Abstract
OBJECTIVE To examine role transition and support requirements for nurse practitioner (NP) graduates in their first year of practice from the perspectives of the NPs and coparticipants familiar with the NPs’ practices; and to make recommendations for practice, education, and policy.
DESIGN Descriptive qualitative design informed by focused ethnography and narrative analysis using semistructured, in-depth, qualitative interviews.
SETTING Primary health care (PHC) settings in Ontario in which NPs worked.
PARTICIPANTS Twenty-three NPs who had graduated from the Ontario Primary Health Care Nurse Practitioner program, and 21 coparticipants including family physicians, NPs, and managers who were familiar with the NPs’ practices.
METHODS Anglophone and francophone NPs in their first year of practice in PHC settings were contacted by e-mail or letter. Participating NPs nominated colleagues in the workplace who could comment on their practice. Interviews were conducted within the first 3 months, at 6 months, and at 12 months of the NPs’ first year of practice and were transcribed verbatim and coded. Job descriptions and organizational charts demonstrating the NPs’ organization positions were also analyzed. The researchers collaboratively analyzed the interviews using a systematic data analysis protocol.
MAIN FINDINGS Familiarity of colleagues and employers with the NP role and scope of practice was an important element in successful NP role transition. Lack of preparation for integrating NPs into clinical settings and lack of infrastructure, orientation, mentorship, and awareness of the NP role and needs made the transition difficult for many. One-third of the NPs had changed employment, identifying interprofessional conflict or problems with acceptance of their role in new practice environments as reasons for the change.
CONCLUSION The transition of NP graduates in Ontario was complicated by the health care environment being ill-prepared to receive them owing to rapid changes in PHC. Strategies for mentorship and for the integration of new NPs into PHC settings are available and need to be implemented by health professionals and administrators. Recommendations for family physicians to support NP graduate transition into practice are provided.
Nurse practitioner (NP) graduates in their first year of practice have reported considerable challenges in the transition to their new role.1–3 A supportive environment and realistic professional expectations of the newly graduated NP can positively influence the transition of the new NP into primary health care (PHC) practice.2 In Ontario, there is a requirement that NPs work collaboratively with physicians in providing PHC. The professional relationship that new graduates form with family physicians is an important factor to ease the transition experienced by NPs.
A number of researchers from the United States have examined the role transition of NPs.1–6 These researchers suggest that the increase in autonomy and the collaborative practice expectations of this new role make the shift from registered nurse to NP complex and demanding. Since 1995, the Primary Health Care Nurse Practitioner (PHCNP) program in Ontario, through a consortium of 10 university schools of nursing, has been preparing NPs to work in PHC settings. The program completed by the NP participants in this study was a 7-course certificate completed after the nursing baccalaureate that could be completed in 1 year of full-time study or longer-term part-time study. It is now in the process of being raised to the graduate level and incorporated into master’s degrees in nursing.
Enrolment of nurses in NP programs in Ontario has now doubled to fill the need in PHC. A number of initiatives in Ontario in the past 5 years (eg, family health teams that require interprofessional practice, pilot projects to reduce emergency wait times, hospital clinics for specific populations, and PHCNPs in long-term care facilities) have increased the demand for PHCNPs. No Canadian research exists about the experiences and support requirements of NP graduates and their employers or factors that influence role transition of the PHCNP graduate during the first year of practice. This research seeks to develop an understanding of the experiences and support requirements of new PHCNP graduates.
In this paper, we examine the influence of interprofessional relationships, particularly those with family physicians; explore the factors influencing and hindering successful transition into NP practice; and recommend ways to support new NP graduates.
METHODS
A descriptive qualitative design,7–9 informed by focused ethnography10,11 and narrative analysis,12–17 was used to develop an understanding of the role transition of NPs during the first year of practice in PHC. Brown and Olshansky’s2 theoretical model, “From Limbo to Legitimacy,” was the conceptual framework. This model of the transition to the PHCNP role includes 4 phases: 0 to 1 month, “Laying the Foundation”; 1 to 3 months, “Launching”; 6 to 12 months, “Meeting the Challenge”; and 12 months forward, “Broadening the Perspective.” These phases guided the questions used in both the NP and nominated coparticipant interviews.
