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New Nurse Practitioners’ Perceptions of Preparedness for and Transition Into Practice
ORIGINAL RESEARCH
New Nurse Practitioners’ Perceptions of Preparedness for and Transition Into Practice Ann Marie Hart, PhD, FNP-BC, and Anne Bowen, PhD ABSTRACT
Preparedness for clinical practice is a critical issue for new nurse practitioners (NPs). We assessed new NPs’ perceptions of their preparation for and transition into clinical practice. A national sample of 698 licensed NPs who graduated between 2006 and 2011 and were practicing as NPs in the United States completed a survey related to clinical preparation and practice transition. The majority reported feeling generally or somewhat prepared for practice after their NP education. They also expressed interest in receiving assistance as they transition into practice through residencies and mentoring. Specific findings regarding preparedness and transition into practice are described, and recommendations are offered. Keywords: nurse practitioner education, nurse practitioner mentoring, nurse practitioner preparedness, nurse practitioner residency, nurse practitioner transition Ó 2016 Elsevier Inc. All rights reserved.
N
urse practitioners (NPs) are committed to providing quality health care, and United States consumers are receptive to receiving care from NPs.1 Research supports that patients are satisfied with NP-delivered care2,3 and that outcomes for patients receiving care from NPs are comparable with physician-delivered care.3,4 NPs are integrated into the US health care system and play a substantial role in health care delivery.1,5,6 The number of Medicare beneficiaries receiving primary care from advanced practice registered nurses (APRNs) increased 15-fold between 1998 and 2010.7 Furthermore, with the 2010 Patient Protection and Affordable Care Act, more NPs are being sought to provide primary care services for newly insured Americans.8,9 Despite the success of the NP role, the path from novice to competent NP is often challenging and difficult.10-12 Preparedness for practice is a critical issue for new NPs, many of whom report feeling overwhelmed, frustrated, and inadequate.13 However, research on NP preparedness is limited, and, to date, there are only 2 published studies on this topic.14,15 The first study was conducted in 1988; a survey of 136 APRNs (including 39 NPs) educated in the southeastern US found that NPs www.npjournal.org
were less satisfied with their education than clinical nurse specialists or certified registered anesthetists, specifically regarding clinical pathology, differential diagnosis, laboratory diagnostics, and pharmacology.14 The second study, a national retrospective survey of NPs’ perceptions of preparedness for practice, was conducted in 2004.15 The respondents (N ¼ 562) were primarily master’s-prepared (77%) family nurse practitioners (FNPs, 61%), with an average age of 49. In response to the question “Upon completion of your initial NP educational program, how prepared were you to practice as an NP?” 9.8% of the respondents described feeling “very well prepared,” 38.4% “generally well prepared,” 38.2% “somewhat prepared,” 11.7% “minimally prepared,” and 1.9% “very unprepared.” Respondents indicated feeling most prepared for “health assessment,” “differential diagnosis,” “pathophysiology,” “pharmacology,” “health teaching,” and “management of acute illnesses.” They reported being least prepared for “billing and coding,” “simple office procedures,” “electrocardiogram (EKG) and radiology interpretation,” “microscopy,” and “mental illness management.” Responses to open-ended items revealed 4 main themes related to NP education: The Journal for Nurse Practitioners - JNP
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1) the need for increased rigor, 2) the need for more clinically relevant content and experiences, 3) the need for more clinically experienced faculty, and 4) NP education has come a long way. Finally, 87% expressed that they would have been “definitely” or “possibly” interested in a postgraduate residency program if one had been available. A major limitation of the 2004 study15 was that many of the respondents had completed their formal NP education 10 to 30 years before completing the survey. The evolution of NP education in the last 15 to 35 years increases the need to understand new NPs’ preparedness for practice. Feedback from new NPs can guide curriculum and policy decisions that will advance the next generation of NP leaders; thus, the purpose of this study was to assess NPs’ perceptions of preparation for clinical practice and transition into practice, specifically from NPs who graduated between 2006 and 2011. METHODS
The study involved an electronic, Web-based survey delivered through Key Survey (http://www .keysurvey.com/). The 200415 survey was updated by the authors and several graduate students from the University of Wyoming. The questions were further refined after piloting the survey with a group of NPs in Wyoming. The final survey consisted of 81 multiple-choice items, 27 demographic items, and 6 open-ended items. Eligibility was determined using 3 items: 1) graduating from an initial NP program between 2006 and 2011, 2) being licensed to practice as an NP in the US, and 3) having practiced as a licensed NP in the US. Respondents who did not meet all 3 eligibility items were sent to a thank you page, and participation was terminated. The final survey and its administration received approval by the University of Wyoming’s Human Subjects Committee. On April 25, 2012, an invitation and an electronic survey link were distributed to approximately 51,000 electronic newsletter subscribers by Fitzgerald Health Education Associates, Inc, a leading, national organization dedicated to NP education. One month later, representatives of NP programs and organizations with few or no responses to the electronic invitation were e-mailed directly asking them to 2
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distribute the survey to their NP alumni or constituents. Data Analysis
Data were analyzed using SPSS Statistics 20 (SPSS Inc, Chicago, IL). Frequency data were compared using chi-square and other nonparametric analyses. Scale scores were compared using univariate analysis of variance. Given the large sample size and number of analyses, P < .01 was considered significant. We subjected the 9 general “preparedness and support” questions regarding the respondents’ first year of practice to principal components factor analysis with varimax rotation. Two meaningful factors emerged. The first factor (satisfaction with support) included 6 items with a Cronbach alpha of 0.91 and accounted for 42.5% of the variance. The second factor (feelings of preparedness) included 3 items with a Cronbach alpha of 0.80 and accounted for 29.3% of the variance. The survey included 2 sets of 21 parallel items. In set 1 (importance of preparation), the participants rated the “importance of preparation” for specific practice-related skills, and in set 2 (feeling prepared), they rated the same items based on “how prepared they felt” at the beginning of practicing. Set 1 was subjected to a principal components factor analysis with varimax rotation. Five meaningful factors emerged with eigenvalues greater than 1. The first factor, “managing health concerns,” included 5 items, accounted for 19.58% of the variance, and had a Cronbach alpha of 0.92. The second factor, “basics of health assessment and diagnosis,” included 4 times, accounted for 17.73% of the variance, and had a Cronbach alpha of 0.97. The third factor, “diversity and teaching,” included 4 items, accounted for 13.26% of the variance, and had a Cronbach alpha of 0.78. The fourth factor, “procedures,” included 4 items, accounted for 12.26% of the variance, and had a Cronbach alpha of 0.83. The final factor “evidencebased practice and collaboration” included 4 items, accounted for 10.76% of the variance, and had a Cronbach alpha of 0.76. Note, the factor analysis only included participants who responded to all of the preparedness items. We then examined the NPs’ feelings of preparedness by taking the set 2 questions and Volume
