Sangster-Gormley et al.

BMC Nursing 2013, 12:1

http://www.biomedcentral.com/1472-6955/12/1

RESEARCH ARTICLE Open Access

A case study of nurse practitioner role

implementation in primary care: what happens
when new roles are introduced?
Esther Sangster-Gormley1*, Ruth Martin-Misener2 and Fred Burge3

Abstract
Background: At the time of this study (2009) the role of the nurse practitioner was new to the province of British
Columbia. The provincial government gave the responsibility for implementing the role to health authorities.
Managers of health authorities, many of whom were unfamiliar with the role, were responsible for identifying the
need for the NP role, determining how the NP would function, and gaining team members’ acceptance for the
new role.
Method: The purpose of the study was to explain the process of nurse practitioner role implementation as it was
occurring and to identify factors that could enhance the implementation process. An explanatory, single case study
with embedded units of analysis was used. The technique of explanation building was used in data analysis. Three
primary health care settings in one health authority in British Columbia were purposively selected. Data sources
included semi-structured interviews with participants (n=16) and key documents.
Results: The results demonstrate the complexity of implementing a new role in settings unfamiliar with it. The
findings suggest that early in the implementation process and after the nurse practitioner was hired, team
members needed to clarify intentions for the role and they looked to senior health authority managers for
assistance. Acceptance of the nurse practitioner was facilitated by team members’ prior knowledge of either the
role or the individual nurse practitioner. Community health care providers needed to be involved in the
implementation process and their acceptance developed as they gained knowledge and understanding of the role.
Conclusion: The findings suggest that the interconnectedness of the concepts of intention, involvement and
acceptance influences the implementation process and how the nurse practitioner is able to function in the setting.
Without any one of the three concepts not only is implementation difficult, but it is also challenging for the nurse
practitioner to fulfill role expectations. Implications for research, policy, practice and education are discussed.
Keywords: Nurse practitioner, Implementation, Role, Barriers, Facilitators, Role implementation, Primary care

Background grow, there is no consensus on how best to define, intro-

Advanced practice nursing is an umbrella term used to duce, or implement these roles in primary health care
designate nursing practice that demonstrates competen- (PHC) [5,7,8]. The lack of consensus on how to imple-
cies beyond the traditional scope of the registered nurse ment advanced nursing roles has contributed to the
[1]. Interest in advanced practice nursing roles continues complexity in establishing best practices for their imple-
to spread around the world as evidenced by the 60 dif- mentation [2,7]. Consequently, there is a need for con-
ferent countries in which such roles have been imple- tinued knowledge development of factors affecting
mented [2-6]. While international interest continues to successful role implementation.
The International Council of Nursing, International
Nurse Practitioner/Advanced Practice Nursing Network
* Correspondence: egorm@uvic.ca
1
School of Nursing, University of Victoria, PO Box 1700STN CSC, Victoria,
(INP/APPN) defines nurse practitioner (NP) as “a regis-
British Columbia V8W 2Y2, Canada tered nurse who has acquired the expert knowledge
Full list of author information is available at the end of the article

