DOI: 10.1111/nuf.

12236

ORIGINAL ARTICLE

Meta-synthesis on nurse practitioner autonomy and roles

in ambulatory care
Pauline Wang-Romjue MN, RN, PHN

College of Nursing, University of Colorado

Denver, Aurora, CO
Correspondence
Pauline Wang-Romjue, College of Nursing,
University of Colorado Denver, 13120 E. 19th
Avenue, Aurora, CO 80045.
Email: Pauline.Wang-Romjue@ucdenver.edu
Abstract
Background: Many healthcare stakeholders view nurse practitioners (NPs) as an important work-
force resource to help fill the anticipated shortage of 20,400 ambulatory care physicians that is
expected by 2020. Multiple quantitative studies revealed the attributes of NPs’ practice auton-
omy and roles. However, there is no qualitative meta-synthesis that describes the experiences of
NPs’ practice autonomy and roles.

Aim: To describe and understand the experiences of NPs regarding their practice autonomy and
roles in various ambulatory settings through the exploration of existing qualitative studies: meta-
synthesis.

Design: A qualitative meta-synthesis was conducted to gain insight into ambulatory NPs’ practice
autonomy and roles through content analysis and reciprocal translation.

Methods: Articles published between 2000 and 2017 were retrieved by searching 7 databases
using the following key words: U.S. qualitative studies, advance practice nurses, NP role in ambu-
latory care, NP autonomy, and outpatient care.

Results: Autonomy, NPs’ roles and responsibilities, practice relationships, and organizational work
environment pressures are the four main themes that emerged from the content analysis of the
nine selected qualitative studies.

Conclusion: Within and between states, NPs’ experiences with autonomy and NPs’ roles are mul-
tifaceted depending on state regulations, practice relationships, and organizational work environ-
ments.

KEYWORDS
ambulatory care, meta-synthesis, NP autonomy, NP roles, NP practice

1 INTRODUCTION
On the basis of an anticipated shortage of 20,400 ambulatory care
physicians by 2020, healthcare directors and nurse executives are
under pressure to hire more nonphysician providers to fill this gap.
Based on nurse practitioner (NP) practice characteristics, healthcare
administrators consider NPs a vital resource to help fill this gap. How-
ever, state practice and organizational policy restrictions overshadow
NPs’ ability to practice autonomously. The results of eight quantita-
tive studies support this claim. In addition, the extent of NPs’ practice
autonomy, roles, and responsibilities was revealed by these studies.1–8
However, there is minimal qualitative evidence of the experiential
characteristics of NPs’ practice autonomy and roles. Through a meta-
synthesis, the resulting contextual and experiential attributes of NPs’
practice autonomy and roles will provide answers to the research
question: What do NPs’ practice autonomy and roles look like? At the
same time, this evidence will add depth to the results of the quanti-
tative studies and to the body of knowledge in the field of nursing.
Furthermore, healthcare stakeholders can use this information to plan
effective strategies to maximize NP workforce contributions in the
ambulatory care setting. Therefore, the aim of this study is to describe
and understand NPs’ experiences regarding their practice autonomy
and roles within the various ambulatory settings in which they work
through the exploration of existing qualitative studies: meta-synthesis.
2 BACKGROUND
NPs’ practices exhibit both within and between state variations.1,7,9
The capacity of the NP workforce to provide a full array of healthcare

Nurs Forum. 2017;1–8. wileyonlinelibrary.com/journal/nuf 

c 2017 Wiley Periodicals, Inc. 1
2 WANG-ROMJUE

TA B L E 1 Quality appraisal levels of qualitative studies

Using searcch filters for English la
anguage and publica ation date after 2000,
studies weere identified through Google Scholar (n = 155), the Cochrane

Selection
Level Definition
Library (n = 9), PsychINFO (n = 989), Web of Sciencce (n = 62), CINAHL/
High (H) Using Lett's critical review form, the analysis EBSCO (n = 3,576), PubMed (n n = 116), and Ovid ME EDLINE (n = 183)
indicates that there is high validity, reliability, database es. After removing du uplicates (n = 259), th
here were a total of
credibility, transferability, dependability, and 4,8831 studies.
confirmability of the study
Medium (M) Using Lett's critical review form, the analysis