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computing scores for the 5 constructs identified in set 1. Groups of participants with similar attitudes were then constructed using the 5 preparedness scores in a hierarchical agglomerative clustering procedure using squared Euclidean distance and Ward linkage. This approach was chosen because Euclidean distances are the simplest way of computing geometric distances between 2 participants based on the coded dimensions, and squaring this distance places greater weight on participants who are farther apart.16 Open-ended items were analyzed for themes using content analysis,17 a qualitative methodology for forming accurate and reproducible inferences from texts and other sources (eg, recorded speech) within a specific context. RESULTS Demographics
A total of 698 NPs completed the survey, all of whom reported having completed their NP education between 2006 and 2011, being licensed as NPs in the US, and having provided care to patients as licensed NPs. The respondents were primarily female (94%), with an average age of 42 (standard deviation [SD] ¼ 9.99) years. Most described themselves as non-Hispanic and white (86.4%). The majority (90.2%) had completed a master’s NP program, and 69.4% were prepared as FNPs. Table 1 (available online at http://www.npjournal.org) provides a summary of participants’ demographic information. Preparedness for Practice
For the item “Upon completion of your initial NP educational program, how prepared were you to practice as an NP?” 3.3% of the respondents described feeling “very well prepared,” 38.9% “generally well prepared,” 43.0% “somewhat prepared,” 11.1% “minimally prepared,” and 3.7% “very unprepared.” On a 5-point scale ranging from 1 (very unprepared) to 5 (very prepared), respondents indicated feeling most prepared for assessment (mean [M] ¼ 4.39, SD ¼ 0.86), pathophysiology (M ¼ 3.86, SD ¼ 0.93), wellness (M ¼ 4.39, SD ¼ 0.86), patient rapport (M ¼ 4.39, SD ¼ 0.86), and relationship building (M ¼ 4.39, SD ¼ 0.86), and episodic care and least prepared for chronic conditions, complex patients, ordering and interpreting diagnostic tests (EKGs, X-rays, and labs), www.npjournal.org
and specialty areas (eg, dermatology, orthopedics, and cardiology) (Table 2). First Year of Practice
Several survey items specifically assessed the first year of clinical practice as an NP. For the item “Looking back on 1st year of clinical practice as an NP, I was provided adequate clinical support,” 19.8% responded “strongly agree,” 42.8% “agree,” 11.3% “neither agree or disagree,” 19.4% “disagree,” and 6.7% “strongly disagree.” Only 17% reported having a formal mentor, 40.1% had an informal mentor,
Table 2. Upon Completion of Your Initial Nurse Practitioner Education Program, How Prepared Were You for __?a M (SD) Health assessment
4.30 (0.86)
Evidence-based practice
4.30 (0.93)
Health teaching
4.29 (0.92)
Caring for patients of different cultural backgrounds
3.89 (1.04)
Pathophysiology
3.83 (0.93)
Management of chronic concerns
3.76 (0.92)
Differential diagnoses
3.72 (1.01)
Management of acute concerns
3.72 (1.02)
Collaboration and referral
3.72 (1.08)
Motivational Interviewing
3.67 (1.36)
Pharmacotherapy
3.58 (0.98)
Caring for noneEnglish-speaking clients
3.31 (1.30)
Laboratory interpretation
3.29 (1.16)
Management of emergent concerns
3.28 (1.10)
Management of multiple or complex health concerns
3.06 (1.04)
Management of mental health concerns
2.89 (1.07)
EKG interpretation
2.60 (1.41)
Simple office procedures
2.46 (1.59)
Suturing
2.38 (1.48)
Coding and billing
2.30 (1.26)
X-ray interpretation
2.20 (1.37)
EKG ¼ electrocardiogram; M ¼ mean; SD ¼ standard deviation. a Scale: 1 ¼ very unprepared, 2 ¼ minimally prepared, 3 ¼ somewhat prepared, 4 ¼ generally well prepared, and 5 ¼ very well prepared.
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18.6% reported having both formal and informal mentors, and 24.3% reported having no mentors during their first year of NP practice. Mentors included physicians (64.64%), other NPs (27.88%), and physician assistants (2.79%); however, differences in perceptions of support did not differ considerably by type of preceptor or by frequency of consulting with preceptors. Lastly, for the item, “During your first year of practice, did you ever feel like you were practicing outside of your competence level?” 47.7% replied “yes” and 52.3% replied “no.” Postgraduate NP Residency
Several items addressed interest in postgraduate NP residency programs. Most of the participants indicated interest as follows: “extremely interested” (58%), “somewhat interested” (32%), “neither interested or disinterested” (6%), “somewhat disinterested” (2%), and “not interested” (2%). Similarly, most indicated they would have been “extremely” (40.25%) or “somewhat” (36.75%) likely to have applied to a residency had one been available. Responses were split regarding the desired length of residency, with 47% desiring a 6-month program and 47% desiring a 1-year program. Regarding the lowest annual salary they would consider for a 40- to 50-hour/week residency, most were above $50,000 (> $60,000 [42.6%]; $51,000-$60,000 [26.4%]; $41,000-$50,000 [20%]; $20,000-$40,000 [9.4%], < $20,000 [0.6%], and no salary [1%]). Regarding residency location, respondents indicated “definite” (39%) or “possible” (9%) interest even if the residency required relocation. Characteristics of the Preparedness Cluster
Of the respondents, 81% (n ¼ 565) had completed all of the preparedness items and were included in the factor and cluster analyses. Four clusters of participants emerged based on feelings of preparedness and were labeled as follows: 1) very strong (n ¼ 172), 2) strong (n ¼ 169), 3) average (n ¼ 168), and 4) weak (n ¼ 56). Table 3 (available online at http://www .npjournal.org) illustrates the cluster means, standard deviations, and F scores on “feelings of preparedness” by factor. It is interesting to note that none of the groups felt particularly strong in “procedures,” whereas the “very strong” cluster was significantly 4
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higher than the other groups in preparedness regarding “patient health concerns,” “basic assessment and diagnosis,” “procedures,” and “evidence-based practice and collaboration.” The 4 clusters did not differ by age, years of RN experience, years of NP experience, years since completing their NP program, type of NP program (eg, campus based, online, or hybrid), or frequency of consulting with a mentor during the first year of practice. However, there were significant differences across the groups in their first year (“satisfaction with support” [F3,561 ¼ 36.145, P < .00] and “overall feelings of preparedness” [F3,561 ¼ 86.67, P < .00]). The “very strong” and “strong” groups were not significantly different, but both were higher than the other 2 groups, and the “average” group was higher than the “weak” group on “satisfaction with support.” In terms of “overall feelings of preparedness,” the 4 groups were significantly different and in the expected directions. Differences were noted among the clusters regarding the item, “Did you ever feel like you were practicing outside of your competence level?” (very strong [37.4%], strong [42.9%], average [60.1%], and weak [62.5%]). Additionally, clusters differed regarding interest in a postgraduate residency program (c2 ¼ 24.01, P < .000). The percentage of participants indicating that they were “extremely” or “very likely” to apply to an NP residency by group was as follows: very strong (29.0%), strong (47.9%), average (41.9%), and weak (51.9%) (c2 ¼ 15.36, P < .002). Themes Related to Preparedness
