Accident and emergency departments have been increasingly under pressure with overcrowding of patients and a strain on limited medical resources over recent years. One of the innovative strategies to meet this demand has been the expansion of the role of the emergency nurse practitioner (ENP) to help reduce the workload and waiting times.
This strategy has gained popularity, however, there is no international standardisation and recognition for the ENP. This review aims to critically evaluate and summarise the best available literature investigating the ENP role, outcomes and its impact on patient experience, quality of care, use of resources and organisational outcome of costs/benefits.
Prior to the introduction of ENPs in EDs, all patients presenting to these departments would have to be seen by a doctor for examination, diagnoses, treatment and prescription. Over the years, the demand for acute and emergency services has risen above supply of medical staffing, and patients have been increasingly waiting long hours to see a doctor for same-day emergency consultation [1,2]. This increase is a patient safety issue [3] – causing crowding, poorer patient outcomes and impacting negatively on patients’ quality of care, clinicians and the hospital [4] – putting pressure on an already limited medical workforce in EDs [5].
The main increase in attendance and crowding is due to the rise in ageing population, predicted to be 61% more by the year 2030 [6], coupled with high prevalence of co-morbidity and chronic illnesses [7]. The other causes of crowding may also be due to departmental delays in assessments, treatment, discharge planning, variations in patient pathways and general population growth [8].
Introducing the emergency nurse practitioner
There is no universal definition of the ENP other than they have acquired experience through long-term practice and additional training within their clinical specialty. The Royal College of Nursing (RCN) defines ENPs as “a registered nurse who has undertaken specialist education and training to independently assess, diagnose, treat and discharge patients presenting with a range of undifferentiated and minor to moderate injuries or illnesses in the emergency care setting” [9]. Depending on the country and healthcare setting, this role is subject to variation in education and practice provision [9-10]. The changes in professional role boundaries between doctors and nurses, the transformation of nursing scope of practice and the reduction in junior doctors’ hours in the UK have made it possible for nurses’ roles to diverge away from a traditional nursing orientation to new challenging concepts [11].
The ENP role empowers nurses with advanced clinical training to practice within specialist fields locally, at the same level as junior- to mid-grade doctors in patient assessments, diagnostic test ordering and interpretation of results, triage, diagnosing, treatment, prescribing, management to discharge and referrals [12]. ENP training duration is much shorter than medical doctor training and therefore makes it a quicker option for solving medical workforce shortages, and improving patient access and quality of care issues [13].
The creation of these roles was intended as a long-term investment rather than a ‘quick fix’ for service performance or workforce pressure issues [14], however it has been controversial as it breaks professional boundaries and causes inter-professional tensions, giving rise to questions about accountability, professional identity, career structure and autonomy, because the ENP title is not yet recordable or regulated.
Objectives
In this comparative review, I aimed to systematically explore available literature to identify studies that compared the ENP’s outcomes to that of the doctors in the domains of:
- Patient experience including waiting time, satisfaction and dissatisfaction
- Quality of care
- Organisational costs/benefits.
I also aimed to critically appraise the quality of included studies, determining the best available evidence on the ENP role and its impact on patient and staff, while contributing to the quality of available evidence for ENP outcomes.
A comprehensive search of relevant electronic databases and reference lists for peer-reviewed studies investigating the outcomes of the ENP role in emergency departments in comparison to doctors was done and systematically reviewed. Two independent authors selected studies based on inclusion and exclusion criteria using validated software EndNote™ and Rayyan. Data was extracted using TIDieR Checklist for a mixed methods analysis using standardised tools.
Results
A review of 16 included studies from 10 countries (Australia, Canada, Iran, Indonesia, Netherlands, New Zealand, Norway, Singapore, England, and USA) showed that the ENP’s role is an evolving trend and is a widely accepted and invaluable solution in healthcare workforce crises internationally, and even though there is lack of scope of practice standardisation currently, it has been validated and can improve care outcomes for stakeholders. However, ENP training remains inconsistent and educational preparation for the role is not standardised across settings. To sustain public confidence, expectations from the multidisciplinary team, enhance ENP career progression and professional identity, educational institutions and healthcare policy makers have a big role to play in supporting the training, regulation and education of ENPs. As the population of the world continue to increase, healthcare service demands will also rise, and more doctors and nurses will be needed to deliver the care. There is paucity of research focusing on the clinical, managerial and perceived impact of the ENPs’ role in EDs and the costs-benefits to the stakeholder.
Looking forward
The success of the ENP role calls for more rigorous research to inform policy makers, employers, educational training and research institutions internationally in support of role standardisation, professional regulation and strategic long-term planning for health service.
Implication for education
ENP training and qualification should be mandatory and standardised. And while the RCN has recently released their ‘Competency Framework for Registered Nurses in Emergency Care: Level 1 and 2’ [9], there is still further need for accreditation recorded with designated professional councils. This would promote interprofessional collaboration, accountability, career progression and standard quality of care. Emergency nurse practitioner development, titles and scope of practice, which appear to differ from country to country, need to be standardised internationally.
Implication for policy
Commissioners can expedite the expansion of ED capacity by maximising the invaluable ENP workforce to reduce workload, variations of patient pathways and improve positive patient experience. This article calls for a collaboration dialogue between healthcare services’ stakeholders to make decisions with implications on policies and strategies to develop and promote ENP role recognition and possibly a professionally recordable ENP identification as this would be appealing and beneficial for aspiring ENPs.
Implication for practice
The review findings suggest that ENPs working in collaboration with doctors in A&E departments could contribute to service improvement by improving access to care, flexibility of service, quality of care, patient experience, continuity of care by acting as a contact point for all staff, reduce waiting times in ED and help to reduce workforce crises/shortages that are a continuing (and increasing) healthcare issue internationally. In practice, ENPs should aim to articulate their skills and competencies into their practices, work towards formal credentialing and recognition of their role by requesting a recordable qualification with the Nursing and Midwifery Council.
Implications for future research
This review revealed a paucity of research evidence in the valuable role and outcomes of ENPs and calls for more rigorously controlled studies of high quality to provide the best contextual account of the ENP role and its impact on bridging the care delivery gap between nurses and doctors. A thorough evaluation of cost-benefits to the organisation would be vital in adding to the current evidence base to better inform policy makers, researchers and future practice. This indicates a strong case for recommendations in favour of high-quality research on the ENP model of care in EDs and to provide a better understanding of the role, career progression and professional identity.
Conclusion
Emergency nursing practice has seen an expansion of its role in response to workforce crisis and the findings from this review suggest that ENPs are comparable to doctors, effective, beneficial for sustainable workforce solutions and invaluable in improving quality of care and service delivery. However, the ENP qualification is not yet regulated.
The effects of long waiting times and crowding in EDs have been well documented in previous research and the interventions targeted to bring solutions have been numerous. This review concludes that ENPs working in collaboration with doctors in ED can be a long-term beneficial solution. Globally, it has been well expressed that the ENP model is a validated, safe and effective quality and capacity improvement strategy among others for healthcare stakeholders – the majority of the included studies in this review suggested that ENP outcomes can equal, and in some cases improve patient outcomes and quality of care. Key performance indicators such as reduced waiting times can also be improved and sustained by the effective use of ENPs, a part of the largest skilled safety-critical workforce, especially in the face of an uncertain future in healthcare.
References
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[All links last accessed May 2026]
Declaration of competing interests: None declared.