Screening
4,831 studies were screened Papers excluded after assessme ent
indicates that there are some questions
against th
he inclusion and of the title an
nd abstract (n = 4,290)
regarding the validity, reliability, credibility,
excluusion criteria. and for oth her reasons (n = 53 32)
transferability, dependability, and
Reason for exclusion:
e
confirmability of the study • Non-ambu ulatory (n = 21)
Low (L) Using Lett's critical review form, the analysis • Topic Irreleevant (n = 368)

Eligibility
indicates that there is a lack of clarity in terms 9 studiess were assessed • Quantitativve (n = 7)
forr eligibility. • Mixed Metthods (n = 2)
of the validity, reliability, credibility,
transferability, dependability, and • Review (n = 22)
• Commentary (n = 15)
confirmability of the study
• Position Statement (n = 13)
Final numberr of qualitative studies

Final number of studies

• Outside off U.S. (n = 50)
for meta-syn nthesis (n = 9) • Letter to Editor (n = 11)
• Case Studyy (n = 2) • Editorial (nn = 9)
• Ethnograph hy (n = 1) • Not Retrievable (n = 2)
• Grounded T Theory (n = 2) • Opinion Pa aper (n = 12)
• Hermeneutics (n = 1)
services is greatly influenced by the range of NPs’ practice autonomy • Narrative (n
n = 1)
and roles.1 If the NPs’ scope of practice is comprehensive, as it is for • Qualitative (n = 2)
physicians, the NP workforce could help fill the care gap created by
the predicted shortage of physicians.10 The NP workforce's ability FIGURE 1 Algorithm of literature search strategy
to fill this care gap is strengthened by its anticipated growth of 30%
by 2020.3,11 Using Sandelowski and Barroso's12 qualitative method 4 METHODS
of collecting, interpreting, and combining qualitative studies for this
meta-synthesis, we aim to provide a contextual and experiential A literature search of seven electronic databases was performed to
snapshot of the NP's practice autonomy and roles. identify qualitative studies for this meta-synthesis. The following key
search terms were used: U.S. qualitative studies and advanced prac-
tice nurses (APNs), NP role in ambulatory care, NP autonomy, and