© 2013 Sangster-Gormley et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
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base, complex decision-making skills and clinical compe- develop an NP role description, create a format for
tencies for expanded practice, the characteristics of submission of proposals for new NP positions, and
which are shaped by the context and/or country in recommend strategies to introduce and implement the
which s/he is credentialed to practice” [9]. Although NPs new role.
have been in existence in the United States for more
than 40 years, their introduction is more recent in other Implementation
countries including Canada. Researchers have identi- What is meant by implementation can differ from one
fied difficulties with implementing the NP role in PHC setting to another; therefore, in this study, we defined
settings where team members are unfamiliar with it implementation as the process used by the health au-
[10,11]. The purpose of this study was to understand thority to add an NP to the health care team in PHC set-
and explain the process used to implement the NP role tings. From the literature we knew that complex
into a health authority in BC, and factors that influenced organizational systems function synergistically to influ-
the ability of NPs to enact the role. The purpose of this ence expected outcomes of any new initiative [22-25].
paper is to describe the results of that study. Implementing the NP role in a health care system does
In British Columbia (BC), Canada, legislation and not occur in isolation of the overall system because con-
regulation of the NP role were established in 2005 and textual and environmental issues influence the process.
the first NPs were hired into regional health authorities Canadian researchers have identified barriers to imple-
beginning in 2005. Health authorities in BC are funded menting the NP role in acute and long-term care, and
by the Provincial Ministry of Health. NPs are salaried PHC settings. Barriers include restrictive legislation and
employees of health authorities. They practice in acute regulation of the role [10,11], lack of role descriptions
and long-term care and in PHC settings. This study was and understanding of the role, conflicting expectations,
conducted in 2009 and, at that time, the NP role was inadequate administrative and physician support and in-
relatively new to the province of BC, and there were less sufficient long-term human resource planning, as well as
than 200 NPs registered in the Province [12]. poor understanding of how the NP role interfaces with
Health Canada [13] defines PHC settings as the first other members of the health team [10,11,26-31].
place people go when they need care, advice on health Although multiple barriers to implementation have
promotion or illness prevention, and/or referral to other been identified, facilitators also exist. Facilitators include
parts of the health care system, and where care is deliv- manager and physician support and knowledge of the
ered to individuals, families, communities, and popula- NP role, the NP’s prior work experience and level of
tions of patients. In the last 20 years numerous education, trust and acceptance by team members, and
Canadian provincial and national reports have high- patient satisfaction with the NP [10, 26-32]. Managers
lighted the need for changes to the way PHC is delivered can facilitate implementation by helping team members
[14-17]. Nationally identified concerns include inad- to understand the reason for adding the role, by sup-
equate attention to health promotion and disease pre- porting them as they experience the stresses of change
vention, lack of continuity of care among providers and that occur with the addition of the new role, and by
institutions, difficulty obtaining access to care, barriers helping to incorporate the NP into the team [32].
to integrating primary health care providers such as NPs Findings of previous researchers demonstrated that
into the system, and the need for intersectoral action successfully implementing the NP role for the first time
and collaboration [14,15,18]. into PHC settings is a complex process. In our review of
As part of PHC reform, federal and provincial govern- current literature, we found that facilitators in one set-
ments have been interested in implementing the NP role ting could become barriers if they were not addressed
in primary health care [15-17,19]. Consequently, be- appropriately, and likewise, barriers could become facili-
tween 1996 (Alberta) and 2009 (Yukon), all provinces tators [33]. Clearly, these barriers or facilitators influence
and territories in Canada enacted legislation enabling role implementation and the long-term sustainability of
the NP role [20]. The province of British Columbia (BC) the role. Based on the work of previous researchers,
was one of the last provinces to implement legislation we recognized the need to better understand NP role
for regulation of the role [21]. implementation, and to explore influencing factors more
The health authority, included in this study, began deeply.
implementing the NP role in 2007 with the hiring of the Therefore, we began this study with an integrative re-
first NPs in PHC settings. NPs were expected to increase view of the literature which resulted in identifying and
access to care, and manage chronic diseases. Senior defining three sensitizing concepts that influenced im-
