Implementation and Evaluation

Despite strong research to support the effectiveness and safety of nurse practitioners (NP), the implementation of this role in hospitals varies across the province and is subject to changing organizational priorities and political agendas [1].

When preparing to implement NP’s new authority to treat and discharge, organizations should examine current policies and existing practices to consider how maximizing NP utilization can increase the efficiency and effectiveness of current care processes. At the same time, hospitals should examine the role and accountabilities of all health-care team members and identify the NP role and responsibilities within their own particular inter-professional teams.

The following is a list of key enablers that are needed to successfully integrate NPs into the care of hospital patients.

For sample tools and resources, please see the Tools for NP Implementation section.

Key Enablers

  1. Enabling legislative and regulatory framework
    A regulatory framework that allows full utilization of NPs is key to their integration in hospital settings [2]. In Ontario, many regulatory barriers have been removed. For example, NPs working in hospitals are permitted to admit, treat and discharge hospital patients, as well as to refer directly to specialist physicians. However, NPs are still not able to order all medical imaging tests, and are not able to prescribe controlled substances [3]which could acts as a barrier and prevent them from working to their full scope of practice. However, the government is considering authorizing NPs to prescribe controlled substances [4]to improve access to care for Ontarians. Get more information on legislation and regulation governing NP practice.
  2. Solid body of evidence supporting the safety and cost-effectiveness of NP care of hospital patients (see Evidence: Quality and Evidence: Economic).
  3. Role definition
    Implementing the NP role in hospitals may present unique challenges since the NP role encompasses roles traditionally under both medical practice (such as diagnosing, admitting and treating) and nursing practice (such as care of the whole person and psychosocial support). [5].

    NPs, staff, patients, nursing and medical leadership, and hospital administrators must understand the responsibilities of respective team members. By clarifying stakeholder expectations, a common understanding of NP roles can facilitate implementation of NPs into the care team[2]. Where there is an overlap of roles and responsibilities, such as between NPs and physicians, there is a need for clarity in understanding roles and balancing shared responsibility [6].
  4. Stakeholder involvement and support
    Identification of champions of the NP role is key to help with role enactment and implementation.  An NP champion, as well as well as champions from medical and nursing leadership, and hospital administration, can contribute to promoting a common understanding of the role [2].

    Nursing leadership and senior nursing administrators also play a key role in introducing and fully integrating the role of NPs in an organization [7]. These nursing leaders develop the NP role and link it with organizational priorities. Support from physicians is also key in order to move towards valuing and accepting the NP role in hospitals [2]. Support from NP peers, other hospital leaders and hospital staff is also important [5].
  5. Planning for and evaluating change
    Implementing the NP role must start with defining goals as well as organizational need [8]. A comprehensive review of related enabling legislation and hospital by-laws  and policies is needed. The aim of this review is to identify and eliminate barriers to NPs working to full scope of practice.A systematic process to develop, introduce and implement the role is recommended [7].

    A communications plan is needed to inform and promote “buy-in” and collaboration from all professions that make up health-care teams, thereby ensuring all health-care professionals work effectively with NPs. Mechanisms for NPs to be registered as the Most Responsible Provider must be established and electronic health record processes must reflect new models of care [9].
  6. Leadership and reporting structure
    Several reporting structures for NPs exist in practice, and there is little research to date to address which reporting structure is optimal. However, it is suggested that NPs report to a senior nursing administrator rather than a medical director or other physicians[7]. This may be important to continue to evolve and fully implement the NP role, as well as to deal with NP practice issues, role barriers, and role socialization [7][E2] . Novice NPs are encouraged to be trained by experienced NPs, rather than socialized into their roles solely by physicians; this ensures the valuing of profession-specific knowledge, time set aside for nursing research and professional development.[8].
  7. Structures affecting NP role evolution
    Factors external to the individual NP, team and unit will affect NP practice and how the role develops. These structures include factors in the health-care system, factors inside the organization, as well as nursing and medical leadership. [2].If the role of an NP is characterized as an advanced nursing role with specific skills that add value to the interdisciplinary team, rather than as a physician extender, this will contribute to the sustainability of the role [7, 8].

    Another factor important for the evolution of the NP role is NP education as well as NP research. The development of advanced practice research methods is needed in order to develop a body of research evidence to support the role of the NP, as well as other advanced practice nursing roles [7]. In 2001 a Chair in Advanced Practice Nursing position was funded by CHSRF and CIHR. This position lasted 10 years and contributed to the evolution of the role of advanced practice nurses in Canada by increasing capacity of research in the field of advance practice nursing [7].




1.            Woods, L., Evaluating the clinical effectiveness of neonatal nurse practitioners: An exploratory study. Journal of Clinical Nursing, 2006. 15(1): p. 35-44.

2.            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.

3.            College of Nurses of Ontario. Practice Standard: Nurse Practitioner. 2011.

4.            Ontario Office of the Premier. Enhancing the Role of Ontario Nurses. Ontario Government Working Toward Better, More Comprehensive Patient Care 2013  [cited 2015 July 13]; Available from:

5.            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.

6.            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.

7.            DiCenso, A., Bryant-Lukosius, D., Clinical Nurse Specialists and Nurse Practitioners in Canada: A Decision Support Synthesis. 2010, Canadian Health Services Research Foundation.: Ottawa, ON.

8.            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.

9.            van Soeren, M., et al., Report to Ontario Ministry of Health and Long-Term Care: The Integration of Specialty Nurse Practitioners into the Ontario Healthcare System. 2009.