Areas of Preparedness. The items, “Areas where you felt particularly prepared for practice as an NP?” and “Areas where you felt particularly unprepared for practice as an NP?” received 650 and 685 written responses, respectively. These responses reflect the data in Table 2 (available online at http://www .npjournal.org) (ie, no additional themes were discovered). Thoughts on NP Preparation for Practice. Of the participants, 48% (n ¼ 354) responded to the open-ended item “Please feel free to share any thoughts regarding NP preparation for practice.” The main theme, “New NPs need help transitioning into practice,” was expressed in 50% of the written responses, with 90% of these specifically Volume
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mentioning the need for a postgraduate formal mentor or residency. Examples include the following: “We are well prepared - but the role transition should not be underestimated - formal mentoring is important to the first few years of practice.” “We desperately need residency programs. Even nurses I know who worked for 10-15 years as an RN [registered nurse] prior to their NP education found it challenging transitioning to the NP role.” “I could have benefited from mentoring, support, or a residency e anything that would have helped transition from acute care setting to independent primary care. I feel much of my stress could have been alleviated with a residency or internship program or at the very least, an assigned mentor and transition period.” Practicing Outside of Competence Level. Almost half (49%) of the respondents responded “yes” to the item “During your first year of practice as an NP, did you ever feel like you were practicing outside of your competence level?” and were asked to explain their response. Analysis of these responses revealed 8 themes: 1) complex patients, 2) patients with emergent needs, 3) obstetric patients, 4) mental health concerns, 5) chronic pain management, 6) EKG and X-ray interpretation, 7) being on call, and 8) hospital admissions. “Complex patients” was the most common theme (eg, “intense clinically complex patients with diabetes, hypertension, and pulmonary disease”). Although not a major theme, some respondents explained they were practicing outside of their competence level when practicing in a specialty area, which differed from their educational preparation (eg, “The only position I could find was in oncology, and I wasn’t trained in that area.”).
both surveys had similar demographics, including sex, age when began NP program, and master’s level preparation. Although significant changes have occurred in NP education throughout the decades (eg, requirements for stand-alone advanced pathophysiology, pharmacotherapy, and health assessment courses; development of standardized role and specialty competencies; and so on), perceptions of preparedness were remarkably similar between the 2 surveys (Figure). Additionally, respondents from both surveys felt most prepared in similar areas (eg, health assessment, differential diagnosis, and wellness) and least prepared in the exact same areas (eg, mental health and coding/billing). Although one might expect that more recent NP graduates would feel more prepared than those who graduated before 2004, the fact that there were few differences between the 2 studies might reflect that the majority of respondents from both studies were prepared in master’s NP programs and that many of the most significant changes to NP education have occurred with the shift to doctor of nursing practice (DNP) education. Alternatively, similarities in perceptions of preparedness might reflect that newer graduates’ perceptions are appropriate for the end of their NP education, and it is interesting that similar studies have not been conducted with physicians and physician assistants at the end of their formal education. Although most of the respondents reported receiving some sort of mentoring during their first year of practice, their high interest in postgraduate residency programs suggests that formal mentoring
Figure. General preparedness for practice: 2012 vs. 2004 data (2004 data in parentheses).
DISCUSSION
Several similarities were noted between the 200415 and current survey’s objective responses, despite the fact that most of the 2004 survey’s respondents graduated before 2000 and the current survey included only recent graduates. Respondents from www.npjournal.org
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may be an important step. The predominant themes in the open-ended comments support this notion because the majority of comments focused on the need to assist NPs’ transition to practice after they had completed their formal education. It is interesting to note that almost the same percentage of respondents from the 200415 and current surveys expressed interest in participating in a postgraduate residency program. Furthermore, the fact that the primary theme from the current survey’s subjective responses was on postgraduate transition into practice likely reflects that new NPs are more comfortable with their educational preparation (ie, comfortable with areas in which they feel most and least prepared) and are also aware of the small but growing number of postgraduate NP residency programs now available across the US.18 The findings associated with the cluster analysis were particularly interesting. Although nursing experience before NP education has been suggested as being helpful to new NPs,11,19 neither age nor years of nursing experience were associated with higher feelings of preparedness, a finding also supported by Rich20 and Barnes.21 The frequency of consultation with a mentor during the first year of practice was also not associated with improved feelings of preparedness, a finding that suggests that mentoring does not alter how new NPs perceive their preparedness for practice yet may be beneficial to all new NPs, regardless of their feelings of preparedness. Several study limitations need to be considered. The respondents represent a convenience sample of NPs subscribed to an electronic Listserv for a national NP educational organization. Thus, NPs who were not on this Listserv or tend not to join Listservs do not share the beliefs and experiences that were found in this study, although the similarity of findings between the 200415 and current study as well as the large sample size argue against this. Second, because most of the NPs in this study were master’s prepared and the DNP is now the preferred degree for initial NP education,22 these data do not reflect DNPprepared NPs. Third, the study’s primary investigator is an FNP with a primary care background; thus, most of the items were developed from this perspective and may not reflect preparedness items 6
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appropriate for acute care NPs or NPs with pediatric, neonatal, or psychiatric mental health population foci. Fourth, the participants who had graduated in 2006 completed the survey 6 years after they had graduated, which may have impacted their ability to recall their preparedness for and first year of NP practice; however, interestingly, no significant differences were noted among participants who had graduated between 2006 and 2011. Lastly, because of logistical issues between the 2 investigators, this study was submitted for publication several years after it was completed; thus, the data may not represent current beliefs about NP preparedness and practice transition. Responses to the item, “During your first year of practice as an NP, did you ever feel like you were practicing outside of your competence level?” should be also be interpreted with caution. First, respondents were simply asked whether they “ever” felt like they had practiced outside of their competence level and were then asked to briefly explain this. Second, respondents were not asked “how often” they felt they had practiced outside of their competence level; thus, a “yes” response might reflect a 1-time occurrence. Third, the reader is reminded that this item asked about practicing outside of competence level (ie, the ability to do something well), not “scope of practice” (ie, activities that a licensed professional is allowed to perform in a specific profession).23 Lastly, the study was conducted in 2012 with NPs who had graduated between 2006 and 2011 (but was not submitted for publication until 2016 because of logistical issues with the authors); thus, the data are dated and might not reflect NPs who have completed programs in more recent years. CONCLUSION
