The Impact of Nurse Practitioner Services in the Emergency Department towards Clinical Effectiveness

The Impact of Nurse Practitioner Services in the Emergency Department22

The Impact of Nurse Practitioner Services in the Emergency Departmenttowards Clinical Effectiveness

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University name

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The emergency department is crucial as it offers medicalinterventions for various accidents and injuries. In the recent time,the emergency department has witnessed an increase in the demand forservices as well as reduced patient satisfaction claims. Therefore,this change has necessitated the adoption of the necessary humanresources in the form of nurse practitioners who assist in providingquality care in less time. This dissertation aims at analysing theeffect of introducing the nurse practitioners in the emergencydepartments on the quality of care services, the time of stay andpatient satisfaction. Many studies have been conducted worldwide toassess the effect of advanced nurse practitioners in improving thequality of care services. Reliable data is supporting the importanceof nursing professionals in initiating change in healthcare.Therefore, the emergency departments should readily embrace the newchanges if they aim at improving the quality of health care.

Keywords: emergency department, healthcare, nursepractitioners


I would like to recognise the various stakeholders who aided methroughout the process of conducting this dissertation. I would liketo appreciate my family and colleagues for the support as well as thedifferent officials from the Cardiff University who assisted me inany way.

Table of Contents


Page NO.

Title page





Table of content


Chapter 1


Dissertation aim


Chapter 2


Research strategy


Key words


Literature review




Chapter 3

Quality improvement


Importance of Service Improvement in Healthcare System


Leadership in Health Care System


Leadership Theories


Leadership Styles (Transformational Leadership)




Chapter 4

Barriers to Implementation


Ethical Consideration










The Impactof Nurse Practitioner Services in the Emergency Department towardsClinical Effectiveness

Chapter 1

The growing use of the advanced nursing services for the treatment ofvarious conditions and diseases has raised the interest of theefficiency of the nursing profession in health care (West et al2012). An important indicator of quality services in the medicalsector is the type of services offered in the emergency areas. In thecontemporary world, the nursing practitioners have taken up a vitalrole in the medical field, and they seem to be closer to the patientsthan the doctors are. The nurses are responsible for conductingvarious essential services in the hospitals such as the diagnosis ofpatients, minor surgeries and administering drugs. The building up ofpressure on the services offered by the emergency departmentsnecessitated the invention of creative strategies, which incorporatedthe emergency nurse practitioner services.

In Australia, there was an overwhelming adoption of this practice,which outpaced the practice’s evaluation models (Mullins 2010).Still little has been established on the impact of the of nursepractitioner services in the emergency department safety and qualityof patient care. London hosts over three million patients in theemergency sectors every year who have limited medical institutionsthey can access to seek abrupt therapeutic services. The citizens inthe United Kingdom have high expectations on the local emergencydepartment’s potential to provide consistent and high-qualityservices (Giltinane 2013). Formerly, the emergency departments wereknown as the accident and emergency departments, and before then,they were called casualty.

Advanced nursing practice relies on the skills of the individualnurse (Taylor et al., 2014). The emergency departments operatewithout closing so that the patients can have a guarantee ofaccessing medical services at any time. Emergency units exist toserve people who may be involved in some fatalistic situations thatwould require the immediate intervention from the medicalpractitioners otherwise, many people would die. Other servicesoffered by the nursing professionals in the emergency departmentsinclude the telephone consultations. According to Gopee and Galloway(2013), this function reduces the backlog that is experienced in theemergency rooms and is suitable for the less severe health issuessuch as minor cuts. Telephone triage services serve in a variety ofplaces such as general practices and the primary health care setting.Other specialist services such as the paediatrics use this method tocommunicate with the various clients and personnel. In the recenttimes, the medical departments have experienced a growth in the useof telephone triage to manage the massive demand for emergencyservices, especially on general health issues. Some examples of thisservice in different nations include the NHS Direct in England andthe Norwegian primary care out-of-hours services.

In the city of Sheffield in the United Kingdom, the medics introduceda nurse profession that would head the minor injury unit in case anyaccident and emergency unit closed down (Sharma and Jain 2013).Previous studies on this project indicate that there were high levelsof client satisfaction from the services offered by the minor injuryunit although there is no evidence showing cost effectiveness(Johnson and Raterink 2009). There is an increased importance in therole of the advanced nurses in the national health services,especially in the emergency departments. Improvement of serviceswould require the collaboration among the various stakeholders sothat they can establish a culture that supports the changes, andvarious principles of the organisation are applied. An organised,systematic plan provides an opportunity for evaluating the reasonsand causes of failure of a system (Ledlow and Coppola 2013). Thus itis possible to determine what to fix. At the micro levels, thesignificant conditions affecting the patients and making a differencein their lives are the location where the nurses are working. Theskills of influencing changes and improving the quality of servicesrequire proper orientation to the environment and the formation of adirect line with the patients. Nurses have to understand themagnitude of the role bestowed on them to achieve changesuccessfully. In nursing, leadership is an important factor toconsider because, in most cases, nurses work in an ideal setting.

The illustration below is a depiction of the professional nursingpractice


This dissertation aims atinvestigating the impact of incorporation of the nursingpractitioners in the emergency departments and what significantdifference it causes as compared to the regular nursing practice. Thepaper examines the role, the relationship, and aims of nurse leaders.Management and leadership are components of Interprofessionalcollaboration practices that affect the nurses. The article discussesboth the pros and cons of the presence of these health professionalsand ultimately it assesses the overall impact of the nurses as eitherconstructive or deleterious to the health services quality. It isworth noting that, clinical effectiveness relies on the care given tothe patients and their families in a bid to attain the best results.The primary thematic question is does the introduction of nursingpractitioners in the emergency departments make any impact on thequality of health services and leadership?


