Journal of the American Association of Nurse Practitioners
Background and purpose: Little is known about the facilitators and barriers to the workforce transition of novice nurse practitioners (NPs) in primary care. This research aimed to identify factors contributing and detracting from a successful initial workforce transition for novice NPs in the primary care setting.
Methods:A descriptive, cross-sectional study was conducted via online survey administered to a national sample of 177 NPs who graduated from an accredited NP program and were practicing in a primary care setting for 3–12 months. Open-ended responses were analyzed using the Krippendorff content analysis method.
Conclusions: This study demonstrated that facilitators of the novice NP transition are the presence of mentorship and social support, finding meaning in their work, job satisfaction, and work–life balance. Barriers to the novice NP transition are lack of support and respect, role ambiguity, and workload.
Implications for practice: More mentorship, support, role clarity, and respect are needed to facilitate the novice NP workforce transition. More research is needed on interventions that can be implemented by health care organizations to improve the facilitators of role transition identified in this study.polypharmacy.
Nurse practitioners (NPs) play an increasingly central role in the provision of health services in the United States. Nurse practitioners provide the nation with an opportunity to expand access to high-quality, cost-effective care. Historically and increasingly more recently, NPs have practiced in community-based primary care settings, mostly in medically underserved and rural areas (Barnes, Richards, McHugh, & Martsolf, 2018; Reagan & Salsberry, 2013). Nurse practitioners are particularly well suited for primary care given their holistic and patient-centered approach to care, which includes care coordination and sensitivity to social and cultural factors that affect health (Cassidy, 2013). Although the production of NPs has dramatically increased in recent years from 7,600 in 2006 to more than 25,600 in 2016 (Salsberg, 2015), new NPs entering the workforce continue to face challenges and stressors related to a lack of confidence assuming increasingly autonomous roles as clinicians (Barnes, 2015a; MacLellan, Levett-Jones, & Higgins, 2015).
Despite rigorous processes and standards for the licensure, accreditation, certification, and education of NPs (APRN Consensus Workgroup & National Council of State Boards of Nursing APRN Advisory Committee, 2008), many NPs entering the workforce lack confidence in their ability to practice independently, particularly in the first year and when managing complex patients (Brown & Olshansky, 1997; Hart & Macnee, 2007; Heitz, Steiner, & Burman, 2004; Kelly & Mathews, 2001). Novice NPs entering the primary care workforce face many difficulties (Barnes, 2015b; Brown & Olshansky, 1997; MacLellan, Higgins, & Levett-Jones, 2017), which can lead to feelings of discontentment and lower job satisfaction. This in turn has been associated with increased intent to leave and high turnover (DeMilt, Fitzpatrick, & McNulty, 2011; Sargent & Olmedo, 2013). According to Flinter (2011), the discrepancy during the first year between primary care physicians who have undergone a residency program and novice NPs who lack this additional training places them under increased stress and makes the transition more difficult for them, the practice team, and the organization. This is also recognized in the Institute of Medicine (IOM, 2010) Future of Nursing report, which calls for greater attention to the transitional period of nurses following degree completion. In recent years, there has been a proliferation of NP residency and fellowship programs, now numbering around 70 (Martsolf, Nguyen, Freund, & Poghosyan, 2017), beginning with the first NP residency program at Community Health Center, Inc. in Connecticut in 2007 (Flinter, 2011). Although there is some evidence that participation in NP residency programs may lead to greater confidence, improved job satisfaction, and increased professional status for new NPs (Flinter & Hart, 2017), these data are limited.
Due to a dearth of literature related to the transitional period of new NPs in primary care (PC), the researcher developed a theoretical framework (Figure 1) based on a review of the literature upon which to base a national study of new NPs in the first year following graduation (Faraz, 2017). This framework identified several factors key to a successful transition and turnover intention of the novice NP (Figure 1). These include the individual characteristics of the NP (e.g., educational background, prior work experience, mentorship, support networks, and sense of meaning); role acquisition (e.g., role ambiguity, self-confidence, and perceived competence); and job satisfaction (e.g., professional autonomy, quality of professional and interpersonal relationships, time to complete work, and job benefits) (Faraz, 2017).
There is strong evidence that individual characteristics, role acquisition, and job satisfaction affect novice NP transition to the PC workforce. However, prior research was conducted during a markedly different health care climate prior to passage of the Affordable Care Act, increasing primary care provider shortages, ageing baby boomers, and increasing complexity of chronic disease management. Therefore, the facilitators and barriers most critical to a successful transition for novice NPs may have evolved. Thus, the current research addresses an important gap in the literature by investigation facilitators and barriers to a successful transition of novice NPs in the PC workforce.