health authority managers allocated responsibility for plementation [33]. The concepts were intention, involve-
overseeing implementation to a newly established NP ment and acceptance. We defined intention as how the
steering committee. The committee’s mandate was to role is defined and the goals and outcomes expected as a
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result of implementation. Involvement refers to the care centre; and PHC 3, mental health care team. In
active participation of team members in determining the each setting we followed the same research protocol,
functions for the NP role. Acceptance relates to the team which meant posing the same interview questions to key
members’ recognition and willingness to work with the informants in similar roles, and reviewing similar docu-
NP. A complete description of the integrative review and ments [34]. Written informed consent was obtained
the process used to develop the concepts has been from each participant before the interview began. Only
reported elsewhere, thus we will not repeat the descrip- adults 18 years of age and older were selected to
tion in this paper [33]. The three concepts were subse- participate.
quently used to develop the research questions that
guided our study. Data Sources
The research questions were: In each PHC setting we interviewed the manager dir-
ectly responsible for the administrative day-to-day func-
1. How do intentions for the NP role identified in PHC tioning of the setting, at least one physician working
settings influence the process of NP role with the NP, and at least one of the staff such as an RN
implementation? or a medical office assistant, and the NP. In addition to
2. How are managers, physicians, other staff, and NPs interviews, we conducted document reviews to corrob-
involved in the process of NP role implementation in orate data from the interviews or contribute to our
PHC settings within the health authority? understanding of the context of the setting [34].
3. How does acceptance by managers, physicians, and
other staff of the NP role in PHC settings influence Inclusion criteria
the process of implementation? We only included settings where the NP had been work-
4. How are NPs enacting the role domains of clinical ing for a minimum of six months. Only English speaking
practice, collaboration, research, leadership, and participants, who worked directly or indirectly with the
change agent in PHC settings? NP, and were working in the PHC setting six months or
more before the NP was hired were included. Because
Ethics approval these participants had been in the setting before and
This study received ethics approval from the Human during the time the NP was hired, they provided unique
Research Ethics Board for Dalhousie University, the perspectives and insights into how intentions for the role
University of Victoria, and the health authority in which were developed, who was involved in the decision to hire
the study was carried out (Protocol #2008-1896). Writ- the NP, and how acceptance for the role occurred [35].
ten informed consent was obtained from each partici-
pant before the interview began. Only adults 18 years of Data collection
age and older were selected to participate. All interviews, with the exception of one, occurred face-
to-face in a private, mutually agreed upon location. One
Methodology interview was conducted over the telephone. Interviews
Design took approximately 60 minutes and were audio-recorded
To answer the research questions we used an explana- and later transcribed verbatim. One researcher (ESG)
tory single case study with three embedded units of ana- conducted all interviews and reviewed all documents.
lysis and adhered to Yin’s [34] approach for case study An interview guide was used to generate discussion of
research. We also employed Yin’s technique of explan- how key informants were involved in the implementa-
ation building for data analysis. The goal of analysis tion process, their understanding of the intention for the
using this technique is to build an explanation about the role, and their views on how the role was accepted
case, or to explain how the NP role was implemented in (available upon request).
the health authority. In a narrative format, we built an Pertinent documents such as project charters, the pro-
explanation of the process by using an iterative process posal submitted for approval of the NP position, and the
of comparing the data to the study’s conceptual frame- NP role description were reviewed. We accessed infor-
work and research questions [34]. By constantly refer- mation pertaining to the health authority, for example
ring to these, we were able to maintain our focus on the strategic plan, from its website. We accessed munici-
how the role was implemented and how, or if, the con- pal websites for information related to geographic loca-
cepts of intention, involvement and acceptance influ- tions of the settings. Competencies and standards for
enced the process. The case studied was the process of NP practice were obtained from the College of
NP role implementation as it was occurring in PHC set- Registered Nurses of British Columbia’s website. Table 1
tings in one of BC’s six health authorities. We refer to is a summary of the number and types of participants
the settings as: PHC 1, physician office; PHC 2, seniors’ interviewed in each setting and documents reviewed.
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Table 1 Data sources