Literature review


Conducting a literature reviewgenerates critical information on the data and evidence that wouldjustify the dissertation. It is important to organise and clarify theopinions of the writers so that the reader can grasp the evidence andthe issue (Halm 2010). Literature review supports a research topicand guides the researchers, basing their studies on evidence.


Inclusion Criteria

Inclusion Criteria


Articles published after 2006


International papers


Papers in English Only


Qualitative Studies




Exclusion CriteriaNumber

Articles published before 2006


Cohort study


RCT papers (non-related topics)


Other papers


Seminar papers


I adopted a variety of techniques when it came to the search forliterature to be used in the study. I used a variety of academicwebsites to get the articles that were in relation with thediscussion that would follow. Notably, I used Google Scholar as thesearch engine in getting sources to be used in the study. Reviewedarticles in form of PDF that had relevant information on the topic ofstudy. Further, I used professional journals such as BMJ,PubMed and PubMed Central in getting articles for use in executingthe discussion. The inclusion criteria was based on the issues to bediscussed and the keywords. Further, articles to be used were thosewithin a timeframe of 10 years that is from 2006 to 2016. Englishas my default language. My search initial yielded 56 articles, and Iused exclusion criteria to limit the content to forty articles. Ieliminated the case studies, cohort studies, non-related topic papersand the seminar papers. To strengthen my search strategies further, Iused the various themes related to the topic to make the properselection of articles.

Main themes:

• Length of stay in emergencydepartment

• Patient satisfaction

• Quality of care


Emergency medicine Patientsatisfaction Emergency department Interpersonal skills AcuityLength of stay Technical expertise Waiting time nurse leadernurse practitioner advanced nursing practice

Chapter2: Literature ReviewPatient Satisfaction

Patients come to the hospital to seek treatment. Nurse practitionershave the mandate to ensure that after administration of treatment,the patients are satisfied with the nature of services that areoffered. Notably, patients admitted to the emergency department findthemselves in dire states and expect better treatment to theirsatisfaction. Different researchers have conducted studies that seekto explain the impact of nurses in the emergency department on theimprovement of patient satisfaction. Dinh et al. (2012) recognize thesignificant role played by the advanced nurse practitioners when itcomes to patient satisfaction through the services provided. Theservices provided by the advanced practitioner nurses are essentialin enhancing the satisfaction levels of patients. Dinh et al. (2012)acknowledge the fact that patients are the recipients of healthcareservices. Because of the same, it is critical that they are providedwith the best services possible. In the study, Dinh et al. (2012)conducted a study with 236 participants including the advanced nursepractitioners and the doctors at the ED. Patients were expected totake a self-administered survey that sought to determine thesatisfaction levels of the patients. The results indicated there wasa high satisfaction rate among patients served by the ANPs comparedto doctors. The study was valid considering the approach that wasadopted. Dinh et al. (2012) illustrate that 60% of the patients whohad visited the emergency department rated the survey as excellent.The patients attended to at the emergency department were sufferingfrom a musculoskeletal injury. Findings of the study indicate thatthe patients were satisfied with the reduction in time taken to servethem. It could be a reflection of the fact that the presence ofnurses in the emergency department is critical to improving theoverall patient outcomes. However, it is essential to consider thatthe study could have some limitations key among them being thepossibility of facing the effects of bias. The researchers adoptedthe use of convenience sampling that could introduce a bias that islikely to affect the outcome of the results. Further, it is criticalto consider the fact that the completion of the survey may have beena problem because patients who were to see the doctors would wish fora reduced waiting time. Those who were able to see the doctor earlyenough could give a positive score in the survey. Overall, it iscritical to consider the fact that advanced nurse practitioners havea significant role to play in increasing the patient satisfactionrate.

Soleimanpour et al. (2011) investigate patient satisfaction at theemergency department concerning factors such as physicians’communication with the patients, nurses’ communication, and thesecurity guard’s courtesy. The patient satisfaction rate was,however, dependent on the average amount of time they waited to beserved. The satisfaction rates were recorded as security guard’s(78.3%), physician’s communication with the patients (82.5%) andnurses’ communication with patients (78%). In the study, the rateof satisfaction at the lowest level was measured at 7.7. The resultsare an indication of the fact that various factors determine patientsatisfaction at the emergency department. However, it is evident thatindeed patient satisfaction rate to a greater extent depends on therole played by the individual nurse practitioner. For example, inthis study, patients identified the concept of time spent waiting tobe served as a significant factor in determining the satisfactionlevel. The researchers enrolled a total of five hundred patients atthe emergency department who took a questionnaire. However, theresearchers identify other factors to be of critical significancewhen it comes to patient satisfaction at the emergency department. Itis crucial to consider such factors in addition to the concept of therole of the nurses when it comes to improvement of patientsatisfaction rate. Findings of the study are useful in helpingconfirm the role played by nurses when it comes to improvement ofservices offered to the patients. It is critical to acknowledge thefact that advanced nurse practitioners play a fundamental role whenit comes to the enhancement of patient satisfaction.

