRNs should result in new jobs (at least 4,053 but possibly as many as 7,507), more payroll (from $257 to 476 million) and higher taxes (from $21.8 to 40.3 million). An expanded supply of APRNs would make impressive progress toward alleviating the anticipated shortage of physicians in 2020, and in the best case holds the promise of entirely eradicating the shortages of primary care physicians, OB/GYNs and anesthesiologists. North Carolinians would enjoy better access to care of equivalent or better quality even as the system shed some unnecessary costs in the process. It is rare that a health policy change is capable of generating such positive gains across all these dimensions.