Participant PHC 1 PHC 2 PHC 3
interviews
Physician office Seniors care centre Mental health care team
Manager 2 1 1
Physician 1 1 1
RN 1 0 1
NP 1 2 1
Medical office assistant 0 1 0
Staff coordinator 0 1 0
Community member 0 0 1
Total participants 5 6 5
Documents Reviewed Demonstration project charter Project charter Proposal
NP role description, NP competencies and scope of practice, health authority’s strategic plan

Data analysis also purposively selected [39]. Variation among the

Interview data were imported into N-Vivo 8.0. We began settings included geographic location, model of care,
data analysis by first capturing data related to the concepts and patient populations. Table 2 illustrates the model
of intention, involvement and acceptance [36,37]. Second, of care, population density and patient population of
within each concept, we sorted data into categories and each unit of analysis.
themes. Third, as more data were collected, preliminary From our data collection we learned that the decision
codes were expanded and collapsed to refine the coding to hire an NP in PHC settings was determined in one of
categories [38]. Finally categories and relationships emerged two ways: 1) an administrative directive from senior
from the data that was used to explain how the sensitizing health authority managers, and 2) approval of proposals
concepts influenced implementation. developed and submitted to the NP steering committee
We used a data abstraction tool developed for this study by managers from PHC settings. Either way, the process
to assist with examining the documents for content related did not require involvement of other team members in
to the NP role and how the NP was expected to function. early discussions.
Key documents were not coded but were used to under- For example, the process used in the physician office
stand the social context in which they were developed and (PHC 1) and the seniors care centre (PHC 2) involved
supported the writing of the narrative describing how the senior health authority managers meeting with the phy-
NP role was implemented in each PHC setting. Because of sicians who indicated interest in the NP role and/or
the small sample size and the need to protect confidential- developing project proposals that were submitted to a
ity, we refer to participants collectively and do not identify federal government initiative called the Primary Health
anyone by role, gender, or title. Care Transition Fund [40] for funding. Similarly, the
managers who submitted proposals to the NP steering
Validity and reliability committee were not required to involve team members
Validity and reliability were addressed in a variety of ways. in the writing of the proposal. As a result of this top
Initially, we developed a case study protocol which included down approach to implementation, before the NP was
interview questions, and a list of the types of documents to hired, few team members participated in efforts to deter-
select for review. Data were obtained from a variety of key mine a need for an NP or how the addition of an NP
informants and documents. At the completion of each would change care delivery.
interview, we summarized our understanding of infor- This was significant because at the time most of the
mants’ responses and asked them to verify the accuracy of NPs in this study were hired (2007 & 2008) the role was
our summary. We did not return transcripts to participants new to BC, having been legislated in 2005. As a result,
for their review. Throughout the study we discussed our team members in PHC settings were unfamiliar with the
findings among ourselves and used rich, thick descriptions role and had little knowledge of how best to use the
to explain our findings [34]. NP’s capabilities. The first BC NPs, who graduated in
2005, had been mentored by family physicians during
Results their educational programs because there were no regis-
We used an explanatory single case study of one pur- tered NPs in the province until 2006. This meant that
posively selected health authority with three embed- the first NP graduates had only been exposure to the NP
ded sub-units of analysis (PHC settings) that were role through NP faculty members teaching in the
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Table 2 Units of analysis