3 DESIGN AND QUALITY APPRAISAL
Meta-synthesis was the qualitative design used to conduct this analy-
sis. Meta-synthesis refers to an analytical process of purposefully col-
lecting, interpreting, and combining data across qualitative studies.12
Based on the literature search criteria discussed next, the primary
investigator and two research assistants collectively searched seven
databases and selected nine qualitative studies for appraisal. Each
researcher individually appraised each of the nine studies using the
Lett's critical review form.13 The researchers used the systematic set of
guidelines from this form to critically appraise these qualitative stud-
ies. The guidelines for evaluating qualitative research quality and rigor
included 15 assessment questions on the study purpose, design, meth-
ods, sample selection, data collection, procedural rigor, data analysis,
theoretical connections, credibility, transferability, dependability, con-
firmability, conclusions, and implications. Upon completion of the crit-
ical appraisals, each researcher assigned a quality rank of high (H),
medium (M), or low (L) to signify the degree of validity, reliability, and
rigor of each study (see Table 1). After the quality rankings were com-
pleted, each researcher grouped the findings into themes. Next, all
three reviewers convened to compare their findings, assign final qual-
ity rankings for each study, and group the findings across studies into a
meta-summary. Major themes emerged from the team interpretation
and consensus on the primary study findings. Therefore, these results
were far removed from the original experiences of the participants that
were revealed to the primary researchers.
outpatient care. Qualitative studies based out of the United States
and written in English between 2000 and 2017 that described the
experiential characteristics of NPs’ practices and the ability of NPs to
freely exercise professional judgment in patient care delivery in the
ambulatory care setting were included. The research team chose these
inclusion criteria to identify the most current NP practice trends in
the United States. Studies of registered nurses and/or studies that
did not meet the inclusion criteria were excluded (see Figure 1). The
initial search resulted in 5,090 articles. After eliminating 259 dupli-
cates, 4,831 articles remained for detailed evaluation. A total of 4,822
studies were considered irrelevant and were excluded. The remaining
nine studies were retained for further appraisal. Initially, the research
team had concerns about the content usefulness and quality of two
studies. However, after a lengthy discussion, the reviewers agreed to
include these two studies. Therefore, nine studies were included for
data extraction and synthesis.
5 SEARCH RESULTS
Primary care (PC; n = 8) and obstetrics/gynecology (n = 1) were the
contextual characteristics from which the primary researchers con-
ducted their qualitative research in the nine studies. In addition to
the contextual characteristics, patients’ experiences with NPs’ roles
and NPs’ experiences with their practice autonomy and roles were
included. Twenty-one patient participants and 103 NP respondents
WANG-ROMJUE
were the total sample in seven studies. Two case studies did not include
participant samples and/or sample sizes.14,15
With the exception of these case studies, individual interviews
and/or focus groups were the primary researchers’ principle method
of collecting data. However, the primary researchers’ study designs
that underpinned the data collection varied. One used ethnography,16
one used narrative inquiry,17 one used hermeneutics,18 two applied
grounded theory,19,20 and the remaining studies used a qualitative
approach.9,14,15,21
6 DATA EXTRACTION AND SYNTHESIS
Findings from each study were extracted, interpreted, and combined
in the investigation process (see Table 2). First, after reviewing each
study, each researcher individually grouped the findings and created
themes from each study. Second, the team of three convened to dis-
cuss the individual list of themes from each study and compared these
themes across the entire study collection to condense and create new
themes and subthemes, for interpretation. Disagreements on ideas or
the meanings of the newly created themes were addressed by discus-
sion and revisiting the evidence in the primary study for clarification
and consensus. Third, to validate these findings, the primary author
conducted a reciprocal translation of the created themes by mapping
the newly created themes and interpretations back to the primary pub-