Jennings et al. (2009) in her studies sought to determine the impactof the advanced nurse practitioner in the improvement of patientsatisfaction. Jennings et al. (2009) conducted a survey among 202patients where 103 were seen by the advanced nurse practitioner whilethe other 99 were considered by the doctors (n=103 and n=99). Thequestionnaire that had 16 questions indicated that a significantnumber of patients were satisfied with the services provided by thenurse practitioners in the emergency department. According toJennings et al. (2009), 12 out of the 16 patients who took part inthe study acknowledged that they were satisfied with the nature ofservices provided by the advanced nurse practitioners. The nursepractitioners were identified as being competent in areas such ashealth education, counselling, and management of individual cases.The decision by patients to score positively in the survey is aconfirmation of the fact that indeed nurses play a significant rolein the emergency department when it comes to the realization of ahigh rate of patient satisfaction. It is critical to appreciate thefact that nurses have a greater role to play when it comes to theenhancement of treatment of patients in the emergency department.Their input is critical toward the attainment of better treatmentoutcomes for patients eventually resulting in increased rates ofsatisfaction. However, it is crucial to consider that the studiesconducted could have potential challenges that can affect the resultsand the final analysis. Fain et al. (2013) reiterate that use of thequestionnaire may lead to multiple mistakes that can affect theeventual results of the analysis. Nevertheless, it is vital toappreciate the fact that at some level there is agreement toward thefact that patient satisfaction rate is majorly dependent on theavailability of nurses at the emergency department.

In a different study approach, some researchers indicate that patientsatisfaction depends on other factors to be playing a fundamentalrole in the improvement of patient satisfaction. For example, Ryanand Rahman (2010) state that patient satisfaction depends on theavailability of health insurance. Notably, patients who had wereuninsured were highly satisfied compared to those who were not. It isa reflection of the fact that most of the patients get satisfied withthe nature of services provided based on their economic status.

Lengthof Stay in Emergency Department

The increased demand for emergencydepartment services implies longer waiting times and delays in givingmedical services. Therefore, it is important to assess the waitingtime as a crucial measure of the efficiency of the emergencydepartments. A previous analysis conducted by Dinh et al. (2012)annualised the provision of care services by the ENT in the fasttrack unit (FTU).The study observed delays in the delivery ofattention services among the ENP as compared to the physicians. Whenthe ENP assessed the patient, they used seven more minutes. The studyfound the case to have a p-value of 0.006. The waiting time for eachpatient was calculated from his or her medical records of theirhospital visits. In contrast to this analysis, Colligan et al. (2011)conducted an observational study that analysed the effectiveness ofthe ENPs and the physicians in treating minor and major cases in theemergency departments. The findings of the survey were reducedpatient stay when served by the ENPs than the doctors. The p-valuewas (p&lt0.00001) implying that this result was unlikely to be bychance. There were significant differences between the waiting times14 minutes by the ENPS and 50 minutes by the physicians.

The analytical work of Jennings etal (2008) supported the necessity of the introduction of emergencynurse practitioners on the waiting times and span of stay of thepatients in one of the central emergency departments in Melbourne,Australia. The gap of the emergency nurse practitioner exists, and itis part of the Victorian state funded projects meant to improvepatient care (Giltinane, 2013). This study utilised all the patients’subgroups in general emergency departments. The expected outcomemeasures were the waiting times and length of stay. The investigationclassified the subjects into two groups one that was managed by theemergency nurse practitioner and the other by the traditional modelof care. There were statistically significant differences in thewaiting times and length of stay in the emergency departments betweenthe two groups. The average waiting period for the emergency patientsserved by the ENP was by far less than the traditional model group(p&lt0.0002). We can presume that the implementation of theemergency nurse practitioners in Melbourne, led to significantreduction in the waiting spans in the emergency departments.Therefore, the nurse practitioners are a potential solution to thelong-term influx in demand for emergency department services. Thisstudy was the initial research of its sort in Australia that usedsignificant sample sizes to compare the difference in the waitingspans impacted by different medical practices.

Thompson and Dowding (2009)combined theory with practical examples and provides a briefexplanation about the major obstacles in the decision mechanisms ofthe nursing practitioners. The text reviews the updated research inprofessional judgement and the clinical decision making. It focusedon the relevant evidence, skills and knowledge in the nursingpractice, combining the contemporary theories with the analysis ofevidence-based practices in the learning processes andself-evaluation aspects. The study found that the introduction ofENPs in the emergency departments lead to significant changes in thespeed of service provision in the emergency departments (p&lt0.001)while the levels of satisfaction with medical services increasing ata similar rate. The importance of this work to the nursingpractitioners is that it informs their decision-making mechanisms,therefore, reducing the time of stay in the medical departments. Thiswork provides an analytical framework for the advanced nursingspecialists’ assessment.

Qualityof Care

Scholarly literature reviewsindicate a positive impact of the role of emergency nursepractitioners (ENP) in enhancing high standards of services offeredin the emergency departments (Giltinane 2013). The ENP areresponsible for making many decisions in the health departments(Warburton, 2009). Effective leadership is the secret towards theefficient operation of all clinical practices Marquis and Huston(2009). However, the analytical method applied to analyse the qualityof healthcare is not sure. There are varying definitions of thequality of health care among various nationalities. For instance, inAustralia, clinical evaluation forms were used by the qualityassurance departments in Oman to assess the length of stay in theemergency departments of the tertiary health institutions in 2004.While the average duration of stay was 4 hours, the rate of thosepatients discharged before this time increased by 45% for those whoattend the emergency departments and required admission. Therefore,introducing the role of ENP in Oman is crucial to enhance the currentquality of care. The quality of health care is about providing thebest care services to the patients (Thompson and Dowding 2009).