Ethics approval was granted by the University of Ottawa Research Ethics Board. The study was completed over a 2-year period. Semistructured telephone interviews were conducted within the first 3 months, at 6 months, and at 12 months of practice. All interviews were recorded and transcribed for qualitative analysis using NVivo software. Documents (including internal documents such as job descriptions and organizational charts supplied by participants, and policies from employing agencies, regulators, professional organizations, and government ministries) provided contextual data and triangulation. The researchers collaboratively analyzed the interviews using a systematic eclectic form of narrative data analysis developed by Bailey.14
Narrative analysis is based on the understanding that individuals make sense of their experiences and communicate these understandings by constructing stories, “discrete unit[s] of discourse, topically centered and temporally organized.”15 We worked in groups of 2 or 3 to identify stories. More than 500 stories were identified and saturation was achieved by the end of the interview process. We then jointly developed 5 main themes. Subsequently, in the same author groupings, we examined the stories from 1 or 2 of the main themes to identify content, meaning, and interpretation of each theme.
Participants included a purposive sample of 17 anglophone and 6 francophone NPs from one cohort of graduates and coparticipants (physicians, NP colleagues, or administrators) nominated by the NPs who could comment on the NPs’ practices. Participants represented a range of PHC rural and urban practice. Anglophone NPs ranged in age from 29 to 61 years (mean [SD] 42.8 [9.7] years). Most had numerous years in clinical practice (mean [SD] 19.2 [11.1] years), predominantly in emergency (10 of 17) or critical care (4 of 17) settings. All had bachelor’s degrees in nursing and 3 had master’s degrees. The francophone NPs ranged in age from 27 to 46 years (mean [SD] 37.7 [6.5] years). Their years in clinical practice ranged from 3 to 23 years (mean [SD]14.3 [7.0] years), mainly in emergency and critical care. One was master’s-prepared. The 15 nominated anglophone coparticipants included 6 physicians, 5 nurse practitioners, and 4 administrators, 2 of whom were nurses. They had, on average, 17.8 years of professional experience and only 6 of 15 had previous experience working with NPs. Two NPs were unable to secure nominated coparticipants to participate in the study owing to strained working relationships. The 6 nominated francophone coparticipants included 3 physicians and 3 NPs. They had an average of 25.5 years of professional experience; 5 of 6 had previous experience working with NPs.
FINDINGS
Five themes were identified in the NPs’ and coparticipants’ stories: transition to the NP role, contextual factors affecting NP role transition, interprofessional relationships, provincial policies and politics, and educational preparation. Content analysis of the documents collected identified many factors influencing NP transition and practice, such as employers’ readiness for NPs and policies affecting NP ability to practise to their full scope of practice. Table 1 summarizes the 5 main themes identified in the analysis of interviews and documents.
DISCUSSION
The reports of the NPs and their nominated coparticipants reflected many of the findings of Brown and Olshansky,2 particularly in how the NPs described achieving greater confidence by the end of their first year of practice. These NPs evolved from feeling overwhelmed in their new role to feeling confident in their ability to function, and began to look for opportunities to improve care with population-based strategies and health promotion. In contrast to the work of Chang and colleagues,4 addressing a collaborative but dependent NP-physician relationship within acute care, the model of practice within the organizations participating in this study varied. Although all the NP participants collaborated with a variety of health care professionals, including physicians, as primary care NPs, they worked in an autonomous role. While Brown and Olshansky focused on the perceptions of NPs,1,2 this study also sought the perceptions of nominated coparticipants. Colleagues who had previously worked with NPs were more aware of the need to support and mentor the new NPs, but many coparticipants in new PHC environments knew little of the anxieties or the obstacles new NPs faced.
Mentorship by a colleague during the NP’s first year of practice had a positive effect on the transition to the new role. All newly hired NP graduates would benefit from formal mentorship when beginning practice, preferably with experienced NPs or physician colleagues. Previous studies of NP practice recommended that the government implement mentorship programs to support NPs in their transition process.18,19
When hiring a newly graduated NP into a practice setting, it is essential that physicians, administrators, receptionists, and nurses understand how NPs can work effectively within the PHC team (Box 1). Employers should ensure job descriptions and organizational charts are in place. In 2005, an Ontario study on the Integration of Nurse Practitioners into Primary Health Care18 identified poor understanding of the NP role and professional territoriality as some of the barriers to integration of the NP role. In 2006, the Canadian Nurse Practitioner Initiative developed an Implementation and Evaluation Toolkit for NPs in Canada,20 which was designed as a guide for employers to support successful integration and evaluation of NPs into PHC and to ease the transition.
