Course name

University name

City, state


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


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 content


Page NO.

Title page





Table of content


Chapter 1


Dissertation aim


Chapter 2


Research strategy


Key words


Literature review




Chapter 3

Quality improvement


Leadership tools


Qualities of a good leader






Transformational leadership


Chapter 4







Chapter 1

The Impact of nurse practitioner services in the emergencydepartment towards clinical effectiveness

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, Dawson,Admaschew and Topakas 2012). An important indicator of qualityservices in the medical sector is the type of services offered in theemergency areas. In the contemporary world, the nursing practitionershave taken up a vital role in the medical field, and they seem to becloser to the patients than the doctors are. The nurses areresponsible for conducting various essential services in thehospitals such as the diagnosis of patients, minor surgeries andadministering drugs. The building up of pressure on the servicesoffered by the emergency departments necessitated the invention ofcreative strategies, which incorporated the emergency nursepractitioner 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, theywere called casualty.

Advanced nursing practice relies on the skills of the individualnurse (Taylor, McNicholas, Nicolay, Darzi, Bell and Reed 2014). Theemergency departments operate without closing so that the patientscan have a guarantee of accessing medical services at any time.Emergency units exist to serve people who may be involved in somefatalistic situations that would require the immediate interventionfrom the medical practitioners otherwise, many people would die.Other services offered by the nursing professionals in the emergencydepartments include the telephone consultations. According to Gopeeand Galloway (2013), this function reduces the backlog that isexperienced in the emergency rooms and is suitable for the lesssevere health issues such as minor cuts. Telephone triage servicesserve in a variety of places such as general practices and theprimary health care setting. Other specialist services such as thepaediatrics use this method to communicate with the various clientsand personnel. In the recent times, the medical departments haveexperienced a growth in the use of telephone triage to manage themassive demand for emergency services, especially on general healthissues. Some examples of this service in different nations includethe NHS Direct in England and the Norwegian primary care out-of-hoursservices.

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 a common 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?

Chapter 2

Literature review: Introduction

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.

Searching strategy

Various methods are useful ingathering resources and accelerating the process of investigation. Inmy work, I used the Google Scholar as a search engine to explore thethemes, and content from various sources such as books, articles,PDFs and peer-reviewed journals. I also used other sources of datasuch as PubMed, Oman MOH e-library, BMJ and SAGE. I limited my datato that written between the years 2006 and 2016 with English as mydefault language. My search initial yielded 56 articles, and I usedexclusion 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. These issues include:

• 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

Literature review

Patient satisfaction

Patient satisfaction is a result ofquality health care. There is the need to raise the levels of patientsatisfaction in the emergency departments in a bid to provide qualityservices. Dinh et al. (2012) conducted an observational study of theemergency departments at district-based hospitals in Australia aimingat investigating the quality of care provided by the ENP andemergency doctors. The study utilised a sample of 240 patients,analysed by the ENP and physicians in the fast track unit.Convenience sampling does not use random samples, and it might leadto biased findings. The study collected data throughself-administered surveys among the patients. One of the importantaspects to analyse about the study was the response rate, which stoodat 75%. If the reply rate ranges from 60-80%, then the sample isconsidered excellent. Only 75% of the total patients were able tocomplete the initial evaluation significantly limiting the study. Theabove limitation may lead to a selection bias, which is a majorproblem in many surveys.

Polit and Peck (2010), state thatbias is a common risk in the internal validity of non-experimentaldesigns. The study concluded that the ENP care in the emergencydepartments yielded higher patient satisfaction compared to theemergency doctors (p&lt0.002). The p-value is the probabilitydifference between the chance and the cause and effect relationship(Holland and Rees 2010). Jennings et al. (2008) asserted the findingof the above study after conducting a survey on the trauma centre inAustralia.

The study aimed at assessing thepatient satisfaction. The survey administered questionnaires to 202emergency department patients to compare care delivery of theemergency nurse practitioners against the emergency doctors. Amongthe total 16 questions asked, 12 of them showed significantdifferences in patient satisfaction with a p-value of (&lt0.005).The study affirms the importance of nursing practitioners inproviding quality services. The study findings indicate that need foremergency nursing professionals in the emergency departments towardsservice improvement. Some previous studies conducted in theinstitution used a similar style of administered questionnaires(Jennings et al. 2008 Dinh et al. 2012). The self-administeredquestionnaires are a cheap and fast way of obtaining information froma large sample.