lications from which the evidence was obtained (see Table 3). Lastly,
four main themes emerged from this group analysis.
7 RESULTS
From our exploration, four main themes surfaced to represent NPs’
experiences with their practice autonomy and roles in the ambulatory
care setting: (a) autonomy, (b) NPs’ roles and responsibilities, (c) prac-
tice relationships, and (d) organizational work environment pressures.
Autonomy included two subthemes: independent practice and self-
empowerment. NPs’ roles and responsibilities comprised three sub-
themes: practice, role friction, and role comprehension.
Practice relationships included three subthemes: intrapractice rela-
tionships, interpractice relationships, and NP–patient relationships.
Organizational work environment pressures encompassed the organi-
zational constraints subtheme.
NP autonomy denotes the NPs’ independent decision-making
ability to choose the best patient care delivery method based on
their knowledge, skills, critical thinking, and judgment within the full
scope of practice as delineated by state regulations and organizational
policies. By applying these behaviors for the granting agencies, NPs
are actualizing their independent and interdependent roles. In four
studies, the perception of NPs regarding their practice autonomy is in
line with this definition of autonomy. Practice autonomy is perceived
by NPs as the freedom to have the “decision-making authority” to
care for patients “alone” without physician involvement: to practice
independently as the patients’ primary provider.9,15,18,19 Additionally,
3
“self-reliance,” full “prescriptive authority,” and “billing privileges” are
integral aspects of autonomy to NPs. NPs believe these privileges must
be achieved for “genuine independent practice” to occur. However, the
deficiency and disparity of these privileges are apparent across many
states.9,18,19 Currently, 28 states have restrictive regulations on NPs’
prescriptive authority and billing privileges.22 The lack of autonomy
hinders NPs’ opportunities to build confidence and self-esteem in
their roles: self-empowerment.9,18,19 Self-empowerment is another
attribute that NPs prize as an important part of their practice auton-
omy, and it reinforces their competence in their role and their ability
to affect patient outcomes.18,19
Based on the evidence, NPs’ roles and responsibilities are multidi-
mensional. They include diagnosing, prescribing treatments, promot-
ing health, preventing disease, providing holistic care, advocating for
the patient, teaching patients, and being versed with computer/virtual
technology. These duties suggest that NPs straddle the medical
curative model and the nursing model in providing patient care,
which precipitates role friction, a recurring subtheme corroborated
by the primary studies’ findings.17,19 The NPs’ struggle of “blending”
these two models, with patient care time constraints, creates internal
ambivalence about departing from the nursing model of care.17,19 The
NPs’ role friction is compounded by unclear organizational guidelines
regarding the NPs’ practices and the lack of comprehension of the
NPs’ duties and functions by administrators, physicians, and patients.
Some nursing and nonnursing administrators assume that NPs cannot
diagnose patients and/or prescribe treatments since they are regis-
tered nurses with an additional title. Certain physicians view NPs as
apprentices who need their clinical supervision to complete patient
care. Such external inattentiveness leads NPs to explain and defend
their roles.9,17–19 Thus, NPs’ roles and responsibilities are multilayered
and are accompanied by complex practice relationships.
The qualitative evidence points to three main types of practice
relationships NPs’ experience in their daily work: (a) intrapractice; (b)
interpractice; and (c) NP–patient relationships. Brown and Draye19
described findings about intrapractice relationships that were congru-
ent with other studies. Specifically, NPs creating alliances and part-
nerships through honest and direct communication with ancillary staff,
registered nurses, and nursing supervisors helps maximize collabora-
tion and team work.19
Intrapractice relationships refer to the NPs’ professional relation-
ships with the immediate staff, such as medical assistants (MAs),
licensed vocational nurses, registered nurses, and the clinic manager.
All of these individuals work together to coordinate and process
patient care for the NPs. However, evidence has indicated that ancil-
lary staff, such as MAs, undermine the NPs’ practices by not preparing
their patients in advance for the NP-patient encounter like they would