This study assessed perceptions of preparedness for and transition into practice from new NPs across the US. Perceptions of overall preparedness for practice and in specific practice areas were remarkably similar to findings from an earlier study of NPs who had completed their education before 2005.15 The NPs indicated feeling most prepared for practice in the core areas of NP practice (eg, health assessment, pathophysiology, pharmacotherapy, differential diagnosis, evidence-based practice, health teaching, and so on) and least prepared in mental health Volume
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management, coding and billing, EKG and X-ray interpretation, and office procedures. These areas in which NPs feel least prepared are areas NP educators should aim to strengthen curriculum and evaluation, particularly mental health, which has huge public health implications and the largest shortage of providers in the US.24 Our findings have implications for transitioning into NP practice. The participants in this study desired help transitioning into practice and were interested in postgraduate residencies. Mentoring25,26 and a formal orientation21 have been identified as being important to successful new NP transition, yet most of the NPs in this study lacked formal mentors. Interestingly, physicians provided most of the mentoring to the NPs in this study, yet physicians have a different educational background and a somewhat different role than NPs. Thus, efforts to improve the transition experience for new NPs should continue, including the development of evidence-based recommendations for transitioning into practice, guides for mentors of NPs (ie, both for mentors who are NPs and for mentors who are not NPs), and postgraduate residencies and fellowships. In 2011, the Institute of Medicine published its landmark “Future of Nursing”27 report, which contained specific recommendations for assisting nurses to practice at their highest level of education and scope. In 2015, this same group re-evaluated nursing’s progress toward these recommendations and noted significant progress, particularly in the areas of doctoral education and postgraduate residencies, both for RNs and APRNs.28 Reviewing these 2 reports in light of this study, NP educators and supporters should continue to commit to doctoral education for NPs, as well as to the development of postgraduate residencies, fellowships, and other transition experiences for new NPs. Interested readers are also encouraged to visit the newly established National Nurse Practitioner Residency and Fellowship Training Consortium.18 SUPPLEMENTARY DATA
Tables 1 and 3 for this article can be found in the online version at http://dx.doi.org/10.1016/ j.nurpra.2016.04.018. www.npjournal.org
References 1. Dill MJ, Pankow S, Erikson C, et al. Survey shows consumers open to greater role for physician assistants and nurse practitioners. Health Aff (Millwood). 2013;32(6):1135-1142. 2. Budzi D, Lurie S, Sing K, et al. Veterans’ perceptions of care by nurse practitioners, physician assistants, and physicians: a comparison from satisfaction surveys. J Am Acad Nurse Pract. 2010;22(3):170-176. 3. Martínez-González NA, Djalali S, Tandjung R, et al. Substitution of physicians by nurses in primary care: a systematic review and meta-analysis. BMC Health Serv Res. 2014;14:214. 4. Stanik-Hutt J, Newhouse RP, White KM, et al. The quality and effectiveness of care provided by nurse practitioners. J Nurse Pract. 2013;9(8):492-500, e1-13. 5. Moote M, Krsek C, Kleinpell R, et al. Physician assistant and nurse practitioner utilization in academic medical centers. Am J Med Qual. 2011;26(6):452-460. 6. Park M, Cherry D, Decker SL. Nurse practitioners, certified nurse midwives, and physician assistants in physician offices. NCHS Data Brief. 2011;69:1-8. 7. Kuo Y, Loresto FL, Rounds LR, et al. States with the least restrictive regulations experienced the largest increase in patients seen by nurse practitioners. Health Aff (Millwood). 2013;32(7):1236-1243. 8. Poghosyan L, Lucero R, Rauch L, et al. Nurse practitioner workforce: a substantial supply of primary care providers. Nurs Econ. 2012;30(5):268-274, 294. 9. Selvam A. Annual report shows nurse practitioners pushing for increased autonomy in their roles. Mod Healthc. 2013;43(12):28-30. 10. Barton TD. Student nurse practitionersea rite of passage? The universality of Van Gennep’s model of social transition. Nurse Educ Pract. 2007;7(5):338-347. 11. Cusson RM, Viggiano NM. Transition to the neonatal nurse practitioner role: making the change from the side to the head of the bed. Neonatal Netw. 2002;21(2):21-28. 12. Heitz LJ, Steiner SH, Burman ME. RN to FNP: a qualitative study of role transition. J Nurs Educ. 2004;43(9):416-420. 13. Barnes H. Nurse practitioner role transition: a concept analysis. Nurs Forum. 2015;50(3):137-146. 14. Brower HT, Tappen RM, Weber MT. Missing links in nurse practitioner education. Nurs Health Care. 1988;9(1):33-36. 15. Hart AM, Macnee CL. How well are NPs prepared for practice?: Results of a 2004 questionnaire study. J Am Acad Nurse Pract. 2007;19(1):35-42. 16. Kaufman L, Rousseeuw PJ. Finding Groups in Data: An Introduction to Cluster Analysis. New York, NY: Wiley; 1990. 17. Krippendorff K. Content Analysis: An Introduction to Its Methodology, 3rd ed. Thousand Oaks, CA: Sage Publications; 2013. 18. National Nurse Practitioner Residency & Fellowship Training Consortium. Washington, DC. http://www.nppostgradtraining.com/. Accessed January 15, 2016. 19. Fleming EE, Carberry M. Steering a course towards advanced nurse practitioner: a critical care perspective. Nurs Crit Care. 2011;16(2):67-76. 20. Rich ER. Does RN experience relate to NP clinical skills? Nurse Pract. 2005;30(12):53-56. 21. Barnes H. Exploring the factors that influence nurse practitioner role transition. J Nurse Pract. 2015;11(2):178-183. 22. American Association of Colleges in Nursing. AACN position statement on the practice doctorate in nursing. Washington, DC: Author; 2014. http://www .aacn.nche.edu/publications/position/DNPpositionstatement.pdf. Accessed January 15, 2016. 23. Klein TA. Scope of practice and the nurse practitioner. Adv Pract eJournal. 2005;5(2). http://www.medscape.org/viewarticle/506277. Accessed January 15, 2016. 24. World Health Organization, Mental health atlas 2011. http://www.who.int/ mental_health/publications/mental_health_atlas_2011/en/. Accessed January 15, 2016. 25. Barker ER. Mentoringea complex relationship. J Am Acad Nurse Pract. 2006;18(2):56-61. 26. Hill LA, Sawatzky JV. Transitioning into the nurse practitioner role through mentorship. J Prof Nurs. 2011;27(3):161-167. 27. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011. 28. National Academies of Sciences, Engineering and Medicine. Assessing Progress on the Institute of Medicine Report: The Future of Nursing. Washington, DC: The National Academies Press; 2015.
Ann Marie Hart, PhD, FNP-BC, is a professor and DNP program director at Fay W. Whitney School of Nursing at the University of Wyoming in Laramie and can be reached at [email protected]. Anne Bowen, PhD, is a professor at the Department of Psychology at the University of Arizona in The Journal for Nurse Practitioners - JNP
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Tucson. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.
Fitzgerald Health Education Associates (FHEA) for their support of this project and their interest in advancing NP education and research.