After receiving Institutional Review Board approval, a convenience sample of NPs practicing in PC settings was recruited through all Commission on Collegiate Nursing Education (CCNE)-accredited master’s nursing programs, social media sites, and snowballing. An e-mail was sent to the contact administrator listed on the CCNE website (www.aacn.nche.edu) for each of the accredited master’s nursing programs in the United States (n = 431) and to the contact administrator listed for all primary care–focused NP residency or fellowship programs (n = 8) found on the GraduateNursingEDU.org website (www.graduatenursing. org) that described the purpose of the study, a statement regarding benefits of the research, and a request to disseminate a recruitment e-mail on behalf of the researcher to their NP graduates or cohort.
A total of 29 NP educational programs from all regions of the United States and five NP residency/fellowship programs forwarded the e-mail to their graduates. Nurse practitioner programs agreeing to facilitate recruitment circulated a letter electronically written by the PI explaining the project and inviting participation of eligible alumni who met the inclusion criteria. It is possible that additional programs forwarded the recruitment letter without notifying the researcher. An estimated 1,740 novice NPs received the recruitment e-mail via their NP educational or residency/fellowship program, although accurate response rates are difficult to assess through this indirect sampling technique. Additional recruitment methods simultaneously used to increase participation included posting the recruitment letter for the study and a link to the survey on NP group pages via the social media site Facebook and the professional networking site LinkedIn.
The letter inviting participation asked interested candidates to follow a link (included in the e-mailed letter) to the survey. After reading the informed consent front page, the study candidate checked a box agreeing to participate and began the survey once they met the inclusion criteria, which was determined by answering four screening questions which were: 1) Are you currently employed as a NP?; 2) Have you been employed as a NP for at least 3 months?; 3) Have you been employed as a NP for more than 12 months?; and 4) Are you at least 18 years old?. Most participants who screened out of the survey did not meet the employment criteria; that is, they either had been employed as a NP for less than 3 months or longer than 12 months. The survey took approximately 10–15 minutes for most participants to complete as indicated by recorded survey start and end times, and all those who completed the survey were offered compensation with a $5 Amazon gift card by providing their e-mail address on a secure page that was kept separate from their responses. To prevent multiple entries by a participant, computer IP addresses were used to identify unique visitors, and users with the same IP address were prevented from accessing the survey more than once. Data were downloaded from Qualtrics, and statistical analysis was conducted using SPSS for descriptive statistics and the Krippendorf content analysis method for qualitative analyses.
Open-ended questions were designed to garner more information about environmental factors affecting the overall experience of these providers. Five open-ended questions: “What factor has been most influential in your job satisfaction/dissatisfaction to date?”; “Is there an issue not included in the survey that you feel is important to your job satisfaction?”; “Do you have any further comments about your transition to your first NP role?”; and “Please provide any additional information that may help to understand your responses (i.e., relocating for family reasons or starting a family)” were included to assess aspects of the workforce transition that were not captured through the Likert-type questions.
Quantitative data were analyzed using SPSS version 22.0 for descriptive statistics. Answers to the open-ended questions at the end of the survey were analyzed in aggregate for themes by the researcher using the Krippendorff content analysis method. This method allows for inferences to be drawn from trends and patterns in the text provided by participants in a systematic and replicable manner (Krippendorff, 2013). By engaging with the text through an iterative process, the researcher was able to identify the emergence of themes and subthemes.
Study demographic characteristics. There were 293 surveys started, and 177 completed surveys of the 207 who met the inclusion criteria. The sample contained 92.9% (n = 158) women with an average age of 35 years (SD = 8.2), 79.7% (n = 141) of whom held a master’s degree in nursing. Table 1 summarizes additional demographic and career characteristics of the sample.
Total word count was 7,585 for the open-ended answers. Comments ranged in length from 1 to 190 words, with an average length ranging from approximately 10 to 33 words per open-ended question.
Qualitative analysis themes
Facilitators of transition.
Support/mentorship. “Having support as a new NP is incredibly important and makes the transition to practice much more bearable.”
New NPs overwhelmingly mentioned the importance of support in facilitating their transition. Sources of support varied but mostly focused on support of colleagues in the workplace. Specifically, support from the medical director, collaborating physicians, and fellow NPs were mentioned the most, followed by support and administrative staff. Support from colleagues helped new NPs gain confidence in their roles and those who found mentors, whether in other NPs or physicians, expressed gratitude. In fact, mentorship was a theme that came up frequently, demonstrating a great need of new NPs to have regular contact with a more senior clinician. The majority of novice NPs also stated a desire to participate in a residency or fellowship program following graduation. Many felt unprepared by their basic NP education for the many challenges of practicing as a NP, and those who participated in a residency program or practiced in a “residency-like” practice environment expressed gratitude for this additional supported experience.
