How are acute care nurse practitioners enacting their roles in healthcare teams? A descriptive multiple-case study

In many countries, acute care nurse practitioners contribute to patient care through an expanded scope of practice that includes nursing and medical activities. There have been calls across nations to establish better understanding of how nurse practitioners enact their roles in healthcare teams. The 2006 introduction of cardiology nurse practitioners in Quebec, Canada provides an opportunity to examine this process more closely. The purpose of the study is to understand how nurse practitioners enact the medical and expanded nursing portions of their role in healthcare teams. A descriptive multiple-case study design was used. The study was conducted in two university-affiliated teaching hospitals in Quebec. Data were collected from March 2009 to May 2009. Data sources included interviews (N=59), field notes, documents, and a time and motion study (N=108 h 53 min) of nurse practitioner activities using a validated observation tool. The interviews were conducted individually or in groups. Content analysis was used to analyse the qualitative data. Descriptive statistics were generated for the time and motion study. The clinical role component, including nursing and medical activities, occupied the largest portion of the nurse practitioners' work time. The pace of nurse practitioner work activities was faster in the first half of the workday in response to patient care demands. The enacted nurse practitioner scope of practice was sensitive to the local context, and the needs of team members, patients and families. Nursing and medical leadership, and the transfer of prescriptive authority and decision-making autonomy affected how nurse practitioners enacted the medical and expanded nursing portions of their roles. Participants believed the pace of work influenced the nurse practitioners' ability to develop relationships with team members, and enact all the components of their role. The practitioners' scope of practice changed in response to pressures inside and outside healthcare teams or a lack of healthcare system structures. The study findings appear to be applicable to nurse practitioners working in other specialties, and in other countries. Future research needs to examine how the pace of work affects the nurse practitioners' ability to provide care.