Acknowledgments The authors wish to acknowledge and thank Margaret Fitzgerald, DNP, FNP-BC, and Marc Comstock, MBA, with
1555-4155/16/$ see front matter © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.04.018
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New Nurse Practitioners’ Perceptions of Preparedness for and Transition Into Practice Ann Marie Hart, PhD, FNP-BC, and Anne Bowen, PhD ABSTRACT
Preparedness for clinical practice is a critical issue for new nurse practitioners (NPs). We assessed new NPs’ perceptions of their preparation for and transition into clinical practice. A national sample of 698 licensed NPs who graduated between 2006 and 2011 and were practicing as NPs in the United States completed a survey related to clinical preparation and practice transition. The majority reported feeling generally or somewhat prepared for practice after their NP education. They also expressed interest in receiving assistance as they transition into practice through residencies and mentoring. Specific findings regarding preparedness and transition into practice are described, and recommendations are offered. Keywords: nurse practitioner education, nurse practitioner mentoring, nurse practitioner preparedness, nurse practitioner residency, nurse practitioner transition Ó 2016 Elsevier Inc. All rights reserved.
N
urse practitioners (NPs) are committed to providing quality health care, and United States consumers are receptive to receiving care from NPs.1 Research supports that patients are satisfied with NP-delivered care2,3 and that outcomes for patients receiving care from NPs are comparable with physician-delivered care.3,4 NPs are integrated into the US health care system and play a substantial role in health care delivery.1,5,6 The number of Medicare beneficiaries receiving primary care from advanced practice registered nurses (APRNs) increased 15-fold between 1998 and 2010.7 Furthermore, with the 2010 Patient Protection and Affordable Care Act, more NPs are being sought to provide primary care services for newly insured Americans.8,9 Despite the success of the NP role, the path from novice to competent NP is often challenging and difficult.10-12 Preparedness for practice is a critical issue for new NPs, many of whom report feeling overwhelmed, frustrated, and inadequate.13 However, research on NP preparedness is limited, and, to date, there are only 2 published studies on this topic.14,15 The first study was conducted in 1988; a survey of 136 APRNs (including 39 NPs) educated in the southeastern US found that NPs www.npjournal.org
were less satisfied with their education than clinical nurse specialists or certified registered anesthetists, specifically regarding clinical pathology, differential diagnosis, laboratory diagnostics, and pharmacology.14 The second study, a national retrospective survey of NPs’ perceptions of preparedness for practice, was conducted in 2004.15 The respondents (N ¼ 562) were primarily master’s-prepared (77%) family nurse practitioners (FNPs, 61%), with an average age of 49. In response to the question “Upon completion of your initial NP educational program, how prepared were you to practice as an NP?” 9.8% of the respondents described feeling “very well prepared,” 38.4% “generally well prepared,” 38.2% “somewhat prepared,” 11.7% “minimally prepared,” and 1.9% “very unprepared.” Respondents indicated feeling most prepared for “health assessment,” “differential diagnosis,” “pathophysiology,” “pharmacology,” “health teaching,” and “management of acute illnesses.” They reported being least prepared for “billing and coding,” “simple office procedures,” “electrocardiogram (EKG) and radiology interpretation,” “microscopy,” and “mental illness management.” Responses to open-ended items revealed 4 main themes related to NP education: The Journal for Nurse Practitioners - JNP
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1) the need for increased rigor, 2) the need for more clinically relevant content and experiences, 3) the need for more clinically experienced faculty, and 4) NP education has come a long way. Finally, 87% expressed that they would have been “definitely” or “possibly” interested in a postgraduate residency program if one had been available. A major limitation of the 2004 study15 was that many of the respondents had completed their formal NP education 10 to 30 years before completing the survey. The evolution of NP education in the last 15 to 35 years increases the need to understand new NPs’ preparedness for practice. Feedback from new NPs can guide curriculum and policy decisions that will advance the next generation of NP leaders; thus, the purpose of this study was to assess NPs’ perceptions of preparation for clinical practice and transition into practice, specifically from NPs who graduated between 2006 and 2011. METHODS
The study involved an electronic, Web-based survey delivered through Key Survey (http://www .keysurvey.com/). The 200415 survey was updated by the authors and several graduate students from the University of Wyoming. The questions were further refined after piloting the survey with a group of NPs in Wyoming. The final survey consisted of 81 multiple-choice items, 27 demographic items, and 6 open-ended items. Eligibility was determined using 3 items: 1) graduating from an initial NP program between 2006 and 2011, 2) being licensed to practice as an NP in the US, and 3) having practiced as a licensed NP in the US. Respondents who did not meet all 3 eligibility items were sent to a thank you page, and participation was terminated. The final survey and its administration received approval by the University of Wyoming’s Human Subjects Committee. On April 25, 2012, an invitation and an electronic survey link were distributed to approximately 51,000 electronic newsletter subscribers by Fitzgerald Health Education Associates, Inc, a leading, national organization dedicated to NP education. One month later, representatives of NP programs and organizations with few or no responses to the electronic invitation were e-mailed directly asking them to 2
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distribute the survey to their NP alumni or constituents. Data Analysis
Data were analyzed using SPSS Statistics 20 (SPSS Inc, Chicago, IL). Frequency data were compared using chi-square and other nonparametric analyses. Scale scores were compared using univariate analysis of variance. Given the large sample size and number of analyses, P < .01 was considered significant. We subjected the 9 general “preparedness and support” questions regarding the respondents’ first year of practice to principal components factor analysis with varimax rotation. Two meaningful factors emerged. The first factor (satisfaction with support) included 6 items with a Cronbach alpha of 0.91 and accounted for 42.5% of the variance. The second factor (feelings of preparedness) included 3 items with a Cronbach alpha of 0.80 and accounted for 29.3% of the variance. The survey included 2 sets of 21 parallel items. In set 1 (importance of preparation), the participants rated the “importance of preparation” for specific practice-related skills, and in set 2 (feeling prepared), they rated the same items based on “how prepared they felt” at the beginning of practicing. Set 1 was subjected to a principal components factor analysis with varimax rotation. Five meaningful factors emerged with eigenvalues greater than 1. The first factor, “managing health concerns,” included 5 items, accounted for 19.58% of the variance, and had a Cronbach alpha of 0.92. The second factor, “basics of health assessment and diagnosis,” included 4 times, accounted for 17.73% of the variance, and had a Cronbach alpha of 0.97. The third factor, “diversity and teaching,” included 4 items, accounted for 13.26% of the variance, and had a Cronbach alpha of 0.78. The fourth factor, “procedures,” included 4 items, accounted for 12.26% of the variance, and had a Cronbach alpha of 0.83. The final factor “evidencebased practice and collaboration” included 4 items, accounted for 10.76% of the variance, and had a Cronbach alpha of 0.76. Note, the factor analysis only included participants who responded to all of the preparedness items. We then examined the NPs’ feelings of preparedness by taking the set 2 questions and Volume