PHC Setting PHC 1 PHC 2 PHC 3
Model of Care Physician office Seniors PHC Centre Mental Health Care Team
Location Small urban Urban Rural/remote
Population density >20,000 >100,000 3,800
Patient Population Family practice Seniors 70+ Mental health & addictions

programs. Therefore, NPs were hired into settings where There is a need for more than getting the nurse
few, if any, team members were involved in hiring the practitioner’s office set up and computer access, those
NP, and where they had not participated in discussions kinds of things were all fine. But when it came to the
of how the NP would function, the types of patients the day to day types of things there needs to be a bit
NP care for, nor how the NP role interfaced with other more support from upper management.
roles in the settings.
Senior health authority managers responded to these
Intentions for NP Role implementation requests but the response took three months in PHC 2
Before the NP was hired, study participants were aware and, because of turnover of health authority managers,
that the health authority intended for NPs to provide six months in PHC 1. These delays slowed the teams’
direct patient care for various populations such as eld- discussions of the most appropriate patients for the NP
erly, or people with chronic diseases. However, for parti- to follow, made it difficult for team members to obtain
cipants, knowing that NPs were expected to increase mutual understandings of role functions, and, in PHC 2,
access to care for patients, improve patient outcomes, contributed to turnover of NPs.
and the function of interdisciplinary teams did not pro- In addition to senior health authority managers, parti-
vide insight into how an NP would be expected to enact cipants remarked that team members also looked to NPs
the role or function within the existing team. In all three to explain their role, and although new in the role, NPs
settings, after the NP was hired team members, includ- assumed leadership in varying degrees to define it.
ing professional staff, physicians, other community pro-
viders, and managers had to work together to identify or [NP] certainly exhibited leadership with the team,
clarify role expectations and determine how the NP helping the team understand the nurse practitioner
would function as a new team member. role, showing leadership in terms of clinical
After the NP was hired, unexpected changes, such as competencies, and development and professional
the retirement of a physician in PHC 1 and increasing standards. [NP] also demonstrates leadership in
the age of the patient population in PHC 2, precipitated looking at patient populations and helping the team
the need for participants to clarify how the NP would consider how to deliver care differently.
function. The original intent in PHC 1 was that the NP
would co-manage patients with chronic diseases; how- The NP’s knowledge and understanding of the role
ever, after a physician unexpectedly retired, the team and ability to explain it to others contributed to the
needed to reassign the physician’s patients to another team’s appreciation for how the NP would function. Ul-
provider. In PHC 2 shortly after the NP was hired, the timately, after the NP was hired, team members worked
age of new patients admitted to the centre increased together to clarify the types of patients the NP would
from 55 years and older to 70 years and older. Many of follow and how the NP would function within the
the new older people were frail and had more complex team.
care needs.
In both instances, team members approached senior I think that there may have been a little bit more
health authority managers for assistance in understand- expectation when it was set up that the nurse
ing how to proceed with implementation. Because parti- practitioner would deal with populations that the
cipants were unfamiliar with the NP role, they wanted health authority, as an organization, had chosen as
more direction and structure from senior managers and key populations that they felt had gaps in service. I
looked to them for advice. think that changed as the nurse practitioner role
developed in the clinic because the clinic had its own
I think that for any organization that is looking at needs. So it developed according to the clinic’s
employing a nurse practitioner there needs to be populations and needs rather than what the health
managerial support, logistical support, and practice authority had seen as their populations. It was
support from the beginning. I can’t stress this enough. different in each clinic because the health authority
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was looking at a very large population and pockets of direct patient care. In PHC 1, participants recognized
patients who may not be appropriate in one area. that the NP managed more complex patients and prac-
ticed differently than the RNs. They also believed that,
The process of working together to clarify the inten- as a salaried employee, the NP spent time with patients
tions and expectations of how the NP would function in focusing on chronic disease management, health promo-
each setting to match the needs of the clinic evolved tion, and self-care management. Similarly, participants
over time and required time commitments from team in PHC 2 commented on the NP’s ability to see the “big
members. Because planning for the role took time and picture”. They remarked that she identified patients in