for the physician–patient encounter. Sometimes, this disparity of sup-
port is reinforced by clinic managers and/or administrators who toler-
ate these behaviors.9,19
Interpractice relationships are the second subtheme NPs described
regarding their practice relationships. Interpractice relationships refer
to NPs’ working relationships with healthcare professionals other than
MAs, nurses, and administrators. For example, beyond the NPs’ imme-
diate patient care team, physicians are one category of healthcare
4 WANG-ROMJUE
TA B L E 2 Qualitative studies on np autonomy and roles
Authors Study purpose/design
1. Brown and To explore the experiences of
Draye19 pioneers in establishing
the nurse practitioner (NP)
role and their experiences
in maintaining and building
the NP role in the
contemporary practice
environment; grounded
theory
2. Sears and To evaluate and report a
Hogg- 3-year pilot state program
Johnson15 granting NPs to be primary
providers for injured
workers in Washington
(WA) state; not stated
3. Weber20 To generate grounded theory
from the experiences of
APNs with
computer-based
decision-making systems;
grounded theory
4. Koeniger- To explore NP–client
Donhue16 encounters from a
resource exchange
paradigm; ethnography
5. Hernandez and To explore NPs’ experiences
Anderson17 with caring for
prehypertensive patients
based on their roles in
health promotion and
disease prevention;
narrative inquiry
6. Poghosyan To investigate NPs’ roles and
et al.9 responsibilities as primary
care (PC) providers (PCPs)
in Massachusetts and their
perceptions about barriers
and facilitators of the
scope of practice;
qualitative
7. Weiland18 To understand autonomy via
NPs’ experiences in PC;
Gadamerian hermeneutic
study
Methods Sample Summary of findings/quality
Semistructured 50 NPs attended Breaking free—Leaving familiar roles and
individual focus groups, and exploring uncharted territory
interviews and 17 NPs Molding the clay—Creating new relationships,
focus groups participated in blending two worlds, and stretching one's
individual limits
interviews Encountering obstacles—Meeting resistance,
being determined, and feeling invisible
Surviving the proving ground—Establishing
credibility/networks, explaining oneself,
choosing battles, and fighting for legitimacy
Building the eldership—Sharing the wisdom and
sounding the alarm
Quality = H
Case study WA stakeholders: • NP role expansion increased access to
NPs, laborers, healthcare in rural areas for injured workers
physi- and improved timely reporting
cians,employers,
• Outcomes and costs were not affected by
and L&IT
expansion of the NP role (new attending
provider role) Quality = L
Semistructured 13 Clinical nurse APNs making patient care decisions prior to
individual specialists (CNSs) actual decisions were the core variable, which
interviews and 10 NPs consisted of four user aspects: (a) perceptions
of initial system learning, (b) understanding
how technology works, (c) understanding how
system inferences are derived, and (d) trusting
system-derived data
Quality = M
Semistructured 2 NPs Sufficient time gives NPs the ability to make a
interview and solid exchange relationship—NPs are able to
observation inform, serve, report status, love, and provide
care
Quality = M
Clandinin and 8 NPs’ narrative Realities of practice: Time limits, work climate,
Connelly's accounts of caring patients, and budget goals were pressures
metaphorical for affecting NPs’ roles and autonomy. NPs felt
Three-dimensional prehypertensive unable to fulfill the idealized vision of care
(3D) narrative patients Ambiguous role identity: NPs straddle a role
inquiry space between medicine and nursingBridging models:
(2000) Effective patient management requires NPs
to blend medical and nursing models with
quality communication
Quality = H
Semistructured group 7 NPs NP responsibilities and roles—NPs give episodic,
interviews followed preventative, and chronic care like PC
by individual physicians
interviews of the Regulatory environment—Barriers to practice:
same participant state regulations requiring physician
NPs oversight
Colleagues’/coworkers’ comprehension of the NP
role—Organization to delineate/clarify NP
roles so that staff understands them to
facilitate NP practice.
Work environment—NPs need good
infrastructure and support to give care
Quality = H
Taped in-person Purposeful sampling Relationships, (b) self-reliance, (c)
session with of 9 NPs; PC self-empowerment, and (d) defending the
interview guide NP role
NP autonomy is 7 of 10 in the restrictive
authority of Oklahoma; Quality = H
(Continues)
WANG-ROMJUE 5

