A Study to Describe Perceptions of ARNP Roles in an Acute Care Setting

378 The Journal for Nurse Practitioners - JNP Volume 7, Issue 5, May 2011

Hospitals form health care’s largest industryand are faced with economic, regulatory,and workforce challenges. Patients are

being discharged earlier, and more procedures arebeing done on an outpatient basis, both inside andoutside hospitals.1 Teaching hospitals face an additionalchallenge in the provider workforce because of workrestrictions for resident physicians that went into effectJuly 2003.2 In response to these issues, many hospitalsexpanded their use of acute care nurse practitioners(NPs) in several practice settings, such as critical care,acute care, emergency departments, and acute painservices. Their responsibilities include administration,teaching, research, program development, qualityimprovement, and department projects.3

Collaboration means sharing knowledge and prac-tice with mutual respect and reciprocity and is a com-mon component found in all of these role descriptions.4

Behaviors that are critical to teamwork include beingmindful of the environment or the patient’s condition(situational awareness), conducting situation and back-ground assessment with recommendations and response(SBAR-R technique), communicating reciprocally, and

sharing a common mental model.5 Other behaviorsrelated to collaboration are being committed to patientcare, providing for continuity, maintaining credibility,interacting with families, and building role rapport.6

Acute care NPs typically collaborate with multidiscipli-nary team members, such as physicians, registered nurses(RNs), case managers, pharmacists, social workers, and clin-ical dieticians, but some advanced registered NPs (ARNPs)do not feel that they experience a reciprocal relationshipfrom other team members. Instead, they believe that theyare perceived as consultants, rather than having a uniquepractice with a given population of patients.4 There aremany studies dealing with physician-nurse collaboration, aswell as well-developed measurements for collaboration.7-10

Aside from that, little research has been done about collab-orative partnerships with other disciplines or other disci-plines’ perceptions of the ARNP role. One recent exampleis that of collaboration between RN case managers andsocial workers.8 Another study dealt with respiratory thera-pists’ perceptions of ARNP roles.6

The purpose of this article is to report findings of asurvey of interdisciplinary team members’ perceptions ofcollaboration with acute care NPs.

A Study to Describe Perceptions ofARNP Roles in an Acute Care SettingSarah Elizabeth Cobb, PhD, and Mary Kutash, ARNP

ABSTRACTThe aim of this study was to explore interdisciplinary team members’ perceptions ofthe advanced registered nurse practitioner’s (ARNP) delivery of care and collabora-tion in an acute care setting. A convenience sample of registered nurses and profes-sional non-nursing personnel rated statements pertaining to the ARNP role. Bothgroups were satisfied with the ARNP role. Non-nurse licensed professionals tendedto be more satisfied with the ARNPs than the staff nurses were, specifically in theareas of discharge planning and adding to the quality of care of patients. Nurses weremore satisfied with the ARNP role regarding encouraging evidence-based practiceand sharing resources.

Keywords: acute care, collaboration, delivery of care, nurse practitioner, roles© 2011 American College of Nurse Practitioners

ORIGINAL RESEARCH

www.npjournal.org The Journal for Nurse Practitioners - JNP 379

CONCEPTUAL FRAMEWORKIn their classic conceptual framework for evaluating theNP role in acute care settings, Sidani and Irvine11 used anursing-role effectiveness model to facilitate the identifi-cation and investigation of nursing-sensitive patient out-comes. The model includes 3 components that influenceeffectiveness of the ARNP role:structure, process, and out-comes. Although their modelfocused on the NP role in acutecare, its use can be widened toinclude the scope of otherARNPs.11

LITERATURE REVIEWThis literature review focusesprimarily on the receptivity tothe role of ARNPs, which isindicated in the structural por-tion of the model. Research pertaining to receptivity hasbeen centered on 2 key themes: the impact of the ARNPmodel on delivery of care and the impact of the ARNPmodel on communication and collaboration.