Each stage in career developmentgives an opportunity for the professionals to contribute to thesuccessful change. Gopee (2015) combines the aspects of theory andresearch that explain the concept of ENPs. This work focuses on thevarious forms of mentoring in the health practice. The ENP are theoriginal proponents of mentorships in the medical departments, andtheir role is to guide and direct other professionals towards theobjective of improving the quality of care services. The key featuresof this work include the Francis Report, SAGE journal articles forthe learners, and tools for the mentors in the practice and ateaching resources website for the lecturers. The emergency nursingprofession is a hard concept to grasp and is often paired withmanagement though they are different concepts. Leadership is anoverrated idea that would rescue the institutions in the face offailure (Hartley and Benington, 2010). Development of leadership is acomplicated process that requires the upgrading of knowledge anddevelopment of the overall environment of the ENP. The studyconcluded that the introduction of the nursing practitioners in theemergency departments led to significant improvement in the qualityof care services provided (p&lt0.003)

The studies above used theappropriate measurement tools, which are globally recognised andpresent consistent results, to maintain the consistency of thefindings as well as validating the generalisation of results. Thesetools indicate significant P value results that show improvedmeasures in the medical population (Malloch and Porter 2016, Grossmanand Valiga 2012 and Cain and du Plessis 2013). Some of the studiessuch as those conducted by (Blanket al. 2012) used powercalculations to evaluate their findings. Other studies used the timeframe to assess the progress of their experiments (Jennings et al.2008, Considine 2008, and Warburton 2009). Some studies (Nakayama2011, Morrow, Robert and Maben 2014, Gittell 2010 and Marquis andHuston 2009) make efficient use of questionnaires and case studies intheir inquiry which proves on the originality of their findings.

Through the proper administrationof the nurse practitioners in the emergency departments, the patientsare sure that they will acquire quality services. In health care,leadership concerns policy. According to Sullivan and Garland (2010),the modernization issues indicate the necessity of leadership in theclinical field. There were proposals that the health care systemshould operate as a complex and flexible system. A vital element ofthis project is that the subservient activities no longer control thenurses. It is important to provide skilled and evidence-based care aswell as the use of a performance measure in the delivery of societalexpectations in health care. The primary focus of nurse practitionersis how to facilitate the progress of healthcare with professionalautonomy but with a retained focus on the patient`s welfare whileproviding care services (Rich and Butts 2013). The vitality ofleadership in health care necessitates the understanding of thetheories that support response and the application of the leadershippractices in the United Kingdom.

Li et al. (2013) aim at investigating the impact of delivery of careto the emergency department by the nurse practitioners. The abilityof nurses to execute such functions could be a reflection of the factthat the nurse practitioners in the emergency department can improvequality care to the patients. The researchers adopt a cross-sectionalqualitative study conducted at the emergency department of twoAustralian metropolitan public teaching hospitals. Li et al. (2013)invoke the use of a semi-structured and in-depth interview with fivenurse practitioners and four senior doctors and four senior nurses.The study sought to assess the role played by the nurse practitionersin the ED when it came to the improvement of quality care topatients. According to Li et al. (2013), nurses had a vital role toplay regarding the management of sub-acute presentations at theemergency department. However, the researchers reiterate that therewas ambiguity when it came to the role of the nurse practitioners atthe emergency department. Further, there is the aspect ofcontradiction when it came to the particular role played by the nursepractitioners at the ED as attested by the researchers (Li et al.,2013). Nevertheless, there is an agreement regarding the fact that tosome extent the presence of nurses at the emergency departmentaffects the execution of tasks.

The quality of care accorded to patients depends on various factors.Nurse practitioners have the mandate to ensure that services providedto patients at the emergency department are of the highest qualityfor the attainment of the best outcomes. Research has been conductedto ascertain the impact of nurse practitioners in the emergencydepartment on the quality of care provided to the patients. Thescholarly articles are essential in providing insight toward theunderstanding of the concept of the effect of nurses when it comes tothe provision of quality care services. O’Connell and Gardner(2012) identify with the fact that the presence of advanced nursepractitioners has a role to play regarding the improvement of thequality of care in the emergency department. However, differences areeminent when it comes to the understanding of the measurement of thequality of care to the patients. Notably Cameron et al. (2011)postulate that the measure of the quality of care in the emergencydepartment is ambiguous and may not be feasible. For example, Cameronet al. (2011) state that the Australians define the quality of carebased on the ability to treat a patient with the disease at theemergency department. However, it is critical to have a properframework that can be used to define the concept of quality care. Theambiguity in the definition of characteristics of quality care makesit difficult to determine the rationale for measurement.Nevertheless, it is critical to evaluate the impact of nursepractitioners in the emergency department in the improvement ofquality care.

Colligan et al. (2011) evaluate the difference in service provisionin the emergency department between the advanced nurse practitionersand doctors in the management of the minor injury. The researchersconduct a study on a sample of 420 participants admitted to theemergency department at Auckland hospital. The researchers found outthat the participants identified the concept of a reduced time ofstay in the hospital to less than 40 (forty) minutes when treated byadvanced nurse practitioners. The study is a reflection of the factthat advanced nurse practitioners have a significant role to playwhen it comes to the improvement of the quality of care offered tothe patients. The patients stayreduced with 40 minutes when served by the ENPs compared to emergencyphysicians (P &lt 0.0001).The main reason for this variation is thatthe nurse can finish all the care alone compared to the doctors whooften need assistance in some activities such as dressing and fillingof the patient records. Colligan et al. (2011) indicate that the ENPsare entitled to managing only the minor cases, while the emergencyphysicians are responsible for the critical cases too.