Autonomy.“Great autonomy in patient care–it is entirely up to me whether I am comfortable seeing each patient who presents to our walk-in retail clinic–or whether I feel a particular patient needs to be triaged to a higher level of care.”
Autonomy was cited by new NPs as a positive aspect of their new NP role. Many of the participants in the study were transitioning to the NP role following significant registered nurse (RN) experience and therefore may have been seeking autonomy specifically. Those with limited autonomy expressed dissatisfaction and desired more. Those with more autonomy expressed satisfaction but acknowledged the need for additional support for more complicated patients.
Learning and professional growth/development.“As a new grad, I need a place where I can safely grow and learn.”
New NPs expressed a need for learning and professional growth. They liked collegial work environments where asking questions and teaching were emphasized, and enjoyed opportunities to learn. Didactic lecture on clinical topics was one example provided, but on-the-job learning was the predominant method of teaching and learning. The ability to ask questions or think through clinical scenarios with colleagues was important for new NPs. Also, physicians who were willing to teach were appreciated by new NPs.
Work–life balance. “I work 7 on/7 off so I enjoy working full time and having enough time with my husband and small children.”
Flexibility in work schedule and having time for adequate work–life balance were important to new NPs. Many cited the benefits of having a day off during the week for catching up on administrative tasks or having the time to meet their family obligations and spending time with their spouse and children. Having the flexibility to make their own schedule and being able to take time off as needed were also important. Leaving work on time and not carrying work over such as charting were critical to respondents. New NPs also recognized that having a life outside of work is necessary, and having hobbies or other interests besides their clinical work.
Finding meaning in work.“Patients are by far the most influential factor.”
Feeling like they have a sense of purpose, working within their communities and enjoying the patient population they work with were all aspects of finding meaning in their work that motivated new NPs. Working with underserved populations, those from marginalized groups, and with special needs were particularly valuable to new NPs. Patient validation, such as satisfaction, receiving positive feedback from patients, and feeling appreciated, also had a positive impact, as did patients recommending the NP to others and requesting follow-up appointments. Helping patients and feeling as if they are making a difference were strong motivators for new NPs.
Barriers to transition
Lack of respect.“Being the only NP on the team I feel as though I am being constantly evaluated, challenged, and misinterpreted.”
Many new NPs found a lack of respect from other clinicians, support and administrative staff challenging. Many cited rude comments and being “dumped on” in terms of unpleasant patients. Some even stated bullying or borderline abusive behaviors from fellow NPs, PAs, and MDs, such as an MD becoming angry when asked questions by the NP. Negative attitudes or undermining clinical authority by administrators or support staff were particularly distressing to the new NP. There were also many comments about a general lack of respect for NPs or a disrespectful work environment. A lack of respect for opinions, suggestions for improving the practice, or feeling they have a voice within the organization in terms of policies and procedures were also a common theme.
Role ambiguity. “There are no other NPs at this facility and I am the first person in this role, so figuring out my place has been difficult. In some ways, it is great, but can be very difficult in other ways. My role is not clearly delineated.”
Entering an organization as the first NP was difficult for novice NPs because there was no prior framework for the NP role. Employers not understanding NP scope of practice and educational training placed a strain on novice NPs and inadequate orientation or onboarding programs contributed to the lack of clarity. A lack of knowledge by other clinicians or support staff regarding the NP role led to resentment among novice NPs who were asked to complete nursing tasks or treated with less respect than other clinicians. Not having clear objectives for development and success within the clinical setting was a source of stress among novice NPs.
Lack of support. “My boss (MD) right now completely misjudged my capabilities and scope, even though she said she knew. It put me in a terrible position, and generally feeling terrible about myself as a professional. The utter lack of her understanding makes every day really tough, as there are no benchmarks for my success and development. I am coming up with everything on my own and feeling very lost at sea.”
Lack of support, isolation, and feeling alone were the most cited barrier for new NPs. Many described a lack of resources available for getting their questions answered as well as a lack of mentorship and formal training. Both administrative and collegial support were important and the absence of either had a negative impact on new NPs. Loneliness stemmed from physically being isolated in the workplace without other colleagues to interact with or consult as well as a lack of time for socialization in the workday due to heavy patient loads and administrative demands.
Workload. “Being forced to see too many complicated patients in too short an amount of time.”