this work was not initiated before NPs were hired, it had need of community resources and collaborated with all
to occur afterwards. During this time, while team mem- members of the team, as well as community agencies.
bers worked to define the role, the NPs were constrained The NP in PHC 3 was described by participants as the
in how they practiced. missing piece to the team and complemented the efforts
of other team members to provide comprehensive pa-
tient care. Participants acknowledged that NPs spent
Defining the role more time with patients than physicians, and provided
Participants were asked to define the NP role based on more patient education related to self-care management
their experience working with the NP. All participants of health conditions, as this participant noted:
related most readily to the clinical aspects of the role,
and believed the NP was additive to the team, a bonus. I think in terms of the primary health care
One participant defined the role broadly: setting, they function sometimes better than the
physicians. Because nurse practitioners are not in
The nurse practitioner is primarily a nurse who has a fee-for-service agreement, they have more time
expanded training in diagnosis and treatment. [NP’s] to spend with each patient in terms of counseling
role on a day to day basis is to manage the care of services. Family physicians usually don’t have
patients that present to the clinic, whether they’re enough time to fully counsel patients with regards
[NP’s] own patients or the clinic’s patients. [NP] to the conditions. It sometimes takes a few visits
manages episodic, simple primary care problems like to go over all the details family physicians want
a sore throat and complete physicals and chronic to go through. But with [NP] because of the
disease management and women’s health. Because as freedom of time offers a better service than
a nurse the nurse practitioner has the skills and family physicians.
training to look at the patient’s needs from more
of a holistic, psycho-social as well as physical The NP was also viewed as a competent, knowledgeable
aspect [NP] can manage more fully the whole provider who offered comprehensive patient care and
impact of the patient’s illness or wellness and also who was an asset to the overall team. Participants
deal with the family. related that, as they witnessed the NP’s practice and
their knowledge and understanding of the NP role
On the other hand when the patient becomes more increased, they developed trust in the NP’s capabilities
complex medically, [NP] then knows when to turn the and saw the value of the role. The ability of team
patient over or consult with a physician, whether it’s a members to define the role within the context of the
one off consult, “what’s your opinion” or it’s a hand PHC setting required time and effort on the part of all
off consult, “this is beyond my scope of practice”. The team members and did not come easily.
nurse practitioner role is in primary care management
of episodic illness, chronic diseases, promoting Finding space
wellness, education of patients and their families, as In all settings, NPs expected that they would have a
well as contributing to planning for the physical space in which to practice. A participant
communities’ needs from a health standpoint and described the need to plan for space in which the NP
providing some leadership with other members of would practice:
the medical community including other health team
members like physio [physiotherapist], OT It is important to prepare the site ahead of time. By
[occupational therapist], other nurses, LPNs preparing, I mean look at what we are doing now and
[Licensed Practice Nurse], clerical staff. what it is going to look like when an NP comes.
Rather than appending the role to the existing team, it
NPs in all three settings worked full-time and reported involves the re-creation of the whole team. Team
that they spent at least 75% of their time providing development is important and it needs to begin before
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NPs are hired so there is a space for them when they before the NP is hired, on the first day of work
come in. everybody will know what the role is. Any ground
work would be done prior to the NP starting work.
In PHC 2 an office space and examination room was
not identified for the NP until after she was hired. Maybe better exploration of what the clinic thought
Similarly, in PHC 3, once the NP was hired, the team the role would be. Although, sometimes it’s nice for
had to reassess the most appropriate place for the NP them to evolve it on their own, because it makes the
to practice. After consulting with community stake- nurse practitioner, the office managers, all of the cleri-
holders, they determined that the best place for the NP cals and the physicians to work through a PDA (plan,
to see patients was in a community resource centre. It do, act) cycle to see what works best. I’m not sure you
took four months for that space to be identified. Lack can really mould the role beforehand. However, I think
of physical space was a barrier to the NPs’ practice be- we need to make sure everybody is clear on what the po-
cause the NPs in PHC 2 and PHC 3 could not begin tential for the role is and where nurse practitioners
to practice until space was identified. A participant could be used. But I wouldn’t want to be too stringent
related the need to have designated space for the NP on what we’re doing because I think it changes.
before the NP is hired:

There is a need to get the system clearer upfront and Involvement of managers, physicians, and other staff in
have designated room for an NP. It is not fair if the role implementation
nurse practitioner doesn’t have a decent examination Few team members were involved in the early stages of
room. The nurse practitioner is part of the team and implementation, when plans were first made to hire an
everyone should have a working station. The nurse NP. Participants in PHC 1 and PHC 3 were aware that
practitioner needs a room like physicians. They need discussions were taking place or a proposal had been
to have an exam room with curtains and everything. submitted, but they were not directly involved. In these
two settings, participants indicated that this was not
Participants thought there should have been a system problematic for them. Yet, in PHC 2, the lack of team
in place for planning for the NP by designating physical involvement in the decision of when to hire another NP
space where the NP would practice before the NP was after the first NP resigned was awkward. A participant
hired. remarked:

Long-term planning We all knew from day one there would be an NP. So
PHC 1 was established as a 24 month demonstration it wasn’t a surprise that another nurse practitioner
project, with no guarantee that the NP would be in the was being hired. But the way in which the NP came in
setting over the long term. All participants were aware was not particularly clear and in hind sight that made
of this, however, 18 months into the project, senior it even harder. Somewhere along the way somebody’s
health authority managers had not communicated with communication went a bit astray.
the NP or others about any plans for the future of the
project and the NP’s position. Without knowledge of the Inadequate involvement created problems for partici-
health authority’s plans, participants were unsure of the pants in PHC 2. They related that they were less
sustainability of the role, and this contributed to the invested in the process because of their lack of involve-
NP’s decision not to admit any new patients until the fu- ment in the NP hiring plans.
ture of the role was clarified. In PHC 1 the NP mailed letters to community provi-
Reflecting on the implementation process, in all ders describing the role, however, once medical specia-
three settings participants identified the need to plan, lists received patient referrals from the NP or a patient
in advance, for the addition of an NP, to identify presented prescriptions written by the NP to local phar-
expectations, and to identify appropriate space for macies, these providers called the office asking for clari-
where the NP would practice. One participant fication of the NP’s role. Others in the office, such as the
described it this way: business manager and the RNs were involved in fielding
these calls. In PHC 2 team members were involved in
What I would do differently? First of all, we still have discussions of which patients to schedule appointments
a ways to go before we can take a package that says with the NP. In PHC 3 the manager and lead RN were
“all of these things have to be done in this order when involved in identifying community service agencies that
the nurse practitioner starts” so that on the NP’s first provided services to the same population with whom the
day everything is in place. If the planning is done NP worked.
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Community involvement to manage patients. And also advocating for the nurse
In PHC 1 people living in the community and other practitioner role and paving the way for other nurse
providers were not consulted or advised of plans to practitioners to come.
hire an NP. The NP role was new in the community
and, in the absence of early community involvement In the event managers were unable to answer team
or an announcement; these stakeholders had no know- members’ questions or concerns related to how to
ledge of the NP’s capabilities or presence in the com- use the NP, they looked to senior health authority
munity. In contrast, in PHC 3 discussions were held managers who had been responsible for establishing
with physicians and members of community agencies strategic direction for NP role implementation to
involved with caring for people with mental health and clarify organizational intent.
addictions before the NP was hired. A participant from
PHC 3 described the process used to include these Acceptance of NP role implementation
stakeholder groups as: In the PHC settings, according to participants, team
members needed time to become acquainted with the
We pulled together groups of people that were related NP and gain a better understanding of the role before
to people with profound mental health problems. We accepting the NP as a new team member. A participant
talked to hospital nurses, some of the local First described one way this was accomplished:
Nations workers that have history of working with
these people, the Friendship Centre, a few clergy We had a number of meetings with the nurse
people, and local doctors. practitioner and the team, the nurse practitioner and
the physicians, reviewing the standards, limits, and
Although there was limited involvement of community conditions of the role and all that sort of stuff and
stakeholders in each setting, their early involvement was really trying to be clear about what the nurse
important. practitioner could do.
Moreover, in all three settings, patients in the practices
were unaware of the NP role and participants acknowl- As well, community providers, such as medical specia-
edged that they needed to encourage patients to sched- lists, wanted to become acquainted with the NP’s com-
ule an appointment to meet and get to know the NP. petencies and scope of practice before their acceptance
Patients needed to trust the NP before they allowed the occurred.
NP to provide their care, and there were times when Team members’ acceptance of the NP role was
patients were unwilling to schedule an appointment with influenced by their involvement in clarifying the
the NP, as one participant described: intentions for the role, their increased understanding
of what the NP would do in the practice setting, and
Occasionally I would take a call from a patient and trusting in the NP’s capabilities. One participant
they would want a doctor and I would say “our nurse noted, “Everyone needs to trust the nurse practi-
practitioner could handle your problem” and they tioner and if they trust that the nurse practitioner
would go “no I want a doctor.” knows what he or she is doing, they’re a little more
comfortable.” Other factors, such as prior knowledge
Manager involvement of the individual NP, the NP’s personal attributes,
Involvement of the managers in all three settings was and patient acceptance also contributed to the team’s
critical. In general, managers supported novice NPs to willingness to work with the NP. In all three
identify space in which to work, obtain equipment and settings, the NP had previously spent time as a stu-
meet key stakeholders. Moreover, the managers in all dent NP in the practice setting or in the community
three settings supported the NPs to participate in the in which the setting was located.
community of practice, and facilitated discussions of Prior knowledge and acquaintance with the NP, for ex-
how the NP could be used in the setting. A participant ample working in the setting as an RN or spending time
described the manager’s involvement: in the setting as a student NP prior to being hired,
allowed acceptance to develop more quickly as a partici-
Well I think advocating for the role and trying to pant described:
negotiate and understand where everyone was coming
from because everybody has their own world to live [NP] had been working here as a nurse and has been
in. Trying to figure out how to best meet everybody’s on the team. We knew that [NP] was attending a
needs and still ensure that the patient gets the test nurse practitioner program and hoped to transition
and the nurse practitioner has the information needed into a nurse practitioner role somewhere. When the
Sangster-Gormley et al. BMC Nursing 2013, 12:1 Page 9 of 12
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position came up we were quite aware of the timing