First, the delivery of care by ARNPs has shown posi-tive impacts. Overall, families, staff nurses, and physicianswere satisfied with the delivery of care by ARNPs.6-8,12

Beneficial comments about the role included noting thatARNPs have better continuity with families, are moreknowledgeable about the whole family, and know thenursing staff ’s weak and strong points.6 Staff nursesemphasized their increased opportunities for research andprofessional activities after ARNPs were present on theunit.8 Van Soeren and Micevski13 summarized the themesand recommendations for the role in a qualitative study:ARNPs were concerned about role clarity and balancingmultiple roles, while staff nurses were concerned aboutARNPs’ sharing knowledge with staff, teaching throughin-services, promoting educational or professional devel-opment, and fostering research.

Second, the perceptions of the ARNPs’ collaborationhave varied by respondents’ positions. In comparing anARNP versus medical model of care, patients were moresatisfied with the way ARNPs maintained privacy butmore satisfied with the way physicians explained testresults.16 In a pediatric setting, parents emphasized theimportance of good communication, whereas staff nursesemphasized the importance of treating them as valued

members of the health care team and having increasedopportunities for learning.8

In a similar setting, Copnell et al7 examined the per-ceptions of interdisciplinary collaboration before andafter introducing a modified ARNP model of care into 3neonatal intensive care units. Only 16% of the respon-

dents thought that collaborationimproved after introducing NPdesignates (candidates) into themodel of care. Overall, physi-cians perceived a higher degreeof collaboration with NP desig-nates than did the designates.7

In a study on collaborationamong nurses, physicians, andallied professions, intraprofes-sional relations (esprit de corps)were viewed positively bymany, yet others were more

negative: “There is a siege mentality. It’s the RNs againsteveryone else: social workers, occupational therapists,physical therapists, the doctors.”5 Physicians and alliedprofessionals reported that holistic nursing informationcontributed to inefficiency; they preferred the use ofexception reporting. The esprit de corps “included theactive rejection of interprofessional colleagues and selec-tive participation in interprofessional gatherings.”5

In summary, perceptions of ARNPs’ impact on thedelivery of care and collaboration vary among physicians,nurses, patients, and family members. While all agree thatARNPs add to the care of patients, nurses give emphasisto professionalism and education, while patients and fam-ilies accentuate good communication and a holisticapproach to care. In comparison to ARNPs, physiciansperceive that there is more collaboration between the 2groups. There remains a need to study other disciplines’perceptions of the ARNP role.

ARNP STUDYStudy Rationale and SignificanceAt the time of this study, the hospital employed 12 full-time, service-based acute care ARNPs whose primaryfocus was the delivery of patient care to expedite dis-charge, decrease length of stay, and improve patient out-comes. Their involvement in quality improvement,research, and education activities varied. Although theinstitution evaluated specific ARNP-mediated outcomes

Recognizing andunderstanding perceptionsof care and collaboration

from interdisciplinarymembers can help to

maximize ARNPeffectiveness.


in patient care, the interdisciplinary teams’ perceptions ofthe acute care NPs were needed to explore opportunitiesto improve the role.

ObjectivesThe aim of this study was to learn about interdisciplinaryteam members’ perceptions of the ARNPs’ delivery ofcare and collaboration in an acute care setting. The keyresearch question was “Are there significant differencesbetween Group 1 (staff nurses) and Group 2 (other inter-disciplinary team members) on their ratings of theARNPs’ delivery of care and collaboration?”

Study SettingThis study was conducted in a Magnet™-designated hos-pital with 875 beds and approximately 5900 employees.The institution is a Level 1 trauma center and a teachinghospital affiliated with a state university.