A qualitative analysis by Boudreauxand O`Hea (2004) investigated the quality of services provided by theemergency nursing practitioners and the addition of patientsatisfaction in the emergency sectors by the EPNs than the emergencydoctors. They analysed the effect of the Emergency NursePractitioners (ENP) to the clinical practices and explored thestrengths and shortcoming of the practice using secondary data mainlyfrom other studies. The review provides highlights for improvement offuture research. The study concluded that the perceived waiting timeis closely associated with patients’ satisfaction than with theactual waiting time and indicated that the EPNs had made severalefforts to improve the quality of services and were able to attend tothe patients quicker than the doctors (p&lt0.008), and had shown thepossibility of success.

The qualitative analysis of theimplication of increased patient care on the adjustments inhealthcare towards patient satisfaction (Gittell, Fairfield,Bierbaum, Head, Jackson, Kelly, Laskin, Lipson, Siliski, Thornhilland Zuckerman 2010) indicate that health care institutions facepressure from the managed care services to achieve efficiency. Thehealthcare facilities have made efforts to meet these demands throughcoordination with other professionals and management of theinterdependency of the tasks. The study’s aim was the introductionof the concept of EPNs and the assessment of the influence ofcross-cultural collaboration on the Patient satisfaction. Otherobjectives of the study included the analysis of the impact ofcooperation on the prospective pain and responses and the impact onthe length of stay for the patients in the emergency rooms. The studyconcluded that increased cross-cultural collaboration between thestaff working in the emergency departments led to greater levels ofpatient satisfaction (p&lt0.003). increased collaboration betweenthe EPNs and the emergency departments doctors had the highest impacton patient satisfaction (p&lt0.02)

Based on the research from TheLeadership Challenge, Kouzes and Posner (2011) explore the concept of&quotleadership above all relationships.&quot Their research restson the credibility and certainty of the actions of the EPNs. Theymaintain that EPNs must say what they mean and mean what they say.Their work featured comprehensive studies and all the data andresearch were up dated, conducted in a streamlined format, andrevealed the six principal areas that strengthen a EPN’s ability todevelop and maintain credibility. In the emergency departments,credibility is an important aspect towards patient satisfaction(Blank, Coster, O’Cathain, Knowles, Tosh, Turner and Nicholl 2012).It ensures that the nurse practitioners are responsible for theiractions, and they fulfil their obligations. James and Barry providepractical illustrations of the ideal actions of the EPNs, whichinclude updating the applications and research. This guide provides areference point for the nursing practitioners to understand the needfor credibility in their efforts towards personal and organisationaldevelopment.

In the same way, Marquis and Huston(2009) incorporated application and theory in their work andemphasised on critical thinking, problem solving and decisionmechanisms. They conducted more than 225 case studies and learningprocedures to enhance critical thinking and interactive studies. Thescope of their study included the acute care systems, ambulatoryservices, continued provision of care services and the societalhealth. In their book, Marquis and Huston address some sensitiveissues in the ENP field such as the development of leadership skills,management of the human resources, controlling of the workenvironment and staff relationships, ethics, technology and otheraspects. This study explores the various characteristics of ENPleadership in the emergency departments towards patient satisfaction.It indicates that there have been numerous improvements in the levelsof patient satisfaction in the emergency departments after theintroduction of the ENPs (p&lt0.004). The study gives the reader anopportunity to understand the complex nature of leadership in thehealth departments. This work is crucial for those training to benurse practitioners as it provides a general overview of theprofession’s environment.

Porter and Malloch (2015) conducteda qualitative assessment of the leadership skill-set needed for theEPNs. The key aspect of their work is the separation of leadershipand management. The translations that help the students to adopt theleadership roles are emphasized. Emergency nursing practice is abroad field covering a variety of topics such as the growth of theprofessional role, time management, financial management,negotiation, decision-making techniques among other aspects (Shanks,2016). The text identifies the importance of the nurse practitionerin the medical departments towards increasing the levels ofsatisfaction with emergency services among the patients (p&lt0.001).