and honestly I think that we all hoped that [NP]
would end up here. We knew [NP] and very much
respected [NP’s] abilities and enjoyed [NP’s]
personality.

Prior knowledge by team members of the NP as a stu-

dent NP or as an RN, gave those team members an op-
portunity to establish a relationship, become aware of
the NP’s capabilities, and develop trust. Various partici-
pants described NPs as knowledgeable with good com-
munication skills. NPs also assumed leadership roles by
working collaboratively with other team members to
help them understand the role which also facilitated
team acceptance.
Patients cared for by the mental health care team Figure 1 Context of the health authority.
(PHC 3) typically did not readily accept new health
care providers. It took time for patients in this set-
ting to trust the NP. This was also true in the other NP Role enactment
two settings. Without patients’ prior knowledge of Implementing the NP role was influenced by how well
the role, or an understanding of how NPs functioned, others understood expectations for the role and their
establishing trusting relationships in all settings took acceptance of the individual NP. Acceptance was influ-
time. Despite patients’ initial hesitation, once they enced by prior knowledge of the NP and involvement in
were acquainted with the NP they were satisfied with determining how the NP would function in the setting.
their care and accepted the NP, as described by this In turn, the ability of the NP to actually carry out expec-
participant: tations and enact the role was influenced by how the
role was implemented. We asked NPs to describe how
The patients took to [NP] quickly. And I don’t think they were enacting the role competencies of clinical
we were really surprised at that. Once they realized practice, leadership, collaboration and change agent and
[NP] could do everything a doctor could do and once research. Based on their descriptions we were able to de-
they met and saw the extra time and care [NP] gave termine that NPs were incorporating all of these compe-
they were satisfied. Patients liked [NP’s] caring tencies into their role.
approach and that they didn’t feel rushed. [NP] Based on the findings from this study, we developed a
explained things very well in terms they could conceptual framework, Figure 1, indicating the intercon-
understand. [NP] is very knowledgeable and that nectedness of intention, involvement and acceptance
was obvious to them. [NP] knew what [NP] was and their influence the process of NP role implementa-
talking about and they felt very confident in what tion and NP role enactment. Although we identified the
[NP] told them. concepts from the literature, their relationship to the im-
plementation process was unclear.
Before the NP was hired, participants typically had a In this model the concepts of intention, involvement,
limited awareness or knowledge of the role, and accept- and acceptance are interconnected indicating how they
ance of the NP within the team had to occur after the simultaneously influence role enactment and implemen-
NP was hired. In PHC 1 and PHC 2, where the team tation. The concepts are situated with the context of the
knew the NP, acceptance of happened more quickly. health authority in which the role was implemented.
Nonetheless, although team members may have been Through analysis we were able to determine that these
accepting of the idea of an NP, it was only after the NP concepts are interconnected and each is influenced by
was hired that acceptance of the individual NP occurred. the other and all influence NP role implementation and
Although we did not originally identify community enactment.
members as stakeholders, it is clear that their involve-
ment, knowledge and awareness of the NP role facili- Summary of key findings
tated their acceptance, and acceptance of the role by all In summary, we found that planning for the role be-
stakeholders was closely connected to their prior know- forehand and long-term planning after the NP was
ledge of the individual NP, and clarifying the intentions hired were important to help team members better
for the role. understand the reason the NP role was implemented.
Sangster-Gormley et al. BMC Nursing 2013, 12:1 Page 10 of 12
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Once the NP was hired team members needed to clarify need to expect the process to take time and to recognize
the intentions for the role primarily because they were not that the process used in one setting might not work in an-
involved earlier in the process and did not have a clear other setting. This does not indicate that efforts in one
understanding of it. In the early stages of implementation, setting were right and in the other setting they were
and immediately after the NP was hired, team members wrong. Instead, the context of each setting will influence
sought support and guidance from senior management the process of implementation.
within the health authority to clarify the intentions for the
role. Unexpected changes in patient populations and/or in Limitations
the context of the setting influenced how the NP would This was a single case study with three embedded units
function. Acceptance of the NP was facilitated by team of analysis. The intent of the study was to understand
members’ prior knowledge of either the role or the individ- and explain the process used to implement the NP role
ual. Community stakeholders who needed to or were in the PHC settings of one health authority. Participants
expected to interact with the NP wanted to be involved in included only those who worked in PHC settings. As a
the implementation process and their acceptance of the NP result of focusing on the PHC setting, no data were col-
developed as they gained knowledge and understanding of lected from senior health authority managers. Therefore,
the role. Finally, although relatively new in their roles, ap- perceptions of participants in PHC settings may not re-
proximately two years after being hired, NPs were enacting, flect organizational realities or the intent of senior health
to some degree, all competencies of the role as defined by authority managers. As well, the perceptions of patients
CRNBC. were not represented. Data from senior health authority
managers could have provided insight into expectations
Discussion for the NP role that were not conveyed by participants.
Implementation can be described as the transition Data from patients would have helped to explain how
period following a decision to adopt an innovation [41]. patients, seen by the NP, found the experience and their
Context, environmental issues, and the characteristics of level of acceptance of the NP as a care provider.
the individuals involved all influence implementation. We did not originally identify community members as
Previous researchers identified barriers and facilitators stakeholders however; we learned that their involvement,
to role implementation such as role clarity, team in- knowledge and awareness of the NP role were import-
volvement, and planning for the role [2,10,11,26-28]. ant. We were only able to include one community mem-
From the review of the literature we identified three ber in the study. Additional community members
sensitising concepts that influenced implementation: would have added to our explanation of community
involvement, acceptance and intention. In this study we members’ acceptance of NPs and their role in the
were able to verify that the three concepts influence im- implementation process.
plementation of the role and the ability of the NP to Our findings are based on one interview with each of
enact the role. Our findings also indicate the need to the 16 participants and documents obtained from each
consider these three factors simultaneously throughout setting. Participant observations might have enhanced
the implementation process, as demonstrated by the our understanding of team member interactions and NP
interconnectedness of the concepts in the conceptual role enactment. Another limitation is volunteer bias as
framework, Figure 1. Without any one of the three con- only those participants who volunteered were inter-
cepts, not only is implementation difficult, but it makes viewed. Others who chose not to volunteer might have
it difficult for the NP to fulfill role expectations. In the had different perceptions.
early stages of implementation, when team members are All NP participants were novices when first hired
just beginning to understand the role, it is important for into their positions. Our findings may not be trans-
as many of them as possible to be involved in discussing ferable to settings where the NP is experienced,
how the NP would function and defining the role. where participants are familiar with the NP role, or
Equally important, team members need to be willing to provinces where the role is better established within
accept the NP as a new member of the team. the health care system. Finally, we acknowledge that
participants involved in implementing the NP role in
Contributions to knowledge the practice settings of other health authorities may
This study contributes to the state of the knowledge of have had different experiences.
role implementation in two ways. First, it explicates fac-
tors, such as intention, involvement, and acceptance, to Implications
consider when implementing new roles and highlights the This study contributes to an in-depth understanding of
importance of context. Second, it demonstrates the com- the process of implementing new health care roles. It
plexity of the role implementation process. Stakeholders demonstrates the need for policy makers and other
Sangster-Gormley et al. BMC Nursing 2013, 12:1 Page 11 of 12
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stakeholders to consider multiple factors when imple- References

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doi:10.1186/1472-6955-12-1
Cite this article as: Sangster-Gormley et al.: A case study of nurse
practitioner role implementation in primary care: what happens when
new roles are introduced?. BMC Nursing 2013 12:1.

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