Quality of Care: Improving Outcomes through Care by NPs

With changing hospital funding models, there is a need for quality, evidence-based health services [1]. Quality is derived both in terms of improved outcomes, as well as in patient experience [2]. Quality is also inextricably linked with value and cost-effectiveness. For further information about the cost-effectiveness of nurse practitioner (NP) care, see Evidence: economic.

Nurse practitioners provide safe and effective care for hospital patients. They are autonomous health-care professionals that can be added to existing inter-professional models of care, where the goal is to improve quality of care [3]. They can also be used to remedy gaps. For more information on how NPs work as part of inter-professional teams, see Models of Care.

On the whole, the literature shows that NPs deliver quality care with high patient satisfaction [3]. The following is a brief summary of evidence of NP-sensitive quality indicators. It is intended to support hospital administrators in understanding the  contributions NPs can make towards quality outcomes of care and safety in the following three areas:

  1. Clinical indicators, including patient safety
  2. Organizational indicators and patient flow
  3. Patient experience indicators

Please note: this is based on a scoping review of the literature and is not exhaustive.

Clinical Indicators and Patient Safety



Mortality rate


NPs providing care resulted in decreased [4]or similar mortality rates compared to usual care[2, 5-10].

Morbidity: rate of complications


Care by NPs in various inpatient settings resulted in decreased [7, 11, 12]or comparable rates of complications [6, 8]compared to usual care.

Quality patient care

NPs working in emergency departments provide higher quality care than usual care in terms of documentation[13], as well as adherence to protocols, and appropriateness of referrals [14].

NPs working in the ED showed accurate x-ray interpretation (comparable with that of resident physicians) [14]comparable rates of missed injuries.

NPs showed comparable diagnostic reasoning to physicians [15].

NPs demonstrated comparable clinical outcomes for care of non-high risk myocardial infarction (MI) patients, compared to usual care[16].

NPs working in a surgical intensive care unit (ICU) were correlated with increased adherence to clinical practice guidelines and improved patient outcomes [17].

NPs working in both Neonatal ICU[10]and medical ICU [9]demonstrated equivalent outcomes when compared with resident physician care.

NPs working in ICUs showed equivalent [9]or reduced [18]overall ICU length of stay.


For further examination of NP-sensitive outcomes in multiple clinical practice settings, please see a report prepared by the College of Registered Nurses of Nova Scotia titled "Nurse Practitioner-Sensitive Outcomes" [19].


Organizational Indicators: Patient flow 



Emergency department wait times and access to care


NPs working in the emergency department contribute to decreased wait times and thereby increase access to care [14, 20][21].

Attending physicians working with NPs in a pediatric emergency department  had greater clinical productivity compared to attending physicians working with resident physicians [22]. Thus NPs contributed to improved access to care.

Rate of unexpected ICU transfers


An NP-led critical care outreach/rapid response led to reduced ICU re-admission rates [23].

NPs caring for general medicine patients had similar rates of transfers to ICU compared to usual care (physician only) [6].

Co-ordination of care

Care by NPs contributes to increased co-ordination of care [24, 25].

Timely discharge

Care by NPs contributes to timely discharge and increased continuity of care: (Fry, 2011; Gross, 2004; Kapu, Kleinpell, & Pilon, 2014),(Jarrett, 2009)[9]

Rate of re-admission

Post-discharge follow-up by NPs contributed to decreased rates of re-admission [4]and enhanced quality of life [26].

NP care of inpatients resulted in equivalent rates of re-admission when compared to usual care [9, 27].


Patient Experience Indicators



Patient satisfaction


Care by NPs results in consistently high scores of patient satisfaction, either higher than [13, 14, 21, 26]or equivalent to satisfaction with usual care [5, 12, 28, 29].

Patient-centred care

Care by NPs led to higher levels of care co-ordination, counselling, education and patient participation in care [25].

Patient perception of health status

Under NP care, levels of self-reported health status were equivalent to those reported under usual care [5, 6].


1.            Kapu, A.N., R. Kleinpell, and B. Pilon, Quality and Financial Impact of Adding Nurse Practitioners to Inpatient Care Teams. Journal of Nursing Administration, 2014. 44(2): p. 87-96.

2.            Stanik-Hutt, J., et al., The Quality and Effectiveness of Care Provided by Nurse Practitioners. The Journal of Nurse Practitioners, 2013. 9(8): p. 492-500.

3.            Donald F, K.K., Reid K, Carter N, Martin‐Misener R, Bryant‐Lukosius D, Harbman P, Kaasalainen S, Marshall DA, Charbonneau‐Smith R, Donald EE, Lloyd M, Wickson‐Griffiths A, Yost J, Baxter P, Sangster‐Gormley E, Hubley P, Laflamme C, Campbell‐Yeo M, Price S, Boyko J, DiCenso A., A systematic review of the cost‐effectiveness of nurse practitioners and clinical nurse specialists: what is the quality of the evidence? Nursing Research and Practice, 2014.

4.            Delgado-Passler, P., McCaffrey, R., The influences of postdischarge management by nurse practitioners on hospital readmission for heart failure. Journal of the American Academy of Nurse Practitioners, 2006. 18(4): p. 154-60.