The analysis used a single blindedrandom sample due to the unfamiliarity of the health intervention tothe health providers and the patients (Fain 2013). The studyprevailed in such a way that the health workers were aware of itwhile the blinded, which opened the possibility of bias. The medicalrecords used to analyse the waiting span were rendered inaccurate bythe delay in discharging the patients from the emergency departments.The study supports the introduction of the ENPs in the emergencydepartments to managing care services. Another analysis concludedthat the ENPs had the potential of handling serious cases than theminor cases alone. An observational study by Dinh et al. (2012)analysed the quality of healthcare provided by the ENPs against thatof the physicians. About 155 of the participants were served by theENPs while the emergency physicians examined 165 patients. The choiceof the representation was arbitrary, and the survey usedself-administered patient-satisfaction surveys. The general findingsof the study confirm the improvement of the quality of healthcareservices due to the introduction of the ENPs compared to the normalprocedures (p&lt0.02)


The literature review sought to assess the impact of nursepractitioner services in the emergency department towardseffectiveness. The identified themes extensively evaluate thefundamental role of nurses regarding the improvement of services inthe emergency department. Notably, three primary issues were beingaddressed. They included the impact of nurse practitioner services inin the emergency department on quality of care, patient satisfactionand duration of stay in the hospital. Grossmanand Valiga (2012) identify that ENP can raise the quality of servicesoffered in the emergency departments. The literature reviewdemonstrates the effect of incorporation of the nursing practitionerto improving the quality of care services, increased patientsatisfaction, and the reduced time wastage to reduce the duration ofstay in the hospital. There is a need for continued improvement ofthe nursing practice so that the profession can deal with thechanging requirements of the society. ENPs have the duty to maintainsafe, accessible and high standard care in the emergency departments.The introduction of nursing practitioners is a crucial step towardsquelling the high demands for health services. Effective leadershipis essential for the improvement of the quality of services in theemergency departments and wards. ENP addresses the core values andbehaviours that are necessary for the evidence-based nursing andhealth professional leaders. Oman has a development program titledOman 2050 that aims at improving service provision by improvement inleadership among the ENP.

Chapter 3: Quality Improvement

Importance of Service Improvement in Healthcare System

Service improvement in healthcare systems s of essential significanceconsidering the impact it has on the clinical outcome of patientstreated. All the health carefacilities should ensure that they are in a capacity to improve theirservices to clients for attainment of better patient status(Dacosta,2012). The nurse leaderscan ensure that services are improved through the efficientutilisation of the evidence-based practices as well as the knowledgeobtained from the current studies conducted in the field. The conceptof service improvement in healthcare system will see to it that thereis a reduction in the number of clients being readmitted to hospitalsbecause of the quality provided (Tyagiet al., 2013). Forexample, clients seeking services for the first time are advantagedespecially in a case where there is improved treatment. Through thesame, the possibility of the patients being readmitted to thehospital is eliminated. It does emanate from the fact that thepatients got the best services in the first instance eliminating theurge to go back to the hospital (Ahsanul Haq and Ashraf, 2015).Because of the same, one can conclude that service improvement inhealthcare benefits patients since it eliminates the possibility ofthem being readmitted to the hospital a second time.

The importance of serviceimprovement results in a reduction in the cost of healthcareprovision. Treatment of patients is accompanied by the use ofresources ranging from personnel to the capital used. Improvement ofservices in health care would mean that the resources are adequatelyused and that there is no wastage. It would result in the utilizationof resources efficiently reducing the overall cost of treatment. Theeffect is that the hospital would not be overburdened when it comesto provision of services to the patients. The results emanate fromthe fact that there is an improvement in the nature of services beingprovided at the hospital (Fitzgeraldet al., 2007). Further,improved services in healthcare results in the creation of a goodrapport between the care providers and the patients. It is anadvantageous move considering that patients will have confidence inthe nature of services being provided to them. Under suchcircumstances, chances are that the patient outcomes are likely to bepositive. Unlike a situation where the services are poor, patientswho present to the hospital seeking treatment end up doubting thehealth care system (Giannini,2015). The effect is thatthere would be poor patient outcomes. Such is a reflection of theneed to have improved services in the healthcare system.

Leadershipin Health Care System

The nurse leaders shouldcollaborate to complete various tasks and objectives successfully.Leadership style influences the working of the staff as well as themethods of assigning different tasks and the worker relationship(Dacosta, 2012).The development of leadership in medical systems was based profitmaximisation and expense minimization (Hauck, Winsett and Kuric2013). In the contemporary world, healthcare administration passedmany structural adjustments where various styles that fit in thecurrent health systems developed, and services are now managed thanadministered (Royal College of Nursing 2015). The introduction ofleadership in healthcare met a lot of opposition and debate onwhether it would develop healthcare in a similar way as theprofit-based structures. For leadership to be effective in themedical institutions, all the stakeholders should be interested inchampioning and dividing the responsibilities in ways that lead tobetter health care services.