TA B L E 2 (Continued)

Authors Study purpose/design Methods Sample Summary of findings/quality

8. Dontje et al.21 To examine the challenges Six semistructured 21 adults—average -PHR ease of use dictated by agency guidelines
and barriers of access to participant focus age of -Perceived difficulty interpreting data in the
the patient health record groups with five approximately 64 PHR
(PHR) through a patient's open-ended years; the majority -Challenges navigating multiple PHRs of various
perception; qualitative questions (95%) were white providers
-Fears about safety and security affect PHR use
Quality = L

9. Davis and To provide a model for NPs'
Chapa, 2015 to understand how social
determinants (SD) affect
health; Social
determinants approach
Review of one case NPs NPs are leaders to decrease silos by
study inter-professional collaboration to effectively
address SD by insisting health care and
non-health care policies incorporate a SD
approach. Quality = L.

TA B L E 3 Reciprocal translation

Derived analytic theme and

subthemes Paper no. (as listed in table) Primary study themes
1. Autonomy: This speaks to the understanding of the NPs’ perceptions and experiences of being a self-sufficient sole provider of patient care
a. Independent practice 1 (p. 393, 394); 6 (p. 10); 7 (p. 101); 7 (p. 99, 100) “Decision-making authority” (1, 6, and 2 [authorizing
workman's comp. forms]; 7); “prescriptive authority” (1 and
6); lack of billing privileges (6 and 7); “self-reliance” (7)
b. Self-empowerment 1 (p. 395); 7 (p. 101) “Sustained commitment to practice yield confidence,
self-esteem, eldership”
2. NPs’ roles and responsibilities: This speaks to the understanding of the multifaceted issues on and surrounding the NP role
a. Practice 1 (p. 395, 394); 2; 4 (p. 1052, 1057); 5 (p. 92); 6 Diagnose and prescribe treatment (1, 2, 4, 6, and 7); “health
(p. 9); 7 (99); 8 (p. 427) promotion and disease prevention” (1, 4, 8, and 9); “Holistic
care” (1, 4, and 6); computer technology skills (3 and 5);
“patient advocate” (1, 2, and 7); “patient education” (5 and 6)
b. Role friction “Bridging two 1 (p. 393, 394); 5 (p. 92, p. 93) Societal perception of medical model dominance in curing
roles” (Medical Model and disease (1 and 5); “feelings of inadequacy” (1 and 5); feeling
Nursing Model) like an imposter (5)
c. Role comprehension external 1 (393, 394); 5 (p. 94); 6 (p. 11, 13); 7 (p. 101) Lack of understanding of “NPs scope of practice and skills
inattentiveness competency” (1, 5, 6, and 7)
“Defending the role” 1 (p. 395); 5 (p. 94); 6 (p. 11); 7 (p. 101) “Explaining oneself” (1, 5, 6, and 7)
3. Practice relationships: This speaks to the understanding of the multiple relationships that the NPs experience in daily practice
a. Intrapractice relationships 1 (p. 393, 394) 6 (p. 11); 7 (p. 100) “Undermined” (1, 6, and 7); lack of administration and staff
support (1 and 6); administration support (1)
b. Interpractice relationships 1 (p. 394); 6 (p. 14);7 (p. 100) Lack of physician support (1 and 7); physician support (1 and 6)
c. NP–patient relationships 1 (p. 395, 393); 4 (p. 1056, 1057); 5 (p. 93); 6 (p. Care intimacy (“felt heard and cared for” by patients) (1, 4, 6,
9); 7 (p. 100);8 (p. 825) and 7); dual equality (1 and 7); “patient engagement” (4, 5, 7,
and 8); “self-disclosure” (4)
4.Organizational work environment pressures: This speaks to the understanding of the organizational pressures that NPs experience
a. Institutional constraints 1 (p. 396); 4 (p. 1053); 5 (p. 92) “Time” (1, 4, and 5); “financial constraints” (1 and 5); meeting
institutional metrics (1 and 5)