Length of stay in emergencydepartment

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,O`Reilly, Lee, Cameron, Free and Bailey (2008) supported thenecessity of the introduction of emergency nurse practitioners on thewaiting times and span of stay of the patients in one of the centralemergency departments in Melbourne, Australia. The gap of theemergency nurse practitioner exists, and it is part of the Victorianstate funded projects meant to improve patient care (Giltinane,2013). This study utilised all the patients’ subgroups in generalemergency departments. The expected outcome measures were the waitingtimes and length of stay. The investigation classified the subjectsinto two groups one that was managed by the emergency nursepractitioner and the other by the traditional model of care. Therewere statistically significant differences in the waiting times andlength of stay in the emergency departments between the two groups.The average waiting period for the emergency patients served by theENP was by far less than the traditional model group (p&lt0.0002).We can presume that the implementation of the emergency nursepractitioners in Melbourne, led to significant reduction in thewaiting spans in the emergency departments. Therefore, the nursepractitioners are a potential solution to the long-term influx in thedemand for emergency department services. This study was the initialresearch of its sort in Australia that used significant sample sizesto compare the difference in the waiting spans impacted by differentmedical 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 increasingwith a 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.

Quality of care

Many literature reviews indicate apositive impact of the role of emergency nurse practitioners (ENP) inenhancing high standards of services offered in the emergencydepartments (Giltinane 2013). The ENP are responsible for making manydecisions in the health departments (Warburton, 2009). Effectiveleadership is the secret towards the efficient operation of allclinical practices Marquis and Huston (2009). However, the analyticalmethod applied to analyse the quality of healthcare is not sure.There are varying definitions of the quality of health care amongvarious nationalities. For instance, in Australia, clinicalevaluation forms were used by the quality assurance departments inOman to assess the length of stay in the emergency departments of thetertiary health institutions in 2004. While the average duration ofstay was 4 hours, the rate of those patients discharged before thistime increased by 45% for those who attend the emergency departmentsand required admission. Therefore, introducing the role of ENP inOman is crucial to enhance the current quality of care. The qualityof health care is about providing the best care services to thepatients (Thompson and Dowding 2009).

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.

Colligan et al. (2011) carried outa prospective audit to evaluate the effectiveness of the ENP andemergency physicians in managing minor trauma cases. The analysisinvolved 420 patients and it yielded the first results confirming asignificant reduction in the waiting time due to the introduction ofthe ENPs. The patients stay reduced with 40 minutes when served bythe ENPs compared to emergency physicians (P &lt 0.0001).The mainreason for this variation is that the nurse can finish all the carealone compared to the doctors who often need assistance in someactivities such as dressing, and filling of the patient records.Colligan et al. (2011) indicate that the ENPs are entitled tomanaging only the minor cases, while the emergency physicians areresponsible 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)

Due to the unavailability ofmeasurement tools, the excellence of healthcare is not widelyanalysed. Some nations such as Oman apply the internationalframeworks to evaluate the quality of healthcare delivery. Thisframework uses several measurement aspects to investigate the qualityof care in the emergency sectors.

Administration practices involvemany roles including the handling of conflicts, for instance,Nakayama, Bushey, Hubbard, Cole, Brown, Grant and Shaker (2010)conducted a study on conflict as a negative force in any workenvironment. This study involved fifty-nine educators who includedthe principals and utilised some techniques such as open-endedquestionnaires, focused group discussions and semi-structuredinterviews. The investigation aimed at analysing the implications ofconflict and the best policy options to resolve it. The studyconcluded that conflict could have both positive and negativebenefits. The benefits included heightened relationships among theworkers, improved understanding of each other at workplace and changein attitudes for the better. The overall finding of the study wasthat conflict set back the working environment as it resulted inintolerance, defiant attitudes, division of unity and absenteeism.The nursing practitioner is entitled to control the workplace andresolve all types of conflicts before they culminate into problematicscales (Barr and Dowding, 2012). This precautionary step wouldprevent the interruption of the working places and ensure that themedical services are provided as required.