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computing scores for the 5 constructs identified in set 1. Groups of participants with similar attitudes were then constructed using the 5 preparedness scores in a hierarchical agglomerative clustering procedure using squared Euclidean distance and Ward linkage. This approach was chosen because Euclidean distances are the simplest way of computing geometric distances between 2 participants based on the coded dimensions, and squaring this distance places greater weight on participants who are farther apart.16 Open-ended items were analyzed for themes using content analysis,17 a qualitative methodology for forming accurate and reproducible inferences from texts and other sources (eg, recorded speech) within a specific context. RESULTS Demographics
A total of 698 NPs completed the survey, all of whom reported having completed their NP education between 2006 and 2011, being licensed as NPs in the US, and having provided care to patients as licensed NPs. The respondents were primarily female (94%), with an average age of 42 (standard deviation [SD] ¼ 9.99) years. Most described themselves as non-Hispanic and white (86.4%). The majority (90.2%) had completed a master’s NP program, and 69.4% were prepared as FNPs. Table 1 (available online at http://www.npjournal.org) provides a summary of participants’ demographic information. Preparedness for Practice
For the item “Upon completion of your initial NP educational program, how prepared were you to practice as an NP?” 3.3% of the respondents described feeling “very well prepared,” 38.9% “generally well prepared,” 43.0% “somewhat prepared,” 11.1% “minimally prepared,” and 3.7% “very unprepared.” On a 5-point scale ranging from 1 (very unprepared) to 5 (very prepared), respondents indicated feeling most prepared for assessment (mean [M] ¼ 4.39, SD ¼ 0.86), pathophysiology (M ¼ 3.86, SD ¼ 0.93), wellness (M ¼ 4.39, SD ¼ 0.86), patient rapport (M ¼ 4.39, SD ¼ 0.86), and relationship building (M ¼ 4.39, SD ¼ 0.86), and episodic care and least prepared for chronic conditions, complex patients, ordering and interpreting diagnostic tests (EKGs, X-rays, and labs), www.npjournal.org
and specialty areas (eg, dermatology, orthopedics, and cardiology) (Table 2). First Year of Practice
Several survey items specifically assessed the first year of clinical practice as an NP. For the item “Looking back on 1st year of clinical practice as an NP, I was provided adequate clinical support,” 19.8% responded “strongly agree,” 42.8% “agree,” 11.3% “neither agree or disagree,” 19.4% “disagree,” and 6.7% “strongly disagree.” Only 17% reported having a formal mentor, 40.1% had an informal mentor,
Table 2. Upon Completion of Your Initial Nurse Practitioner Education Program, How Prepared Were You for __?a M (SD) Health assessment
4.30 (0.86)
Evidence-based practice
4.30 (0.93)
Health teaching
4.29 (0.92)
Caring for patients of different cultural backgrounds
3.89 (1.04)
Pathophysiology
3.83 (0.93)
Management of chronic concerns
3.76 (0.92)
Differential diagnoses
3.72 (1.01)
Management of acute concerns
3.72 (1.02)
Collaboration and referral
3.72 (1.08)
Motivational Interviewing
3.67 (1.36)
Pharmacotherapy
3.58 (0.98)
Caring for noneEnglish-speaking clients
3.31 (1.30)
Laboratory interpretation
3.29 (1.16)
Management of emergent concerns
3.28 (1.10)
Management of multiple or complex health concerns
3.06 (1.04)
Management of mental health concerns
2.89 (1.07)
EKG interpretation
2.60 (1.41)
Simple office procedures
2.46 (1.59)
Suturing
2.38 (1.48)
Coding and billing
2.30 (1.26)
X-ray interpretation
2.20 (1.37)
EKG ¼ electrocardiogram; M ¼ mean; SD ¼ standard deviation. a Scale: 1 ¼ very unprepared, 2 ¼ minimally prepared, 3 ¼ somewhat prepared, 4 ¼ generally well prepared, and 5 ¼ very well prepared.
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18.6% reported having both formal and informal mentors, and 24.3% reported having no mentors during their first year of NP practice. Mentors included physicians (64.64%), other NPs (27.88%), and physician assistants (2.79%); however, differences in perceptions of support did not differ considerably by type of preceptor or by frequency of consulting with preceptors. Lastly, for the item, “During your first year of practice, did you ever feel like you were practicing outside of your competence level?” 47.7% replied “yes” and 52.3% replied “no.” Postgraduate NP Residency
Several items addressed interest in postgraduate NP residency programs. Most of the participants indicated interest as follows: “extremely interested” (58%), “somewhat interested” (32%), “neither interested or disinterested” (6%), “somewhat disinterested” (2%), and “not interested” (2%). Similarly, most indicated they would have been “extremely” (40.25%) or “somewhat” (36.75%) likely to have applied to a residency had one been available. Responses were split regarding the desired length of residency, with 47% desiring a 6-month program and 47% desiring a 1-year program. Regarding the lowest annual salary they would consider for a 40- to 50-hour/week residency, most were above $50,000 (> $60,000 [42.6%]; $51,000-$60,000 [26.4%]; $41,000-$50,000 [20%]; $20,000-$40,000 [9.4%], < $20,000 [0.6%], and no salary [1%]). Regarding residency location, respondents indicated “definite” (39%) or “possible” (9%) interest even if the residency required relocation. Characteristics of the Preparedness Cluster
Of the respondents, 81% (n ¼ 565) had completed all of the preparedness items and were included in the factor and cluster analyses. Four clusters of participants emerged based on feelings of preparedness and were labeled as follows: 1) very strong (n ¼ 172), 2) strong (n ¼ 169), 3) average (n ¼ 168), and 4) weak (n ¼ 56). Table 3 (available online at http://www .npjournal.org) illustrates the cluster means, standard deviations, and F scores on “feelings of preparedness” by factor. It is interesting to note that none of the groups felt particularly strong in “procedures,” whereas the “very strong” cluster was significantly 4
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higher than the other groups in preparedness regarding “patient health concerns,” “basic assessment and diagnosis,” “procedures,” and “evidence-based practice and collaboration.” The 4 clusters did not differ by age, years of RN experience, years of NP experience, years since completing their NP program, type of NP program (eg, campus based, online, or hybrid), or frequency of consulting with a mentor during the first year of practice. However, there were significant differences across the groups in their first year (“satisfaction with support” [F3,561 ¼ 36.145, P < .00] and “overall feelings of preparedness” [F3,561 ¼ 86.67, P < .00]). The “very strong” and “strong” groups were not significantly different, but both were higher than the other 2 groups, and the “average” group was higher than the “weak” group on “satisfaction with support.” In terms of “overall feelings of preparedness,” the 4 groups were significantly different and in the expected directions. Differences were noted among the clusters regarding the item, “Did you ever feel like you were practicing outside of your competence level?” (very strong [37.4%], strong [42.9%], average [60.1%], and weak [62.5%]). Additionally, clusters differed regarding interest in a postgraduate residency program (c2 ¼ 24.01, P < .000). The percentage of participants indicating that they were “extremely” or “very likely” to apply to an NP residency by group was as follows: very strong (29.0%), strong (47.9%), average (41.9%), and weak (51.9%) (c2 ¼ 15.36, P < .002). Themes Related to Preparedness