Study Design This exploratory cross-sectional study used self-reporteddata collected from a convenience sample of approxi-mately 250 RNs and 30 professional non-nursing per-sonnel (pharmacists, physical and occupational therapists,clinical dieticians, social workers, and case managers)from the following inpatient areas: pediatrics, neuro-science, trauma surgery, specialty surgery, transplant, jointreplacement, and the burn center. All participants workeddirectly with acute care NPs on these units. A total sam-ple size of 126 was desired. Thissize was calculated at 80%power with a 95% confidenceinterval for a 2-tailed differenceof means test. Calculations werebased on seeking a difference of0.5 on the Likert-type scale(ranges 1-5 scale).

METHODSWaiver of documentedinformed consent was grantedbecause this study used anInternet-based anonymous sur-vey instrument, did not involve greater than minimumrisk to participants, and did not involve coercion. A doc-umented informed consent would have been the onlyconnection to the participants’ data. After institutional

review board review and approval, the final survey instru-ment was prepared using Survey Monkey®.24 Invitationsto participate were emailed to eligible participants.Participants then completed the web-based questionnairethat was password protected. Respondents were free tolog in to the Internet-based survey from any locationthey chose, thus minimizing risk to confidentiality in thework setting. The survey was conducted between January1 and February 1, 2009. Participants were given 4 weeksto respond to the survey. A reminder email was sent 2weeks after the initial mailing.

MeasuresInterdisciplinary health care team members rated state-ments pertaining to the ARNP role using a Likert-typescale from 1 (strongly disagree) to 5 (strongly agree). Thisinvestigator-developed questionnaire was gleaned fromdescriptions of the ARNP role in the literature. No sum-mative ratings were used. Six independent interdiscipli-nary team members agreed that the study instrumentappeared to provide information about perceptions ofARNPs’ collaboration with nurses and non-nurses.

Study ProceduresData were imported in SPSS version 11 for frequencydistributions to check for discrepancies.25 Descriptive fre-quencies and percentiles for categorical data were donefor respondent gender, years of experience, and type oflicense. The type of license (e.g. RN, respiratory therapist,

or social worker) was codedinto a dichotomous variable fornurse status (yes or no) and usedas the grouping variable for t-tests on the ARNP rating scale.Independent t-tests were con-ducted at alpha level .05 for sig-nificance between group means.Chi-squared tests were used fortesting significance between thegroups for nominal data. Thealpha reliability coefficient wascalculated by SPSS.

RESULTSDemographicsMost respondents were nurses (N � 25 of 43; 58%). Otherrespondents were dietitians, social workers, occupational

Nurses emphasizeprofessionalism and

education, while patientsand families accentuate

good communication and aholistic approach to care.


therapists, physical therapists, and pharmacists, totaling 18non-nurse licensed professionals. The age ranges wereidentical in the nurse and non-nurse groups (23-60 years);the nurses were slightly older on average than the non-nurse professionals (40.25 and 37.87, respectively). The agedifference between the 2 groups was not significant (t �

.611, df � 35, p � .545).The years of experience were similar for both groups.

Nurses and non-nurses each had the largest number ofemployees in the least experienced category (0-5 years,40% and 44.4%, respectively). Another 20% of the nurseswere in the more experienced category (16-20 years).For non-nurses, the remaining frequencies were distrib-uted closely throughout all the other categories for yearsof experience. The differences between the groups onyears of experience was not significant ( 2 � 3.714, df� 4, p � .715). Each respondent group had only 1 man,therefore gender was non-significant ( 2 � 0.790, df �1, p � .779). Table 1 lists demographics by nurse status.

Overall, both the nurses and the non-nurse licensedprofessionals were satisfied with the ARNP role. Itemanalysis revealed that the mean score per item was 4.6274(range � .5313; variance .0227) for all participants.However, when data were grouped by nurse status, somekey differences emerged. The mean scores ranged from4.13 low to 4.59 high by the nurses and 4.14 low to 5.00high by the non-nurses.