professionals with whom NPs interact the most to provide patient care.
Based on the published studies, NPs expressed three main challenges
they face in working with physicians: (a) they must have a supervising
physician over their practice on record; (b) they must seek physicians to
sign “some procedures, prescriptions, and medical clearance forms” for
purposes of fulfilling state regulations; and (c) they experience a lack of
collegiality from some physicians.9,19
Third, based on the published studies, NPs view the NP–patient
relationships, even the challenging ones, as the most enriching
relationships above all others. NPs perceive patient engagement
in the NP–patient relationship as one “built on mutual trust,
respect, equality, and interdependency” to make healthcare deci-
sions together.16–18,21 The most rewarding part of this relationship
for NPs is when patients acknowledged being heard and “cared
for”.16–19 However, NPs experienced helplessness and a sense of
failure when patients were reluctant to commit to health promotion
advice.17
Ultimately, the quality of these practice relationships affects the
NPs’ roles, perceptions of autonomy, and capacity to practice at
full scope. In part, these relationships illuminate the organizational
work environment features and pressures in which NPs practice. The
organizational work environment refers to the employee's percep-
tion of and experience with the internal environment quality of the
organization.23
6 WANG-ROMJUE
Several studies indicated that organizational work environment
pressures affect the NPs’ autonomy and roles. In particular, NPs expe-
rienced three main organizational constraints that affect their ability
to fully care for their patients: (a) time; (b) financial constraints; and (c)
institutional metrics requirements.
NPs expressed frustration over the limited time allotment of 15–
20 min to provide comprehensive care for each patient visit. In addi-
tion, their schedules are booked consecutively and/or double booked
to see patients. NPs felt care quality was compromised with insufficient
time to self-reflect and spend time to coordinate care with the ancillary
staff.16,17,19
Institutional metrics, such as organizational budgetary goals and
insurer expectations, drive the time limits placed on NPs to complete
patient encounters. NPs consider this a threat not only to their auton-
omy, but also to safe patient care.
Aside from financial considerations, another organizational pres-
sure NPs faced was productivity metrics. Some organizations spec-
ify a number of patients NPs must see in a day to meet productiv-
ity guidelines.17,19 To reconcile time limitations, some NPs skipped
lunch to provide patient care. These organizational pressures limit
NPs’ autonomy and minimize their ability to provide safe holistic
care.
8 DISCUSSION
In the ambulatory care setting, NPs’ practice autonomy and roles
are multifaceted and expansive. This meta-synthesis emerged from
collecting, interpreting, and combining data from primary research
studies. Four main themes emerged: (a) autonomy, (b) NPs’ roles
and responsibilities, (c) practice relationships, and (d) organiza-
tional work environment pressures. Each aforementioned theme
included its respective subthemes: (a) independent practice and self-
empowerment; (b) practice, role friction, and role comprehension;
(c) intrapractice relationships, interpractice relationships, and NP–
patient relationships; and (d) organizational constraints. These find-
ings were interpretations of the primary researcher's interpretations
and were not the original lived experiences described by NPs to the
current researchers. Thus, the generalizability of the findings is lim-
ited across the population of all NPs. However, since the primary stud-
ies were conducted in different states, the evidence provided a snap
shot of various roles and levels of autonomy NPs experienced. Fur-
thermore, state and organizational barriers surmount facilitators to
NPs’ practice autonomy and roles. Our study interpretations are in
agreement with other quantitative research findings regarding NPs’
descriptions of their practice autonomy and roles and adds the con-
textual and experiential elements to these concepts, which are lacking
in these quantitative studies.2,4,5 However, Pron7 found contradictory
findings in their quantitative study conducted in Philadelphia, Penn-
sylvania with 99 NPs who practice in nurse-managed health centers.
NPs were highly satisfied with their practice autonomy and roles. The
“challenge/autonomy subscale” mean score of the Misener Nurse Prac-
titioner Job Satisfaction Scale was 5.63 on a 6-point scale. The abil-
ity to practice independently in a nurse-managed health center is a
possible reason why NPs scored autonomy so high. Compared with
other healthcare organizations, there are fewer restrictions on NPs’
practice autonomy in nurse-managed health centers.
The dearth of qualitative evidence about NPs’ practice autonomy
limited data thickness and richness. Data thickness refers to there
being many qualitative studies on this topic. Data richness refers to the
existence of multilayered, intricate, and detailed data. However, across
the qualitative studies, this contextual and experiential evidence of
NPs’ experiences regarding their autonomy and roles provides a more
complete picture of what their daily practices look like. In addition,
NPs’ practice autonomy and role experiences add specific depth to
the quantitative evidence. Such qualitative descriptions from differ-
ent settings add to the scarcity of existent qualitative nursing knowl-
edge in this area. The current realities of NPs’ practice autonomy and
roles will inform and guide healthcare stakeholders to transform state
regulations and suboptimal organizational milieu and processes with
specific strategies to optimize NPs’ abilities to practice autonomously.
Increased practice autonomy is vital not only to move the profession
forward, but also to maximize NP contributions to help increase soci-
ety's access to healthcare.
NPs’ autonomy with prescriptive authority and billing privileges is
still limited by some state regulations and local organizational policies.
These restrictions cause NPs to spend precious time seeking physi-
cian endorsement of their treatments and prescriptions, when they
could have used this time to care for patients. Such unnecessary tasks
invoke the NPs’ feelings of inadequacy and inability to actualize prac-
tice autonomy.
NPs struggle to bridge and/or supplant the nursing model with the
medical curative model in their daily practices, which creates role fric-
tion. Some physicians, administrators, and patients exacerbate NP role
friction by equating the NPs’ roles with registered nurses’ roles.19 For
example, in certain organizations, not realizing NPs can prescribe med-
ications, physicians expect NPs on their team to review each patient's
condition with them before prescribing treatments or medications.
Certain administrators view NPs as registered nurses with the ability
to give direct ambulatory patient care without support of ancillary staff
for patient throughput. In other situations, patients refuse to receive
care from an NP because the NP has a nursing license and not a medical
license. Such a lack of understanding of NPs’ roles, skills, and compe-
tencies precipitate the NPs’ need to explain and defend their roles.18,19
From these verbal exchanges, NPs seek to (a) help increase physicians’,
administrators’, and patients’ knowledge of the NP scope of practice;
(b) protect their scope of practice and maintain patient safety; and (c)
shape practice relationships.18,19
Three types of NP practice relationships emerged from the research
studies: (a) intrapractice relationships, (b) interpractice relationships,
and (c) NP–patient relationships. The quality of intrapractice and inter-
practice relationships present the most barriers to NPs for providing
patient care. In the published studies, NPs’ efficiency and efficacy in
patient care delivery were found to be undermined by a lack of sup-
port from their intrapractice team and interpractice partners, such
as physicians.9,18,19 However, the NP–patient relationships emerged
as facilitators to the NPs’ practice autonomy and roles. NPs view the
NP–patient relationship as a partnership between equals. The NPs’
WANG-ROMJUE 7

