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Organizational facilitators and barriers to optimal APRN practice

An integrative review

Schirle, Lori; Norful, Allison A.; Rudner, Nancy; Poghosyan, Lusine

doi: 10.1097/HMR.0000000000000229
Features: PDF Only

Background: The organizational environment can foster or impede full deployment of advance practice registered nurses (APRNs), affecting the quality of care and patient outcomes. Given the critical role APRNs play in health care, it is important to understand organizational factors that promote or hinder APRN practice to maximize the potential of this workforce in health care systems.

Purpose: The aim of this study was to synthesize evidence about APRN practice environments, identify organizational facilitators and barriers, and make recommendations for better APRN utilization.

Methods: A literature search was conducted in CINAHL, PubMed, and PsychInfo, yielding 366 studies. No time or geographic limitations were applied. Study quality was appraised using the National Institutes of Health National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Studies.

Results: Thirty studies conducted in the United States, Canada, and the Netherlands met inclusion criteria. The majority of the studies involved nurse practitioners. Facilitators to optimal practice environment were autonomy/independent practice and positive physician/APRN relations. Barriers included policy restrictions on practice, poor physician relations, poor administrator relations, and others’ lack of understanding of the APRN role. Barriers correlate with job dissatisfaction and increased intent to leave job.

Practice Implications: The review highlights the importance of physician and administration relations, organizational-level policies, and colleagues’ understanding of the APRN role in promoting effective practice environments. Organizations should align policy reform efforts with factors that foster positive APRN practice environments to efficiently and effectively utilize this increasingly vital workforce. Future research is warranted.

Lori Schirle, PhD, CRNA, is Assistant Professor, Vanderbilt University School of Nursing, Nashville, Tennessee. E-mail:

Allison A. Norful, PhD, RN, ANP-BC, is Post-Doctoral Fellow, Columbia University School of Nursing and Columbia University Medical Center Irving Institute for Clinical and Translational Research, New York, New York.

Nancy Rudner, DrPH, APRN, is Graduate Faculty, George Washington University, Washington, DC.

Lusine Poghosyan PhD, MPH, RN, FAAN, is Associate Professor of Nursing, Columbia University School of Nursing, New York, New York.

Dr. Norful was supported by the National Center for Advancing Translational Sciences, National Institutes of Health through Grant TL1TR001875. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

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