Transition to the role | |
Role adjustment + High NP self-expectations in first year − Organizational and professional unfamiliarity with the NP role and needs − Coparticipants frequently not aware of NPs’ struggles | I’m very pleased .… It was probably a pretty stressful year for her. She was a new NP coming into this chaotic system (coparticipant 17 at 12 mo) |
Mentoring + Experienced coparticipants arranged mentoring support for NPs − Some NPs designed their own practices and explained their role while they were still learning it, and they often had to request their own supports | There is certainly a responsibility of us when a nurse practitioner comes, to mentor her through (coparticipant 12 at 6 mo) |
Previous experience + NPs had many years in ICU or ED and brought life experience | Experience [is] the number one thing …. I had almost 30 years when I entered the program ... I’ve moved around a lot, so have met change ... over the years and that’s been … huge in flowing into this role (NP 4 at 12 mo) |
Time management − Much overtime in first 3 mo, decreased by end of first year; increased time doing new-patient assessments and learning EHRs | I know another NP who is new and she’s in trouble. She’s from the FHT and the other NPs are seeing 20-some [patients] a day …. They are booking her the same. And she’s going in on days off to chart (coparticipant 12 at 3 mo) |
Contextual factors | |
Ongoing changes in PHC system in Ontario − Emerging contextual factors: new FHTs, pilot projects in EDs, NP-led clinics, and physician assistants − Funding available for NPs but no infrastructure to support them | The biggest challenge is space … I don’t have an office. I don’t have a space to call my own. So I still have a little cart, and when I was hired the understanding was that would change. Moving buildings, it’s going to be another year (NP 1 at 12 mo) |
Hiring + Fit with agency important to coparticipants | We’re very picky .… If we have the right person [with] the right willingness to learn and the right attitude—”get it done” kind of attitude—we can teach them (coparticipant 11, 3 mo) |
Orientation − Often NPs identified own needs and planned own programs | There wasn’t actually an orientation .... you sort of show up one day and start to work and work the bugs out as you go (NP 2 at 3 mo) |
Continuing education − NPs had to fight for time and reimbursement | Just having to always remind them that money is there for me and there’s really no reason why I can’t have that ... most of the teams are getting between 5 and 10 days a year and they’re getting $1500 to pay for conferences and hotel rooms (NP 8 at 12 mo) |
Evaluation − Many NPs did not have formal evaluation system in place to obtain feedback from employers − Often no job description or professional expectations existed | Recently the office ... without the nurse practitioners knowing, sent out an evaluation form to the physician partners without any input from us. Quite a few of the physicians went to the nurse practitioners and said, “What is this?” (NP 2 at 3 mo) |
Interprofessional relationships | |
Professional colleagues +/− Teams included physicians, RNs, other NPs, and support staff | The physicians …. claim that they were told, that we’re nurses, so we therefore don’t require nursing support (NP 9 at 3 mo) |
NP role confusion − Workplaces that did not understand the role and scope of practice of the NP were confused about what could be expected of the NP − 9 NPs changed jobs over the course of the study (7 anglophones and 2 francophones) owing to challenges in their workplaces | They didn’t know what my scope was. So we’re just sort of learning as we go, all of us, trying to figure out how I fit into [the practice] (NP 2 at 3 mo) |
Relationships dependent upon ... +/− culture and experience of agency +/− organizational position of NP +/− employee status (hired by physician, hired by PHC agency, independent practice) | I don’t think it’s as much respect. I just think it’s ... the knowledge base that should be there to ... understand what the issues are and what kinds of supports and programming need to be in place. [The administrator will say] “You have to see more patients like the doctors do.” And I keep telling him, “One, nurse practitioners don’t work like a physician, and two, I don’t have the support. I can’t see more people until I get those supports” (NP 17 at 12 mo) |
Policy and politics | |
Provincial legislation and regulations − Limits on scope of practice and prescription authority requiring medical directives − Frustration of NPs and medical colleagues about prescribing restrictions | [Physicians] expect that you can manage everything, and again, with medications, prescriptions, they can’t understand, “Why do I have to co-sign for this?” (NP 10 at 6 mo) |
Insecure funding − Continued NP funding for pilot projects announced shortly before end of contracts | We were funded for a full year but we were worried about funding for the [next] year, and we were afraid we were going to lose her, so we actually put her on staff (coparticipant 15 at 12 mo) |
Government agencies and insurance companies − NP referrals and forms are not accepted by some departments and companies such as WSIB and the Ministry of Transportation | Certain insurance companies won’t recognize my notes. The Ministry of Transportation will not recognize any work done by a nurse practitioner, yet I can do disability stuff (NP 10 at 6 mo) |
Physician funding mechanisms − Decisions about whether physicians or NPs saw some patients were based on remuneration formulas, which led to restrictions on NP practice | Right now, as far as the rules go for remuneration for physicians, I can’t function to my full scope. But as far as my practice, my relationships with my patients, and my collaborating physician, I am able to function within my full scope of practice (NP 16 at 12 mo) |
Educational preparation | |
Role transition preparation needs identified by NPs − Educational preparation needs to include what to expect when entering practice, interprofessional conflict and conflict resolution, more clinical time, more exposure to “particular” client groups | During that 3-month final placement, you were actually working full-time and the criticism I do have is that I don’t think there’s enough clinical time during the rest of the program (NP 9 at 3 mo) |