PERCEPTIONS OF ARNP ROLEThree items showed an interesting trend. The non-nurselicensed professionals tended to be more satisfied withthe ARNPs than the staff nurses were, specifically in theareas of discharge planning and adding to the quality ofcare for patients. Question 1 (Coordinating with the teamabout discharge planning) and question 11 (making recom-mendations for discharge planning) approached significantdifference between the groups. Question 13 (Adding tothe quality of care to patients) was significant between the 2groups; non-nurse licensed professionals consistentlyrated the ARNPs as very satisfied, whereas nurses wereless satisfied (t � 22.083, df � 22, p � .049). Details aregiven in Table 2.

Figure 1 illustrates the patterns of ratings for theARNPs by item number and by nurse status. The non-nurse licensed professionals rated the ARNPs higher thanthe nurses did in 11 of 13 items. The 2 items for whichnon-nurses rated the ARNPs lower than the nurses didwere question 8 (encouraging evidence-based practices) andquestion 9 (the sharing of resources with the interdisciplinaryteam). Both groups rated nearly the same for question 10(mentoring the growth of the staff); this was the 1 item forwhich both groups gave ARNPs lower scores.

DISCUSSIONThe perceptions of the ARNP role varied according to thenurse versus non-nurse status. On 11 of 13 items, non-nurselicensed professionals perceived the ARNP role more posi-tively than did the unit nurses who worked on the sameunit as the ARNPs. There was significant difference on 1item, that of question 13 (the ARNP role adds to the overallquality of patient care). The 2 questions related to dischargeplanning were rated less favorably by the nurses andapproached significance; this trend bears further study.

One possible explanation for the difference in per-ceptions about the ARNP role for discharge planning isthat the unit nurses were more focused on immediatepatient care and were not aware of behind-the-sceneplanning. Discharge planning for the institution’s com-plex patient population is often multi-faceted andlengthy. It is possible that nurses’ satisfaction and percep-tion were influenced by how quickly things happen.Another explanation is that the unit nurses had differentexpectations of the ARNPs; it is possible that theyexpected the ARNPs to do (rather than just plan) thedischarge teaching, for instance, or to give the discharge

Table 1. Demographics by Nurse Status

Nurses Non-NursesYears in Practice N (%) N (%)0-5 10 (40) 8 (44.4)6-10 2 (8) 2 (11.1)11-15 3 (12) 2 (11.1)16-20 5 (20) 1 (5.6)21-25 1 (4) 2 (11.1)26-30 3 (12) 1 (5.6)31 or more 1 (4) 2 (11.1)Total 25 (100) 18 (100)

Gender N (%) N (%)Female 24 (96) 16 (94.1)Male 1 (4) 1 (5.9)Total 25 (100) 17 (100)

Age N 25 18Mean 40.25 37.87SD 12.298 11.077Range 23-60 23-60

SD � standard deviation.


instructions to the patients. Perhaps the nurses expectedmore immediate aid in delivering patient care.

The only item that reached statistical significancebetween the 2 groups was the perception of the ARNProle as adding to the overall quality of patient care. Thismay have been influenced by several factors. RNs maybelieve that they have a better understanding of theARNP role. It is possible that nurses may be more criti-cal or have greater expectations than non-nurses. Asmentioned earlier, RNs may expect more help from theARNP with direct care activities. Other explanationscould be that the needs of non-nurses are primarily“orders.” Non-nurses may not be as aware of theARNPs’ role in the quality of patient care and thus ratedthis item significantly higher than the nurses did.

LIMITATIONSThere are some limitations to this study. The responserate was poor: 16%. At the time of this study, the hospitalhad implemented email for all staff. The response ratemay have been higher if the survey was distributed afterstaff became more comfortable with this method ofcommunication. Variation among ARNPs, such as experi-ence, type of certification, and years at the institution,were not considered and may have influenced findings.Additionally, variations in their roles at the institutionwere not explored, such as clinic responsibilities thatrequired some ARNPs to be off the unit.