5.            Newhouse RP, S.-H.J., White KM, Johantgen M, Bass EB, Zangaro G, Wilson RF, Fountain L, Steinwachs DM, Heindel L, Weiner JP, Advanced practice nurse outcomes 1990-2008: a systematic review. Nursing Economics, 2011. 29(5): p. 230-250.

6.            Pioro, M.H., et al., Outcomes-based trial of an inpatient nurse practitioner service for general medicine patients. Journal of Evaluation in Clinical Practice, 2001. 7(1): p. 21-33.

7.            Sise, C.B., M.J., Kelley, D.M., Walker, S.B., Calvo, R.Y., Shackford, S.R., Lome, B.R., Sack, D.I., Osler, T.M., Resource commitment to improve outcomes and increase value at a level I trauma center. The Journal of Trauma, 2011. 70(3): p. 560-568.

8.            Skinner, H., et al., Advanced care nurse practitioners can safely provide sole resident cover for level three patients: impact on outcomes, cost and work patterns in a cardiac surgery programme. European Journal Cardio-Thoracic Surgery, 2013. 43(1): p. 19-22.

9.            Hoffman, L.A., et al., Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. American Journal of Critical Care, 2005. 14(2): p. 121-132.

10.          Mitchell-DiCenso, A., et al., A Controlled Trial of Nurse Practitioners in Neonatal Intensive Care. Pediatrics, 1996. 98(6): p. 1143-1148.

11.          Russell, D., VorderBruegge, M., Burns, S. , Effect of an outcomes-managed approach to care of neuroscience patientes by acute care nurse practitioners. American Journal of Critical Care, 2002. 11(4): p. 353-362.

12.          Fry, M., Literature review of the impact of nurse practitioners in critical care services. Nursing in Critical Care, 2011. 16(2): p. 58-66.

13.          Cooper, M.A., et al., Evaluating Emergency Nurse Practitioner services: a randomized controlled trial. Journal of advanced nursing, 2002. 40(6): p. 721-730.

14.          Carter, A.J. and A.H. Chochinov, A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department. CJEM Canadian Journal of Emergency Medical Care, 2007. 9(4): p. 286-95.

15.          Pirret, A.M., S.J. Neville, and S.J. La Grow, Nurse practitioners versus doctors diagnostic reasoning in a complex case presentation to an acute tertiary hospital: A comparative study. International Journal of Nursing Studies, 2015. 52(3): p. 716-726.

16.          Broers, C.J.M., et al., The post-infarction nurse practitioner project: A prospective study comparing nurse intervention with conventional care in a non-high-risk myocardial infarction population. Netherlands Heart Journal, 2009. 17(2): p. 61-67.

17.          Gracias, V.H., et al., Critical Care Nurse Practitioners Improve Compliance With Clinical Practice Guidelines in “Semiclosed” Surgical Intensive Care Unit. Journal of Nursing Care Quality, 2008. 23(4): p. 338-344.

18.          Kleinpell, R.M., E.W. Ely, and R. Grabenkort, Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Critical Care Medicine, 2008. 36(10): p. 2888-97.

19.          Scotia, C.o.R.N.o.N., 2014 Summary Report: Nurse Practitioner-Sensitive Outcomes. 2014.

20.          Jennings, N., et al., Evaluating outcomes of the emergency nurse practitioner role in a major urban emergency department, Melbourne, Australia. Journal of Clinical Nursing, 2008. 17(8): p. 1044-1050.

21.          Jennings, N., et al., The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: A systematic review. International Journal of Nursing Studies, 2015. 52(1): p. 421-435.

22.          McDonnell, W.M., et al., Relative productivity of nurse practitioner and resident physician care models in the pediatric emergency department. Pediatric Emergency Care, 2015. 31(2): p. 101-106.

23.          Pirret, A., The role and effectiveness of a nurse practitioner-led critical care outreach service. Intensive & Critical Care Nursing, 2008. 24(6): p. 375–382.

24.          Sidani, S., et al., Outcomes of nurse practitioners in acute care: an exploration. Internet Journal of Advanced Nursing Practice, 2010. 8(1): p. 15p.

25.          Sidani, S., et al., Processes of Care: Comparison between Nurse Practitioners and Physician Residents in Acute Care. Canadian Journal of Nursing Leadership, 2006. 19(1): p. 69-85.

26.          Sawatzky, J.A., S. Christie, and R.K. Singal, Exploring outcomes of a nurse practitioner-managed cardiac surgery follow-up intervention: a randomized trial. Journal of Advanced Nursing 2013. 69(9): p. 2076-2087.

27.          Cowan, M.S., M; Hays, RD.; Afifi, A; Vazirani, S; Ward, CR; Ettner, SL, The Effect of a Multidisciplinary Hospitalist/Physician and Advanced Practice Nurse Collaboration on Hospital Costs. Journal of Nursing Administration, 2006. 36(2): p. 79-85.

28.          Jennings, N., et al., A survey of patient satisfaction in a metropolitan Emergency Department: Comparing nurse practitioners and emergency physicians. International Journal of Nursing Practice, 2009. 15(3): p. 213-218.

29.          Dinh, M., et al., Evaluating the quality of care delivered by an emergency department fast track unit with both nurse practitioners and doctors. Australasian Emergency Nursing Journal, 2012. 15: p. 188-194.