perceptions of autonomy and self-empowerment are heightened by experiences regarding their practice autonomy and roles by the afore-
establishing mutual trust, respect, and interdependence through on- mentioned four main themes and their respective subthemes that
going NP–patient relationships.9,16–19 emerged from our interpretation.
Aside from practice relationships, organizational work environment Within the context of the autonomy theme, the NPs’ experiences of
pressures, such as time limitations, financial constraints, and produc- physician oversight on their medication orders along with the inabil-
tivity metrics, create feelings of personal stress for NPs who try to ity to bill healthcare agencies directly for care, in certain states, min-
meet these expectations on a daily basis. These stressors are barriers imize the NPs’ self-reliance. Without attaining these privileges, NPs’
to the NPs’ efficacy in patient care delivery and intensify their percep- independent practice and self-empowerment, the subthemes of auton-
tions about the lack of practice autonomy.17,19 omy, remain evasive. These two issues hinder the NPs’ freedom to have
decision-making authority and care for patients alone.
Within the context of the NPs’ roles and responsibilities theme,
NPs struggle with blending the nursing and medical model along
9 IMPLICATIONS FOR PRACTICE
with receiving unclear descriptions of their clinical practice roles and
responsibilities from their employing organization. Such contentions
According to the themes and subthemes that emerged from these find-
are fueled by ignorance and minimal support of NPs’ roles by physicians
ings, nursing professionals, healthcare stakeholders, and leading orga-
and administrators, which complicates their practice relationships.
nizations can collaborate in various ways to change state legislation,
Practice relationships are the third theme and, based on our find-
improve healthcare professionals’ and public knowledge of NPs’ roles,
ings, comprised intrapractice, interpractice, and NP–patient relation-
and reshape and optimize organizational work climates to help expand
ships subthemes. These relationships are made complex by restricted
NPs’ practices.
prescriptive authority and billing privileges and are strained by physi-
First, the evidence from this meta-synthesis affirms the need for the
cians and administrators who are unfamiliar with the NPs’ roles and
speedy adoption of the Advance Practice Registered Nurses (APRN)
skill sets. NPs spend precious time seeking physicians to endorse
Consensus Model across all states and not just in 12 states. The APRN
their work and/or perform ancillary staff tasks, such as rooming in
Consensus Model defines the practices and recommends state licens-
patients. These events minimize team collaboration, which curtails
ing and certification recommendations for advanced practice regis-
patient access to timely care by NPs.
tered nurses.24 By doing so, the restrictive state regulations on NPs’
The final theme that emerged from our findings is organizational
prescriptive authority and billing privileges may be lifted by policymak-
work environment pressures. Within the organizational work environ-
ers to help accelerate the expansion of the NPs’ practice autonomy and
ment, organizational financial and productivity metrics are stressors
roles.
that affect the NPs’ ability to provide quality care safely and efficiently.
Second, in addition to the American Association of Nurse Practi-
Our contextual and experiential findings regarding the NPs’ daily
tioners’ (AANP) Awareness Campaign, leading organizations, such as
practices are representative of what NPs’ practice autonomy and roles
the Institute of Medicine and the Robert Wood-Johnson Foundation,
look like today and supplement the eight quantitative study findings
should partner with AANP to revitalize and cascade the Awareness
with reasons for why NPs perceive their practice autonomy and roles
Campaign further. Such collective efforts can increase public aware-
as moderate or low.2,4–6 These findings serve to not only provide a bet-
ness and the knowledge of the roles and responsibilities of NPs.25
ter understanding of the NPs’ practice autonomy and roles to the nurs-
Third, healthcare executives and administrators, who wish to
ing field, but also explain what changes are needed to improve their
improve their organizations’ patient care access and throughput,
practices. By informing healthcare stakeholders about NPs’ practice
should use this latest evidence to revise their organizational policies
experiences with autonomy and roles in the ambulatory care setting,
and reshape their organizational work environments to be more con-
we encourage these professionals, who contemplate on modernizing
ducive for effective and collaborative team delivery of patient care.
the healthcare landscape, to apply this evidence to effectively trans-
By transforming organizational work environments, healthcare profes-
form practice barriers to facilitators for the NP workforce.
sionals’ practice relationships may be improved as well.
Lastly, more qualitative studies of NPs’ practice autonomy and roles
in other settings, such as managed care, community health, and Vet- ORCID
erans’ Health Administration clinics, are needed. More evidence is Pauline Wang-Romjue MN, RN, PHN
required to reveal additional issues that affect NPs’ practices. http://orcid.org/0000-0002-2008-0875

10 CONCLUSION
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How to cite this article: Wang-Romjue P. Meta-synthesis on
nurse practitioner autonomy and roles in ambulatory care. Nurs
Forum. 2017;1–8. https://doi.org/10.1111/nuf.12236