According to Dicenso and Bryant-Lukosius (2010), the role of advanced practice nurses, including NPs, is "purposefully dynamic and continually evolving in response to the changing contexts and health-care needs of patients, organizations and health-care systems". NPs working in hospitals often have an area of concentration/specialty and work with an interdisciplinary team to provide a range of services to manage both acute and chronic illnesses [1].
There is evidence to show that NPs are valued members of the interdisciplinary team[2]and contribute to safe, high quality and cost-effective care, thereby meeting both patient and health system needs [1]. The consistent presence of an NP on a hospital unit can promote continuity of care as well as efficiency in care [3, 4]. In order to optimize efficiency and patient outcomes, NPs require autonomy and decision-making capability to make patient care decisions in a timely manner [5, 6]. This can help reduce gaps in care that impede patient flow through the system (e.g. such as timely discharge or transfer).
Nurse practitioners working in hospital settings may operate in a variety of models of care. Two principal models of care are:
- Nurse practitioner as MRP (Most Responsible Provider)
To facilitate moving away from conceptual models that enable a single point of access to the system and towards team-based decisions of care, a shift in thinking, and corresponding policy, is needed. The term “Most Responsible Physician” is best re-shaped into “Most Responsible Provider” to reflect the authority that is now placed in providers other than physicians to admit and discharge.
In this model of care, NPs work as part of an interdisciplinary team and an NP is assigned to a client as the most responsible provider. This NP has primary the responsibility and accountability for the care of the patient across the trajectory of hospital care [7].She/he may report to a senior nursing leader or to a program director. Limited research evidence is available on outcomes of this model of care in a hospital setting [7].
This model has been pioneered in Ontario at Lakeridge Health in Whitby. See the case study.
- Collaborative practice model
In this model, the NP is part of existing care team as a collaborator. While the NP is not the MRP she/he provides comprehensive care to hospital patients and may have shared accountability with a physician colleague. Inter-professional collaboration is key to improve the use of resources, to increase access to services [4]and to provide optimal care [3].
The NP may collaborate with a physician for clinical care issues, as well as report to a senior nurse leader for responsibilities relating to quality improvement [8]. There may be overlap in scopes of practice between NPs and physicians; however, each discipline brings distinct knowledge and expertise [1]. Clarification of roles and responsibilities can facilitate mutual understanding of roles and balancing shared responsibility [2].
For an example of this model in action please click here.
For further discussion on implementation of NPs in hospitals, please see the section titled "Implementation".
References
1. DiCenso, A. and D. Bryant-Lukosius, Clinical Nurse Specialists and Nurse Practitioners in Canada: A Decision Support Synthesis. 2010, Canadian Health Services Research Foundation.: Ottawa, ON.
2. Cobb, S.E. and M. Kutash, A Study to Describe Perceptions of ARNP Roles in an Acute Care Setting. Journal for Nurse Practitioners, 2011. 7(5): p. 378-384.
3. Cummings, G.G., K. Fraser, and D.S. Tarlier, Implementing advanced nurse practitioner roles in acute care: an evaluation of organizational change. Journal of Nursing Administration, 2003. 33(3): p. 139-145.
4. Hurlock-Chorostecki, C., et al., Labour saver or building a cohesive interprofessional team? The role of the nurse practitioner within hospitals. Journal of Interprofessional Care, 2014. 28(3): p. 260-266.
5. Kilpatrick, K., et al., How are acute care nurse practitioners enacting their roles in healthcare teams? A descriptive multiple-case study. International Journal of Nursing Studies, 2012. 49(7): p. 850-862.
6. Hurlock-Chorostecki, C., et al., Hospital-based nurse practitioner roles and interprofessional practice: A scoping review. Nursing & Health Sciences, 2014. 16(3): p. 403-410.
7. Acorn, M., Nurse Practitioners as Most Responsible Provider: Impact on Care for Seniors Admitted to an Ontario Hospital. International Journal of Nursing and Clinical Practice, 2015. 2(126).
8. S. Sidani, S.I., H. Porter, L. O'Brien-Pallas, B. Simpson, L. McGillis Hall, L. Nagel, J. Graydon, A. DiCenso and D. Redelmeir, Practice Patterns Of Acute Care Nurse Practitioners. Nursing Leadership, 2000. 13(3): p. 6-12.