Similarly, Morrow, Robert and Maben(2014) explored the nature and influence of the ENP on qualityimprovement efforts in health institutions. The study used secondarydata collection techniques. The primary sources of informationincluded the implementation of The Productive Ward and the otherstudy on Releasing Time to Care in English hospitals. The studyexplored the leadership techniques and related them to localimplementation. A framework approach was used to investigate theopinion of the staff and recognise the workplace issues. The studywas able to identify four themes that included different leadershiproles and levels in the organisation, the effects of good and badleadership techniques, the role of frontline staff in influencingchange and the ENP’s initiatives to increase learning and sustainimprovements. The setting of administration processes developed inthis study may guide the ENP to implement plans tailored towardsachieving successful leadership at various levels. This study alsoprovides a guideline of the appropriate roles of leadership and thevarious techniques and responses that are likely to be encountered atdifferent stages of implementation. The study provides valuableinformation that would aid to understand the simple and emerginghealthcare techniques, placing particular emphasis on health carestructures and processes. The paper explores the various techniquesthat can be useful in influencing the interaction between healthworkers.

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. 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 health 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, Warburton 2009). Some studies (Nakayama 2011,Morrow, Robert and Maben 2014, Gittell 2010 and Marquis and Huston2009) make efficient use of questionnaires and case studies in theirinquiry which proves on the originality of their findings.


The review of the literature aboutnurse practitioners proves that the ENP can raise the quality ofservices offered in the emergency departments (Grossman and Valiga2012). The literature review demonstrates the effect of incorporationof the nursing practitioner to improving the quality of careservices, increased patient satisfaction and the reduced timewastage. There is a need for continued improvement of the nursingpractice so that the profession can deal with the changingrequirements of the society. ENPs have the duty to maintain safe,accessible and high standard care in the emergency departments. Theintroduction 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

Clinical leadership is entitled toinfluencing service improvements and a subsequent change in theservice so that the profession can maintain its relevance in adynamic world (Hauck, Winsett and Kuric 2013). All the health carefacilities should ensure that they are in a capacity to providequality services to their clients to improve their health status. Thenurse leaders can ensure that there is the efficient utilisation ofthe evidence-based practices as well as the knowledge obtained fromthe current studies conducted in the field. Many literature reviewsare in consensus with the notion that a nurse leader is an importantfacilitator of advanced nursing practitioner services in theemergency departments.

Effective leadership would requireadequate collaboration among the various professional groups and thedevelopment of a culture that accommodates change throughinstitutional development (Hauck, Winsett and Kuric 2013). Thechanges that occur in the medical field face many challenges, andthey require further investigation, evaluation, and planning toimplement them successfully (Hauck, Winsett and Kuric 2013). Themanagement of service improvement should have an effective plan and aproper transformation mechanism to implement the plan (Warburton2009). According to Gage (2013), the National Health ServiceFoundation (NHS) governs the healthcare facilities in the UnitedKingdom and its administration follows sophisticated evidence-basedpractices. Other nations such as Oman have their Ministry of Health(MoH) as the governing body of all the health care systems in thecountry. This organisation has developed several programs to tacklethe challenges in health care. All the nurses in the health sectorneed to have the knowledge about the weight of responsibilitiesbestowed on them, to impact successful changes (Christie, Hamill andPower 2012).

Leadership addresses the corevalues and behaviours that are necessary for the evidence-basednursing and health professional leader (Malloch and Porter (2016).The nurse practitioner should identify the evidence-based practicesthat can improve, translate and measure the nature of leadinginnovations in health care institutions (Hauck, Winsett and Kuric2013). Advanced nursing has an established leadership responsibilityin the organisation, provision, and funding of adequate medicalservices (Sanchez, Smally, Grant and Jacobs 2006). All the citizensare entitled to quality health care and hence it is necessary toaddress the issues of increasing cost of obtaining health services.It is the role of a nurse practitioner to bridge the disparities inhealth care such as the lack of secure, convenient and availablehealth care services and resources (Johnson and Raterink 2009). Thenurses have increased the knowledge on self-help measures among theindividuals and the society in general. The incorporation oftechnology and evidence in nursing may improve the implementation andevaluation procedures associated with the generation of knowledge inthe health sector. The practice of collaboration among the nurses isa good response technique to the needs of the patients and it ensuresthat the available resources are used optimally to provide healthservices to the whole society (Halm 2010).