The leadership role of the nursesstems from their social responsibility arising from a complex socialbase and accountability (Sharma and Jain, 2013). The contract betweenthe society and the profession grants nurses the power over functionsvital to the job. Thus the nurses have control over their affairs.The nurses are expected to act in a mindful and responsible way tomaintain public trust. This type of relationship between the nursesand the society is governed by the qualities of self-regulation, tomaintain quality and adequate performance (Kouzes and Posner 2011).This social contract is an indication of nursing’s concrete valuesand ethics, and it provides the basis for health care provision inthe society (Dacosta,2012). The society approvesthe existence of nursing through granting the practice licenses andlegal documents. The nurses are responsible for providing care to thecommunity members regardless of their social or economic status. Theprovision of professional health care services depends on theeducation and the clinical qualification of the nurses and theirprofessional groups which enforce the ethics and standards of thepractice (Sharma and Jain, 2013).

The use of leadership framework anda patient-based care is necessary for the success of a nursing.Nursing is a profession that has aspects of both science and art(Morrow, Robert and Maben 2014). The source of knowledge forprofessional nursing includes the nursing science, philosophy, andethics. Nurses apply theories to refine and increase their knowledge.These ideas are compatible with the professional values of health andhealth care. The nurses use research results and implement therelevant evidence to their practices.

The NHS (2014) model recognises theimportance of patient-based care as it contains segments on thepatient safety and enhanced communication with the patients. Thisdissertation aimed at improving the quality of services in theemergency departments and wards through the incorporation of nursepractitioners in the health institutions. A vision cannot influencechange if it has any relevant evidence supporting it. Some of thedriving forces for change include improvement of health serviceprovision, high acceptance levels of the advanced nurse practitionersand career development (Taylor et al., 2014). The quality assurancedepartment measures the influence of change.


Different leadership theories have been adopted that seek totransform the overall process of healthcare provision. The type oftheory adopted aims at ensuring that it attains the identified goalsas pertains to service provision. Notably, the different leadershiptheories that exist are that the trait, great man, behavioural andcontingency theory(Derue et al., 2011). The application of thetheory in healthcare depends on one’s perception and the impactthat it has on the overall improvement of care (Cherry, 2014). Thetrait theory identifies the fact that individuals are born withqualities that make them appropriate leaders. Some individuals haveused the theory to help in the execution of services in healthcare.The contingency theory reiterates the fact that there is no singleappropriate style of leadership that is effective (Giltinane,2013). It states that the style of leadership adopted should bebased on the prevailing situation at that given instance. Thebehavioural theory instead focuses on the individual behaviour ofleaders instead of their mental, social or physical characteristics(Cherry, 2014). It is vital to consider that the style ofleadership embraced should be based on the individual. Further, it isessential to acknowledge the role of every individual in ensuringtheir capability to perform the tasks assigned to them. Depending onthe situation in a clinical set up, nurses have the mandate to adoptthe style of leadership that works best. Particularly, those workingin the ED must ensure they employ the leadership style that is inline with the prevailing circumstances.

Gage (2013) postulates that leadershave the ability to develop a favourable working environment amongthe staff to generate high levels of patient satisfaction. Theemergency department manager has to collaborate with different groupsto facilitate the process of service improvement. Gillam andSiriwardena (2013) identify the existence of a continuous debate onwhether managers can be leaders and if the reverse is true. A leadershould show respect to those under their jurisdiction and at the sametime guide the staff towards achieving the institutional goals. Theclassical type of leadership was authoritative and thus it oftenfaced a lot of hostility from the staff (Dacosta,2012). Sharma and Jain(2013) illustrate that it is important for the leaders to be alertwhen they are defining institutional goals to the team so that theycan ensure that the subordinates can identify the tasks they areentitled to do.

The leaders have to make sure thattheir subordinates understand the purposes of the new changes andcreate a connecting environment for their staff. The advanced nursesestablish the plans of health care independently and are alsoconsulted by other healthcare practitioners. It is, therefore,notable that communication, advocacy, and collaboration are someevident characteristics of the nursing field. The nursing practiceapplies the knowledge about the human conditions in all stages oflife and the connection of the individual, family, and the society.Qualified nurses possess the knowledge in the art and science ofnursing that would help the nation to attain and maintain its healthstatus.

Various challenges are eminent inthe emergency departments which call for effective adjustments. Amongthe available human resources in the medical departments, nursingpractitioners are the most flexible and they can adjust theirfunctions to accommodate greater changes. It is possible to achievethe satisfactory scope of the nursing practice in a nation such asOman as other countries have experienced success in establishing theprofession. It is evident that the advanced nurse practice is thefuture of the field, and hence the nurses are motivated to upgradetheir knowledge and expertise and acquire better clinicaldecision-making competencies. Some bodies in Oman such as themidwifery council have championed the development of nursing bydevotion to lifelong learning.

The leaders need to grow thenecessary skills to support positive attitudes among the staff. Theclassical period of between the years 1940 and 1960 was characterisedby behavioural leadership style, bureaucratic, democratic andlaisse-fair practices (Giltinane,2013). Increasing theengagement of the staff in various corporate activities may affectthe general productivity of the firm positively. Cain and du Plessis(2013) reiterate that leaders have to be supportive and fair to alltheir workers so that a culture of engagement thrives in theorganisation. To enhance quality and good leadership in aninstitution, the efficient use of RAPSIES modelis necessary.