Areas of Preparedness. The items, “Areas where you felt particularly prepared for practice as an NP?” and “Areas where you felt particularly unprepared for practice as an NP?” received 650 and 685 written responses, respectively. These responses reflect the data in Table 2 (available online at http://www .npjournal.org) (ie, no additional themes were discovered). Thoughts on NP Preparation for Practice. Of the participants, 48% (n ¼ 354) responded to the open-ended item “Please feel free to share any thoughts regarding NP preparation for practice.” The main theme, “New NPs need help transitioning into practice,” was expressed in 50% of the written responses, with 90% of these specifically Volume
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mentioning the need for a postgraduate formal mentor or residency. Examples include the following: “We are well prepared - but the role transition should not be underestimated - formal mentoring is important to the first few years of practice.” “We desperately need residency programs. Even nurses I know who worked for 10-15 years as an RN [registered nurse] prior to their NP education found it challenging transitioning to the NP role.” “I could have benefited from mentoring, support, or a residency e anything that would have helped transition from acute care setting to independent primary care. I feel much of my stress could have been alleviated with a residency or internship program or at the very least, an assigned mentor and transition period.” Practicing Outside of Competence Level. Almost half (49%) of the respondents responded “yes” to the item “During your first year of practice as an NP, did you ever feel like you were practicing outside of your competence level?” and were asked to explain their response. Analysis of these responses revealed 8 themes: 1) complex patients, 2) patients with emergent needs, 3) obstetric patients, 4) mental health concerns, 5) chronic pain management, 6) EKG and X-ray interpretation, 7) being on call, and 8) hospital admissions. “Complex patients” was the most common theme (eg, “intense clinically complex patients with diabetes, hypertension, and pulmonary disease”). Although not a major theme, some respondents explained they were practicing outside of their competence level when practicing in a specialty area, which differed from their educational preparation (eg, “The only position I could find was in oncology, and I wasn’t trained in that area.”).
both surveys had similar demographics, including sex, age when began NP program, and master’s level preparation. Although significant changes have occurred in NP education throughout the decades (eg, requirements for stand-alone advanced pathophysiology, pharmacotherapy, and health assessment courses; development of standardized role and specialty competencies; and so on), perceptions of preparedness were remarkably similar between the 2 surveys (Figure). Additionally, respondents from both surveys felt most prepared in similar areas (eg, health assessment, differential diagnosis, and wellness) and least prepared in the exact same areas (eg, mental health and coding/billing). Although one might expect that more recent NP graduates would feel more prepared than those who graduated before 2004, the fact that there were few differences between the 2 studies might reflect that the majority of respondents from both studies were prepared in master’s NP programs and that many of the most significant changes to NP education have occurred with the shift to doctor of nursing practice (DNP) education. Alternatively, similarities in perceptions of preparedness might reflect that newer graduates’ perceptions are appropriate for the end of their NP education, and it is interesting that similar studies have not been conducted with physicians and physician assistants at the end of their formal education. Although most of the respondents reported receiving some sort of mentoring during their first year of practice, their high interest in postgraduate residency programs suggests that formal mentoring
Figure. General preparedness for practice: 2012 vs. 2004 data (2004 data in parentheses).
DISCUSSION
Several similarities were noted between the 200415 and current survey’s objective responses, despite the fact that most of the 2004 survey’s respondents graduated before 2000 and the current survey included only recent graduates. Respondents from www.npjournal.org
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may be an important step. The predominant themes in the open-ended comments support this notion because the majority of comments focused on the need to assist NPs’ transition to practice after they had completed their formal education. It is interesting to note that almost the same percentage of respondents from the 200415 and current surveys expressed interest in participating in a postgraduate residency program. Furthermore, the fact that the primary theme from the current survey’s subjective responses was on postgraduate transition into practice likely reflects that new NPs are more comfortable with their educational preparation (ie, comfortable with areas in which they feel most and least prepared) and are also aware of the small but growing number of postgraduate NP residency programs now available across the US.18 The findings associated with the cluster analysis were particularly interesting. Although nursing experience before NP education has been suggested as being helpful to new NPs,11,19 neither age nor years of nursing experience were associated with higher feelings of preparedness, a finding also supported by Rich20 and Barnes.21 The frequency of consultation with a mentor during the first year of practice was also not associated with improved feelings of preparedness, a finding that suggests that mentoring does not alter how new NPs perceive their preparedness for practice yet may be beneficial to all new NPs, regardless of their feelings of preparedness. Several study limitations need to be considered. The respondents represent a convenience sample of NPs subscribed to an electronic Listserv for a national NP educational organization. Thus, NPs who were not on this Listserv or tend not to join Listservs do not share the beliefs and experiences that were found in this study, although the similarity of findings between the 200415 and current study as well as the large sample size argue against this. Second, because most of the NPs in this study were master’s prepared and the DNP is now the preferred degree for initial NP education,22 these data do not reflect DNPprepared NPs. Third, the study’s primary investigator is an FNP with a primary care background; thus, most of the items were developed from this perspective and may not reflect preparedness items 6
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appropriate for acute care NPs or NPs with pediatric, neonatal, or psychiatric mental health population foci. Fourth, the participants who had graduated in 2006 completed the survey 6 years after they had graduated, which may have impacted their ability to recall their preparedness for and first year of NP practice; however, interestingly, no significant differences were noted among participants who had graduated between 2006 and 2011. Lastly, because of logistical issues between the 2 investigators, this study was submitted for publication several years after it was completed; thus, the data may not represent current beliefs about NP preparedness and practice transition. Responses to the item, “During your first year of practice as an NP, did you ever feel like you were practicing outside of your competence level?” should be also be interpreted with caution. First, respondents were simply asked whether they “ever” felt like they had practiced outside of their competence level and were then asked to briefly explain this. Second, respondents were not asked “how often” they felt they had practiced outside of their competence level; thus, a “yes” response might reflect a 1-time occurrence. Third, the reader is reminded that this item asked about practicing outside of competence level (ie, the ability to do something well), not “scope of practice” (ie, activities that a licensed professional is allowed to perform in a specific profession).23 Lastly, the study was conducted in 2012 with NPs who had graduated between 2006 and 2011 (but was not submitted for publication until 2016 because of logistical issues with the authors); thus, the data are dated and might not reflect NPs who have completed programs in more recent years. CONCLUSION