Patient volume and complexity was a major barrier for new NPs, and many mentioned overwhelming volumes and pressure to see more patients without adequate support or resources. Many reported that their organizations stressed a “numbers game” with emphasis on quantity versus quality of patient care and unrealistic expectations for productivity. There was also selfimposed pressure of knowing there are more patients waiting than they could see in the time allotted. The fast pace of the office combined with a lack of time to see patients created stress for new NPs. They expressed the need for more time to see patients as well as more administrative time to complete nondirect patient care tasks such as charting.
Compensation.“I was a little disappointed with a salary for beginning nurse practitioners in our area. I feel like our level of autonomy and responsibility is not reflected in our wages. I was also disappointed with the vacation time of two weeks. I was up to over a month as scheduled of annual leave as a RN.”
Low wages as compared with other colleagues or previous RN salary as well as limited benefits that included paid time off and retirement were often cited as negative forces for new NPs. Although salary was important, other factors mentioned frequently by novice NPs were the lack of bonuses or raises and loan repayment from employers. Additionally, nonmonetary recognition for a job well-done was also cited as well as debt burden and options for loan repayment. Of interest, novice NPs often expressed their dismay in relative terms such as low pay compared with their peers or relative to their workload. They were interested in fair pay, not necessarily high pay. They felt underpaid and undervalued by health care organizations.
Analysis of qualitative responses contributes additional insight into the facilitators and barriers of the novice NP workforce transition that were not otherwise captured in the quantitative portion of the study. Analysis of the quantitative data revealed professional autonomy as the most influential factor in successful NP role transition (Faraz, 2017). Although professional autonomy remained significant in the qualitative data analysis, additional factors also emerged as significant. The quantitative data results were limited to the constructs of the previously established measurement tools that were nonspecific to novice NPs and therefore provided an incomplete picture of the novice NP transition. Future measurement tool development specific to the NP transition to practice is one area of research that is needed to accurately assess novice NPs’ transition experience on a larger scale.
The results of this study validate the theoretical framework developed by the researcher in many ways. Mentorship, social support, and finding meaning in their work were important facilitators of the novice NP transition. Equally important was job satisfaction, comprised of professional autonomy, quality of professional and interpersonal relationships, time to complete work, and job benefits. The aspect of role acquisition, comprised of role ambiguity and perceived competence, and self-confidence, was partly validated, through the desire for more learning opportunities and transition to practice program opportunities. This may be interpreted as a need for development of perceived competence and self-confidence through additional practice opportunities and supported learning. Knowledge of the NP role and proper utilization of NPs was validating of the concept of role ambiguity.
Aspects of the theoretical model that were not mentioned in the comments and not correlated with responses were educational background and prior work experience. It is important that work–life balance was of major importance to novice NPs, something that was not included in the original framework based on a review of the literature. Work–life balance is increasingly valued in society, and greater emphasis has been placed on this in recent years. Including work–life balance as an integral aspect of job satisfaction and measuring this construct through additional questions when collecting data from NPs is recommended.
NPs who participated in a residency or fellowship program experienced a more positive transition experience, feeling supported and mentored, as compared with those who did not. Many NPs expressed a desire or need to participate in a residency or fellowship program having experienced the transition without one. This is in line with previous studies that demonstrated benefits of participating in a NP residency program (Flinter & Hart, 2017) and determined that a formal orientation program is associated with improved NP role transition (Bahouth & Esposito-Herr, 2009; Barnes, 2015b; Cleary, Matheson, & Happell, 2009; Cusson & Strange, 2008; Flinter, 2011). Offering NP residency or fellowship programs, or at the minimum a formal orientation program, should be considered by stakeholders.
This study is limited to novice NPs in PC settings, and the findings will only be generalizable to such NPs. It is difficult to calculate the response rate because it is hard to know how many NPs meeting the inclusion criteria received the e-mail. Although the recruitment request was sent to all CCNE-accredited master’s nursing programs, it was outside the control of the researcher which programs decided to send out the request for participants to their alumni. Direct contact via e-mail and phone to administrators involved in alumni relations may have increased the response rate from NP programs. Additionally, not all NP programs that forwarded the recruitment letter notified the researcher nor were they able to provide information on how many NP graduates received the letter. Furthermore, many NP programs reported that they did not maintain accurate contact information for their graduates. In addition, the social media sites used to advertise the survey were not specific to new graduate NPs practicing in PC settings. There may have been overlap between participants who received the survey from both their educational and their residency or fellowship program, although the sample size for the latter was very small. Differences in individual characteristics such as NP educational background and prior work experience may have influenced novice NP workforce transition expectations and experiences, although this was not readily apparent from the data analysis. Finally, the effect of variations in NP autonomy between states could not be accounted for due to small sample sizes from each state.