Kouzes and Posner (2010) developeda theory that emphasises on the individual leader’s qualities. Thetheory suggests that successful leaders should challenge the workprocesses by identifying the areas they feel there is an urgent needfor making changes. These leaders should propagate a vision, which isshared and understood by the staff. It is the responsibility if theleaders to provide tools and methods that would ease the workingconditions of their employees. According to the theory by Kouzes andPosner, a boss directs the staff, telling them what to do andapproving the applicability of the various methods. The leader shoulddesign the procedures and plans necessary for attaining success in anorganisation. This theory can be applied to the leadership roles ofthe nursing practitioners as it provides a working framework for theprofession where the healing practitioners can derive their values.The theory not only serves as a practical framework but also as anassessment tool for the performance of the nurses’ leadership.

LeadershipStyles (Transformational Leadership)

The health care profession mainlyapplies the transformational type of leadership as it motivates thestaff to give their best efforts at work (Berlin 2014). This stylehas its focus on evidence-based change through effective leadershipand overcoming the various barriers. The individual nursepractitioners are responsible for the quality of services providedwithin their area of operation. The difference in the levels ofstandards may be influenced by variations in education, fieldexperience, and the individual skills. The nurses’ drive is theultimate factor of professional accountability. The nursing field iscontinually evolving and is flexible. Thus, it can adjust as per thechanges that occur to the needs of the society. Nursing practitionerscollaborate with other professionals in areas such as sharing ofknowledge, skills, and ideas in the delivery and evaluation ofhealthcare (Schwartz and Schwartz, 2015). The advanced nurses mayshare various responsibilities and missions with other professionalsand refer their patients to other service providers whenever it isnecessary.


The advanced nurse practitionerscan refer to RAPSIES model to assess their overall performance andthe suitability of their qualifications. The ENPs can also apply thetheories to ensure that the workers are encouraged, and the staff’smorale can be kept in check. The important aspects of the theory arethat it highlights the typical leadership behaviour, qualities, andattitudes but it does not address the socio-political issues that arecrucial for effective leadership (Dacosta,2012). There are variousmodels used for service improvement including the National HealthService (2010), Rapsies, Kotter’s, and NHS (2014). Some of theimplementation strategies include the Plan-Do-Check-Act (PDCA) cycle,the Tuckman Model, Lewin’s theory, power-coercive and empiricalrationale (Johnson and Raterink 2009).

The RAPSIES model is a usefulmethod for the nursing practitioners to develop and initiate plansand medical services. The ENPs can use this framework to enforceadequately care service provision in the emergency departments. Thismodel is a measurement tool that aids to establish the plannedchange. The model consists of seven stages:

Recognition:this is the stage of realising the necessity of changing a variableso that the institution can solve some real drawbacks and enjoys thebenefits of the modification. The leaders have to ensure that thechange they are introducing fits into the institutional culture andthe employees can easily apply it (Dacosta,2012). The introduction ofnursing practitioners in the emergency departments arose from theneed for concrete solutions to the challenges experienced in thesesectors. The health institutions recognised the need for nursepractitioners as the regular nursing system seemed overstretched andthere was the need for introducing a more skilled workforce, whichwould handle their responsibility quickly while still maintainingquality services.

Analysis:this is the evaluation of available choices that relate to theproposed change, the working area, and the staff. The leaders shouldensure a proper working environment and the service provider’spreparedness. The ability of the nurses to develop therapeuticrelationships with their clients justifies the need for theirincorporation into the emergency departments.

Preparation:this stage begins with selecting the important change agents, with apotential to arrive at the desired outcome in a creative way. Growthprocess commences by the selection of the change agents, who shouldbe creative, have the proper field experience and have excellentcommunication skills. The agents have to possess the skills ofdeveloping effective plans and solutions to the expected challenges.The nurse leaders have to ensure that the institution and theemployees are prepared to accept the changes as well as ensuring thatthe required resources and funds are available. It is necessary forthe healthcare professionals to be equipped with the skills torecognise the leadership techniques and the relevant theoreticalframework for their nursing profession.

Strategies:this step involves the careful management and planning of theintroduced change. Gopee and Galloway (2014) propose severalstrategies such as plan-do-study-act (PDSA), normative–re-educativestrategies, empirical-rational, power-coercive and Lewin’sthree-stage process. Also, collaboration among the skilled personnelis needed to foster participation and a collaboration environment.The strategies should be reflective of the scientific method ofenforcing the change to eliminate any anticipated barriers.

Implementation:this stage should reflect the scientific method of applying themodification of the planned strategies for minimization of obstacles.The leaders enforce the already developed plans in the organisationin such a way that they can yield the expected changes and bringabout improved service provision in the emergency departments.

Plan:an adequately constructed proposal file, which contains validindicators that represent the reality of the problem, is prepared atthis stage alongside a strategy with clear objectives. Planning forchange involves the higher management and other paramedical such asthe director of nursing and health affairs who provide greatersupport. The examination room planning and designed should be in anattractive way to accommodate visual aid and comfortable testingfacilities such as couches. The availability of all the requiredresources such as labour, education and training resources, timeframeand funds eases the process of dialogue with the decision makerswhile seeking their approval of the proposed changes.

Do:this is the process where the change takes shape and applies for thefirst time. The nurses begin their leadership roles based on theirtraining. At this stage, the nurse practitioners should implementsuch processes as the registration of the patients, physicalassessments and document the patient’s records or any otheranalysis and follow-up on the patients. The nurse leaders shouldfollow the patient flow, assess the communication hindrances as wellas the suggestions made by the patients and the staff. The nursepractitioner should develop an accessibility period that is to assistthe staff to overcome these barriers.