This study assessed perceptions of preparedness for and transition into practice from new NPs across the US. Perceptions of overall preparedness for practice and in specific practice areas were remarkably similar to findings from an earlier study of NPs who had completed their education before 2005.15 The NPs indicated feeling most prepared for practice in the core areas of NP practice (eg, health assessment, pathophysiology, pharmacotherapy, differential diagnosis, evidence-based practice, health teaching, and so on) and least prepared in mental health Volume
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management, coding and billing, EKG and X-ray interpretation, and office procedures. These areas in which NPs feel least prepared are areas NP educators should aim to strengthen curriculum and evaluation, particularly mental health, which has huge public health implications and the largest shortage of providers in the US.24 Our findings have implications for transitioning into NP practice. The participants in this study desired help transitioning into practice and were interested in postgraduate residencies. Mentoring25,26 and a formal orientation21 have been identified as being important to successful new NP transition, yet most of the NPs in this study lacked formal mentors. Interestingly, physicians provided most of the mentoring to the NPs in this study, yet physicians have a different educational background and a somewhat different role than NPs. Thus, efforts to improve the transition experience for new NPs should continue, including the development of evidence-based recommendations for transitioning into practice, guides for mentors of NPs (ie, both for mentors who are NPs and for mentors who are not NPs), and postgraduate residencies and fellowships. In 2011, the Institute of Medicine published its landmark “Future of Nursing”27 report, which contained specific recommendations for assisting nurses to practice at their highest level of education and scope. In 2015, this same group re-evaluated nursing’s progress toward these recommendations and noted significant progress, particularly in the areas of doctoral education and postgraduate residencies, both for RNs and APRNs.28 Reviewing these 2 reports in light of this study, NP educators and supporters should continue to commit to doctoral education for NPs, as well as to the development of postgraduate residencies, fellowships, and other transition experiences for new NPs. Interested readers are also encouraged to visit the newly established National Nurse Practitioner Residency and Fellowship Training Consortium.18 SUPPLEMENTARY DATA
Tables 1 and 3 for this article can be found in the online version at http://dx.doi.org/10.1016/ j.nurpra.2016.04.018. www.npjournal.org
References 1. Dill MJ, Pankow S, Erikson C, et al. Survey shows consumers open to greater role for physician assistants and nurse practitioners. Health Aff (Millwood). 2013;32(6):1135-1142. 2. Budzi D, Lurie S, Sing K, et al. Veterans’ perceptions of care by nurse practitioners, physician assistants, and physicians: a comparison from satisfaction surveys. J Am Acad Nurse Pract. 2010;22(3):170-176. 3. Martínez-González NA, Djalali S, Tandjung R, et al. Substitution of physicians by nurses in primary care: a systematic review and meta-analysis. BMC Health Serv Res. 2014;14:214. 4. Stanik-Hutt J, Newhouse RP, White KM, et al. The quality and effectiveness of care provided by nurse practitioners. J Nurse Pract. 2013;9(8):492-500, e1-13. 5. Moote M, Krsek C, Kleinpell R, et al. Physician assistant and nurse practitioner utilization in academic medical centers. Am J Med Qual. 2011;26(6):452-460. 6. Park M, Cherry D, Decker SL. Nurse practitioners, certified nurse midwives, and physician assistants in physician offices. NCHS Data Brief. 2011;69:1-8. 7. Kuo Y, Loresto FL, Rounds LR, et al. States with the least restrictive regulations experienced the largest increase in patients seen by nurse practitioners. Health Aff (Millwood). 2013;32(7):1236-1243. 8. Poghosyan L, Lucero R, Rauch L, et al. Nurse practitioner workforce: a substantial supply of primary care providers. Nurs Econ. 2012;30(5):268-274, 294. 9. Selvam A. Annual report shows nurse practitioners pushing for increased autonomy in their roles. Mod Healthc. 2013;43(12):28-30. 10. Barton TD. Student nurse practitionersea rite of passage? The universality of Van Gennep’s model of social transition. Nurse Educ Pract. 2007;7(5):338-347. 11. Cusson RM, Viggiano NM. Transition to the neonatal nurse practitioner role: making the change from the side to the head of the bed. Neonatal Netw. 2002;21(2):21-28. 12. Heitz LJ, Steiner SH, Burman ME. RN to FNP: a qualitative study of role transition. J Nurs Educ. 2004;43(9):416-420. 13. Barnes H. Nurse practitioner role transition: a concept analysis. Nurs Forum. 2015;50(3):137-146. 14. Brower HT, Tappen RM, Weber MT. Missing links in nurse practitioner education. Nurs Health Care. 1988;9(1):33-36. 15. Hart AM, Macnee CL. How well are NPs prepared for practice?: Results of a 2004 questionnaire study. J Am Acad Nurse Pract. 2007;19(1):35-42. 16. Kaufman L, Rousseeuw PJ. Finding Groups in Data: An Introduction to Cluster Analysis. New York, NY: Wiley; 1990. 17. Krippendorff K. Content Analysis: An Introduction to Its Methodology, 3rd ed. Thousand Oaks, CA: Sage Publications; 2013. 18. National Nurse Practitioner Residency & Fellowship Training Consortium. Washington, DC. http://www.nppostgradtraining.com/. Accessed January 15, 2016. 19. Fleming EE, Carberry M. Steering a course towards advanced nurse practitioner: a critical care perspective. Nurs Crit Care. 2011;16(2):67-76. 20. Rich ER. Does RN experience relate to NP clinical skills? Nurse Pract. 2005;30(12):53-56. 21. Barnes H. Exploring the factors that influence nurse practitioner role transition. J Nurse Pract. 2015;11(2):178-183. 22. American Association of Colleges in Nursing. AACN position statement on the practice doctorate in nursing. Washington, DC: Author; 2014. http://www .aacn.nche.edu/publications/position/DNPpositionstatement.pdf. Accessed January 15, 2016. 23. Klein TA. Scope of practice and the nurse practitioner. Adv Pract eJournal. 2005;5(2). http://www.medscape.org/viewarticle/506277. Accessed January 15, 2016. 24. World Health Organization, Mental health atlas 2011. http://www.who.int/ mental_health/publications/mental_health_atlas_2011/en/. Accessed January 15, 2016. 25. Barker ER. Mentoringea complex relationship. J Am Acad Nurse Pract. 2006;18(2):56-61. 26. Hill LA, Sawatzky JV. Transitioning into the nurse practitioner role through mentorship. J Prof Nurs. 2011;27(3):161-167. 27. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011. 28. National Academies of Sciences, Engineering and Medicine. Assessing Progress on the Institute of Medicine Report: The Future of Nursing. Washington, DC: The National Academies Press; 2015.
Ann Marie Hart, PhD, FNP-BC, is a professor and DNP program director at Fay W. Whitney School of Nursing at the University of Wyoming in Laramie and can be reached at [email protected]. Anne Bowen, PhD, is a professor at the Department of Psychology at the University of Arizona in The Journal for Nurse Practitioners - JNP
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Tucson. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.
Fitzgerald Health Education Associates (FHEA) for their support of this project and their interest in advancing NP education and research.
Acknowledgments The authors wish to acknowledge and thank Margaret Fitzgerald, DNP, FNP-BC, and Marc Comstock, MBA, with
1555-4155/16/$ see front matter © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.04.018
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