The advanced nurses focus ondeveloping effective working relationships and collaboration with anaim to achieve their health- related objectives (Rycroft-Malone,Harvey, Kitson, McCormack, Seers and Titchen 2012). Various factorscombine and magnify the importance of physical human interactions,communication, and cooperation. Professional collaboration is thereal partnership, recognition of expertise, power, and respect fromall the parties (Hauck, Winsett and Kuric 2013). For the organisationto be productive, the various proponents have to accept the differenttraits and common nature of activities and responsibilities. Throughcollaboration, the nursing professionals protect the interest of eachparty and their shared objectives. Effective collaboration requiresthe nurses to tackle various conditions through the recognition,assessment, and adaptation to the type of working connections amongthe individuals and other health workers.


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.

Leadership in health care

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(Christie, Hamill and Power 2012). The development of leadership inmedical systems was based profit maximisation and expenseminimization (Hauck, Winsett and Kuric 2013). In the contemporaryworld, healthcare administration passed many structural adjustmentswhere various styles that fit in the current health systemsdeveloped, and services are now managed than administered(RoyalCollege of Nursing 2015). The introduction of leadership inhealthcare met a lot of opposition and debate on whether it woulddevelop healthcare in a similar way as the profit-based structures.For leadership to be effective in the medical institutions, all thestakeholders should be interested in championing and dividing theresponsibilities in ways that lead to better health care services.

The leadership role of the nursesstems from their social responsibility arising from a complex socialbase and accountability (Sharma, M., and Jain, S. 2013). The contractbetween the society and the profession grants nurses the power overfunctions vital to the job. Thus the nurses have control over theiraffairs. The nurses are expected to act in a mindful and responsibleway to maintain public trust. This type of relationship between thenurses and the society is governed by the qualities ofself-regulation, to maintain quality and adequate performance (Kouzesand Posner 2011). This social contract is an indication of nursing’sconcrete values and ethics, and it provides the basis for health careprovision in the society (Christie, Hamill and Power 2012). Thesociety approves the existence of nursing through granting thepractice licenses and legal documents. The nurses are responsible forproviding care to the community members regardless of their social oreconomic status. The provision of professional health care servicesdepends on the education and the clinical qualification of the nursesand their professional groups which enforce the ethics and standardsof the practice (Sharma, M., and Jain, S. 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 nursing practitioners make useof theories, evidence-based knowledge and responses to collaboratewith the patients and other professionals to diagnose, implement andevaluate care services as well as identifying the various outcomes oftheir decisions (Gopee 2015). The advanced nurses utilise theevidence- based practice as a basis for quality patient care and asan evaluation technique for care related to desired results.Cunningham and Kitson conducted an analysis on the United Kingdom’sRoyal College of Nursing clinical leadership courses and concludedthat there are five key areas necessary for developing leadership(Royal College of Nursing 2015). They include:

• Managing self, where nursesevaluate their strengths, weaknesses, and motivations.

• Leading the team- one has toknow the theories that hold and are concerned with working people. Itis important to assess what constitutes of a good team working, thecore skills required for coordination and the dynamics of theworkplaces.

• Another critical area is thepatient-centred care. The nurse practitioners have to identify thekey hindrances of their practice to achieving user-centred attention.The advanced nursing professionals have to assess the possibility oftheory and practice of the client-based care and determine the safetymechanisms.

• For the healingpractitioners to facilitate their leadership skills, they need toestablish proper networks and ensure that they have the appropriateskills for networking.

• Political awareness isanother requirement for developing effective leadership skills. It isimperative to identify the legal structures that may help or hinderthe nursing practitioner’s agenda.

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 no 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, McNicholas, Nicolay, Darzi, Bell andReed 2014). The quality assurance department measures the influenceof change.