The sample size was limited to 1 hospital. In addition,40% of nurse respondents reported years in practice asless than 5. This novice status may have impacted their

Table 2. Perceptions of the ARNP Role

Nurse Non-Nurse t-testN Mean SD N Mean SD t df p

Coordinates with team re: 23 4.26 1.45 15 4.82 0.41 1.678 27.159 0.105discharge planning

Coordinates treatment planning 23 4.43 1.27 15 4.73 0.46 1.027 29.75 0.312

Provides pt/family education re: 23 4.48 1.20 15 4.60 0.74 0.351 36 0.728current treatment plan

Provides pt/family education re: 23 4.35 1.30 14 4.71 0.61 1.157 33.146 0.255discharge needs

Readily available on the unit 23 4.43 1.20 15 4.73 0.59 0.892 36 0.378

Creates optimal environment for 23 4.48 1.16 15 4.87 0.35 1.5 27.753 0.145obtaining orders, asking questions, and responding to problems

Readily responsive to patient 22 4.59 1.18 15 4.87 0.35 0.874 35 0.388needs

Encourages use of evidence- 23 4.52 1.16 11 4.18 0.98 0.84 32 0.409based practice

Shares resources with 22 4.55 1.22 14 4.14 0.95 1.05 34 0.303interdisciplinary team

Mentors growth of staff 23 4.13 1.46 11 4.27 1.10 0.286 32 0.776knowledge

Makes recommendations for 21 4.48 1.17 15 4.93 0.26 1.737 22.683 0.096patient discharge planning

Orders appropriate 21 4.57 1.21 15 4.87 0.35 1.06 24.545 0.300consultations with interdisciplinary team

ARNP role adds to overall 23 4.48 1.20 15 5.00 0.00 2.083 22 0.049*quality of patient care

*p < .05ARNP � advanced registered nurse practitioner; SD � standard deviation; df � degree of freedom.


perceptions. Finally, the amount of time spent with theARNP and the RNs’ designated shift might have influ-enced participants’ perceptions of the role.

IMPLICATIONSWithin the current political and economic environment,there are increased pressures on hospitals to provide qualitycare that is also cost efficient. Within this working environ-ment, new staffing patterns are beginning to emerge,including refining the role of acute care NPs. There isempirical evidence that they are valued by colleagues in thecare they deliver and the research they promote, but there isalso documentation of role confusion within teams and thebalancing of roles between team members.

Further, the extant literature has established that thesatisfaction levels with the quality of care delivered byARNPs differs by profession role and if assessed bypatient or colleague. Recognizing and understandingperceptions of delivery of care and collaboration frominterdisciplinary team members can help to maximizeARNP effectiveness. Although the sample size of thisstudy was small, findings corroborate those of previousstudies that demonstrate the contribution of this groupto quality of care and to the use of evidence-based prac-

tice.6,14,15 Results show that nursing and non-nursingprofessionals perceive that, through collaboration, acutecare NPs contribute to positive patient outcomes and arevalued members of the interdisciplinary team.

Findings suggest areas for further research, such asunderstanding the ARNP role in discharge planning andrefining instruments for assessing perceptions of ARNPsin the acute care setting. Results by Hoffman6 suggestedthat ARNPs’ work schedule may influence staff percep-tions of accessibility and therefore suggests expanding orrestructuring those hours of availability. Examining per-ceptions of interdisciplinary staff by shift worked anddays worked may provide information that can be usedto enhance the role. Replication of this study in differenthospital settings would be beneficial.

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Figure 1. ARNP Ratings by Nurse Status and Question Number


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Sarah Elizabeth Cobb, PhD, RN, is xx at the University of SouthFlorida in Tampa. Mary Kutash is a nurse specialist for nursingresearch in acute care services at Tampa General Hospital in Tampa,FL, and can be reached at [email protected]. In compliance withnational ethical guidelines, the authors report no relationships withbusiness or industry that would pose a conflict of interest.

1555-4155/11/$ see front matter© 2011 American College of Nurse Practitionersdoi:10.1016/j.nurpra.2010.10.004

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A Study to Describe Perceptions of ARNP Roles in an Acute Care Setting