The study:it involves data analysis of the actual outcomes against the expectedresults. There is always the possibility of the occurrence of newchallenges and threats as the change process goes on. This stageinvolves the investigation of how efficient the nursing practices arein an aim to improve the patients’ health conditions through betterclinical outcomes and follow-up compliance. The study is used toassess the performance of the new changes in the medical departments(Schwartz and Schwartz, 2015). Other methods for carrying out thereview may be introduced such as the survey, or questionnairespresented to the patients to the patients to assess the medicaleffectiveness of the proposed changes. The leaders utilise the datagenerated by these review methods to evaluate the strengths and theshortcomings of the applied methods and be able to make changes orcreate new designs that are useful for future implementation.

Act:at this stage, the change agents utilise the evidence they havegathered to plan for the subsequent evaluation. This step involvesthe preparation of documents indicating the various types of actiontaken, the methods used and the outcome of these efforts. Effectingchange successfully requires a lot of effort. Thus, it is necessaryto carry out the change gradually and keep evaluating the otherlocations’ working conditions to assess the differences inresources, the institutional cultures and the levels of acceptance ofthe new changes among those societies.

Evaluation:this phase reviews whether the objectives have been obtained and theanalysis of proof for guidance and continuous service improvement.Evaluation allows the individuals to determine whether his or herplan is effective as they expected or if at all there is need to makeadjustments to the overall process. At this stage, the researcher canconclude whether the introduction of the nursing practice was usefulor not.

Sustaining:is the ability to implement a change continuously without challengesand interferences. The continued follow-up and response to reports onthe progress of the introduced change and the effectiveness of itsimpact is crucial to obtaining and sustaining the senior management’ssupport. The leaders should focus on creating an innovative andcoordinative working environment, which inspires the staff and allowsfor the use of evidence-based practices to support the substantialcontinuity of the change.

Barriersto Implementation

Some of the obstacles that leadersmay face in the nursing practice include insufficient orientation onthe role of an advanced nursing practitioner. The leaders alsoencounter cases of lack or inadequate finance for their activities,which is a major hindrance for the profession (Rich and Butts 2013).Nurse leaders also require mentorship as some tasks may needassistance to complete. The nurse leaders may adopt the doctors astheir mentors.

The four commonly studied barriersincluded innovation, communication, the person and the organisationalsetting perceived to be the major obstacle (Schwartz and Schwartz,2015). The corporate barriers include the low levels of priorityadvance by the management to the evidence-based practice. There arecultural barriers including the ambiguity of roles and practices, theover-emphasized routine patient care and lack of motivation toembrace the changing practice.

Ethical Consideration

Nurses have the mandate to ensurethat they execute the delivery of services to patients in aprofessional and ethical manner. Patient needs must be upheld andtaken into consideration at any given moment. It is vital for thenurses working at the emergency department to coordinate with otherprofessionals to deliver the best care to patients. Emphasis shouldbe on ensuring that one conducts activities in the most ethicalmanner.

Recommendations for ImprovedServices at the Emergency Department

The review of literature indicatesthat nurse practitioners have a fundamental role to play when itcomes to enhancement of services at the emergency department.Notably, nurse practitioners have been instrumental in improving thequality of care, increasing patient satisfaction and reducing theduration of stay in the hospital. However, it is vital to come upwith ways that seek to motivate nurses at the emergency departmentinto executing tasks assigned to them. The leadership should takemeasures that aim at encouraging the nurses to perform better in anddeliver the best services to patients. Further, it is vital that thenurses are given an opportunity to provide their views on how theycan improve the services at the emergency department. Through thesame, it would be possible to attain the best services to patients.


The emergency departments need tobe prepared adequately to meet the demands for quality healthservices, and they should have qualified and competent staff. Theintroduction of nursing practitioners into the emergency departmentsbrought beneficial changes to the quality of services offered as wellas patient satisfaction and reduced stay at the hospitals (Cain anddu Plessis 2013). After considering the presence of numerous barrierssuch as the administrative and the institutional barriers, it isimportant to develop practical measures to support the change (Gillamand Siriwardena 2013). The main strategies for successful change areeffective management strategies and effective leadership. Leadershave to be certain of their abilities to improve and empower theirsubordinates for practical introduction of new changes to theservice. However, any change is prone to various levels of resistanceagainst it. For there to be effective shifts in the nursing practice,the leaders should have concrete evidence and managerial skills sothat they can gain support from the senior management in nursing.

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Cost effectiveness of nurse practitioners

The introduction of changes requires an assessment of its value,therefore, providing a decision basis for implementing the change ormaintaining the existing type of care.

Difference between Leadership and Management










Focused on systems and


Focused on people.


use control.

Inspire trust.


focused on the

bottom line.

focused on the horizon

PDSA Cycle



  • Communicate with stakeholder the new plan.

  • Provide a clear job description and scope of practice.

  • Define the objectives:

  • Foster the quality of care.

  • Increase client satisfaction.

  • Reduce the cost of services.

  • Personal and professional growth

  • Review of the international evidence.

  • Reduce waiting for span

  • Maintain good relationship with the staff

  • Conduct survey for six months.



  • Analyse and discuss the data them in the meeting.

  • Continued evaluation and arrangement

  • Ensure running of the new change.



  • Have a regular meeting.

  • Involve expert from different filed.

  • Compare current data with the previous data.

  • Make a suggestion for improvement.



  • Supervision

  • Evaluate and write a report.

  • Define clear goal and role in the practice.

  • PDSA cycle has to done continuously