The transition to new NP is both an exciting and challenging time, and understanding the facilitators of and barriers to the transition is an important first step in providing adequate support and resources for new graduates. Educators and employers alike have a stake and responsibility in ensuring the preparation of novice NPs; doing so allows a smoother transition and subsequently may affect job satisfaction, turnover intention, and even patient outcomes. This research found that mentorship, increased autonomy, opportunities for growth and learning, and work–life balance were facilitators to the transition, whereas a lack of support and respect, disorganization, and overwhelming schedules were obstacles to the transition. Educational programs should inform students of these workforce issues to prepare them for securing the right position, and employers should have mechanisms in place for providing these desirable workplace attributes to recruit and retain the best NPs for their organization. By improving transitions between the educational and work arena, it is possible to improve novice NP role development, thereby increasing retention of vitally needed primary care providers. This may improve continuity of care, leading to improved patient outcomes.
A. Faraz designed the study, performed data collection and analysis, and wrote the manuscript.
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Numbers of initial hospitalizations
A binomial logistic regression was performed to understand the effects of PIM usage on the likelihood that participants will be hospitalized. The logistic regression model was not statistically significant but did show a favorable statistical trend (p = .079). The model explained 4.4% (Nagelkerke R2) of the variance in hospitalizations and correctly classified 63.2% of cases as no or yes for hospitalizations. The predictor variable of PIM usage was not statistically significant. There was no association with PIM usage and initial hospitalization (Tables 6–8).
Number of 30-day rehospitalizations
Of the 35 patients who had a hospitalization, only four had a rehospitalization within a 30-day period. Given the small sample size of n = 4, a logistic regression was not performed given the inability to determine statistical significance. All 4 (100%) of those with a rehospitalization within 30 days were prescribed PIMs; 2 (50%) of the patient were on two PIMs and 2 (50%) of the patients were on three PIMs. Of the patients discharged on PIMs, 2 (50%) had a new PIM added at discharge.
Limitations of this study included the small sample size and short follow-up duration. A longer follow-up period would have allowed for a larger sample size and a longer length of time to track hospitalizations and rehospitalizations. Also, other potential risks factors for hospitalization were not assessed. Regarding falls, administration logs related to administration time of medications before timing of falls was not recorded to determine whether timing of medication had an effect of falls. Also, this study looked at the 2015 Beers criteria as a whole and did not look specifically at medications designated as a high risk for causing falls. Because this was a retrospective chart review, it was beyond the scope of this study to determine whether other medications had been tried and failed before continuing a PIM therefore justifying an ongoing need for a PIM despite potential other alternatives.
Elderly patients with multiple comorbidities are at risk for falls and hospitalization. Reducing factors that may lead to hospitalization such has prescribing PIMs whenever possible is crucial. Most patients (60%) in this assisted living population were taking at least one PIMs as classified by the 2015 Beers criteria. Although we found no statistical significance between PIM usage and fall rates in this population, there was a favorable statistical trend between PIM usage and hospitalizations. All patients who had a rehospitalization were on at least two PIMs. The elderly may benefit from careful monitoring of their medication regimen and for close consideration of medications on the 2015 Beers criteria with the goals of trying to reduce PIMs whenever appropriate. Using a consistent method to review and reduce PIMs may have a positive outcome on hospital admissions and falls among the elderly. Reviewing medications profiles for ongoing PIM usage after hospitalization to prevent future hospitalizations should be considered. Providers should become familiar with the Beers criteria as one tool for clinical decision making as appropriate. Further quality improvement projects should be done to determine whether reduction in PIM usage prospectively has a positive effect on hospitalization and 30-day rehospitalization rate given the small sample size of this study.
Implications for practice
Although this project demonstrated a favorable, but not statistically significant, relationship between PIMs and hospitalizations, the sample size was small and other potential risks factors for hospitalization were not assessed. Efforts should be made in the future to follow patients prospectively regarding PIMs, falls, hospitalizations, and justification for ongoing usage to gain an ongoing understanding of usage where applicable. Patient complexity, medicationadherence, and other factors that may have resulted in patient hospitalization were not accounted for within the project. Other issues that affected decisions related to prescribing that were not captured in the chart review were failed medication regimens, social factors, and worsening disease. Despite the limitations, benefit exists and providers should still continue to use the 2015 Beers criteria among the elderly population as a guide for clinical decision making when considering medication regimens for the elderly. Providers should be educated on the proper use of the 2015 Beers criteria. Likewise, providers should document rationales for medication selection and the need for continued used of PIMs to ensure optimal care and communication within the team.
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