Leadership styles and tools

Leaders who have the abilities todevelop a favourable working environment among the staff can generatehigh levels of patient satisfaction (Gage 2013). The emergencydepartment manager has to collaborate with different groups tofacilitate the process of service improvement. For some time, therehas been a continuous debate on whether managers can be leaders andif the reverse is true (Gillam and Siriwardena 2013). A leader shouldshow respect to those under their jurisdiction and at the same timeguide the staff towards achieving the institutional goals. Theclassical type of leadership was authoritative and thus it oftenfaced a lot of hostility from the staff (Christie, Hamill and Power2012). It is important for the leaders to be alert when they aredefining institutional goals to the team so that they can ensure thatthe subordinates can identify the tasks they are entitled to do(Sharma and Jain 2013).

The leaders have to make sure thattheir subordinates understand the purposes of the new changes andcreate a connecting environment for their staff. Advanced nursingnecessitates the use of critical thinking during the selection of theavailable evidence-based techniques to provide health services andpromote human functions and responses (Christie, Hamill and Power2012). The advanced nurses establish the plans of health careindependently and are also consulted by other healthcarepractitioners. It is, therefore, notable that communication,advocacy, and collaboration are some evident characteristics of thenursing field. The nursing practice applies the knowledge about thehuman conditions in all stages of life and the connection of theindividual, family, and the society. Qualified nurses possess theknowledge in the art and science of nursing that would help thenation to attain and maintain its health status.

Various challenges are eminent inthe emergency departments which call for effective adjustments. Amongall the 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 (Christie, Hamill and Power 2012). Increasingthe engagement of the staff in various corporate activities mayaffect the general productivity of the firm positively. The leadershave to be supportive and fair to all their workers so that a cultureof engagement thrives in the organisation (Cain and du Plessis 2013).To enhance quality and good leadership in an institution, theefficient use of RAPSIES model

is necessary (Christie, Hamill andPower 2012).

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.

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 (Christie, Hamill and Power 2012).There are various models used for service improvement including theNational Health Service (2010), Rapsies, Kotter’s, and NHS (2014).Some of the implementation strategies include the Plan-Do-Check-Act(PDCA) cycle, the Tuckman Model, Lewin’s theory, power-coercive andempirical rationale (Johnson and Raterink 2009).


The RAPSIES model is a usefulmethod for the nursing practitioners to develop and initiate plansand medical services (Christie, Hamill and Power 2012). The ENPs canuse this framework to enforce effectively care service provision inthe emergency departments. This model is a measurement tool that aidsto establish the planned change. 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 (Christie, Hamill and Power 2012). Theleaders have to ensure that the change they are introducing fits intothe institutional culture and the employees can easily apply it. Theintroduction of nursing practitioners in the emergency departmentsarose from the need for concrete solutions to the challengesexperienced in these sectors. The health institutions recognised theneed for nurse practitioners as the regular nursing system seemedoverstretched and there was the need for introducing a more skilledworkforce, which would handle their responsibility quickly whilestill maintaining quality 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 providerspreparedness. 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 waseffective or 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 strongcontinuity of the change.

Transformational leadership

The health care profession mainlyapplies the transformational type of leadership as it motivates thestaff to give their best efforts at work (M. 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 (Christie, Hamill and Power 2012). Thedifference in the levels of standards may be influenced by variationsin education, field experience, and the individual skills. Thenurses’ drive is the ultimate factor of professionalaccountability. The nursing field is continually evolving and isflexible. Thus, it can adjust as per the changes that occur to theneeds of the society. Nursing practitioners collaborate with otherprofessionals in areas such as sharing of knowledge, skills, andideas in the delivery and evaluation of healthcare (Schwartz andSchwartz, 2015). The advanced nurses may share variousresponsibilities and missions with other professionals and refertheir patients to other service providers whenever it is necessary.


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 international evidence.

  • Reduce waiting span

  • Maintain good relationship with the staff

  • Conduct survey for period of six months.



  • Analyse and discuss the data them in the meeting.

  • Continued evaluation and arrangement

  • Ensure running of the new change.



  • Have regular meeting.

  • Involve expert from different filed.

  • Compare current data with the previous data.

  • Make a suggestion for improvement.



  • Supervision

  • Evaluate and write report.

  • Define clear goal and role in the practice.

  • PDSA cycle has to done continuously