We found that many factors complicated the NP role transition. Many new NPs were hired into settings that had no previous experience with NPs. Lack of knowledge of what the NP could contribute to PHC forced new, inexperienced NPs to develop their roles, create new interprofessional relationships, and carve out both physical and professional space for practice. These added responsibilities and imposed unusual stresses on the NP already experiencing the normal difficulties of role transition. During the study, 9 NPs changed or planned to change positions because of organizational and interprofessional difficulties.
When physicians were the NPs’ employers but unfamiliar with the NP role, the interprofessional relationship was challenging for both groups. For example, physicians might not understand that prescribing limitations made their sign-off on some medications necessary. The situation was exacerbated by funding policies for physician-performed procedures, which led to competition for clients and procedures based on billing opportunities rather than optimal client care. The philosophy and personality of the physician in some situations was a barrier to a positive relationship. This was also identified in the NP integration study.18 Thus, an interdisciplinary collaboration framework and interprofessional education for NPs and family practitioners are needed.
Summary of recommendations for family physicians to support NP graduates’ transition into practice
If employing new NPs, ensure ...
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that new NPs receive formal mentorship and support from physicians and NPs familiar with the role and
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that written resources and colleagues are available for consultation and support.
First-time employers of NPs should ...
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collaborate with an experienced NP to assist with understanding the NP role and job description;
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develop organizational charts, evaluation structures, and continuing education opportunities before hiring the NP;
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ensure all employees understand the NP role;
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provide office and examination room space and equipment; and
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devise interprofessional protocols to facilitate NP referrals.
Colleagues or consultants to the new NP should ...
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familiarize themselves with the scope of practice, organizational expectations for the position, and the limitations on NP practice imposed by regulations;
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plan additional time to consult and support the NP during the first few months of practice;
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plan for continuity of care for the NP with selected patients so that therapeutic relationships can be established; and
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meet regularly in interprofessional teams to identify and resolve any interprofessional problems.
Although rostering all patients to a physician, even though the NP is the provider of all or most of the care, has been adopted by PHC settings employing NPs, this practice contributes to confusion for patients and the health care team. It also creates tensions in interprofessional relationships and challenges for new NP graduates.
Changes need to occur to the diagnostic and prescriptive authority of NPs to allow them to meet patients’ needs within their competencies. The Health Professions Regulatory Advisory Council has reviewed the prescriptive authority of several professions, including nursing. At present, all 3 political parties are supportive of open authority for prescribing for NPs. Legislation has been drafted for third reading by the government.21 Physicians can lobby for recognition of NPs’ prescriptions and referrals to prevent wasting physician time for sign-off on prescriptions and referrals that are within the NP scope of practice. Increased familiarity with NP practice by the interprofessional team will reduce some difficulties encountered by new NPs. This study showed that organizations that had incorporated NPs into their culture were able to support them more effectively during the normal role transition of a new graduate. The francophone NPs had a more positive experience, partly because they were hired in established environments like hospital-based clinics and community health centres.
The NPs identified a number of changes to their educational program that could aid their transition and practice. Longer clinical rotations and graduate-level preparation are being implemented. The program should also prepare NPs for transition, for practice management, and for interprofessional practice.
The competence of NPs as PHC providers is not adequately acknowledged as the health system in Ontario now stands. This challenging health care environment produces tensions in interprofessional relationships and creates challenges for new NP graduates. The Enhancing Interdisciplinary Collaboration in Primary Health Care Initiative22 recommended principles and a framework for interdisciplinary collaboration in PHC. A central principle is trust and respect among health professions. A collegial environment that acknowledges the knowledge and skills of each profession and supports shared decision making, collaboration, and commitment to teamwork will improve health care outcomes, as well as provide a satisfying interprofessional work environment. However, practitioners must understand one another’s roles and scopes of practice. Building joint learning experiences for medical students and family practice residents with NP students would be a step forward in promoting interprofessional understanding. Joint NP and registered nurse learning experiences can also build respect for the contributions each can make to PHC. All practitioners need time to learn to work together in true collaboration.
Limitations
The NP participants graduated from the Ontario provincial program, and their experience might not reflect that of NPs and coparticipants in other provinces. Future studies could include all new NPs practising in Canada. Because the study required that the NP nominate a colleague to also participate, some did not have willing coparticipants, thus limiting the number of eligible NPs who met the criteria defined in the sample selection.
Conclusion
Nurse practitioner graduates in Ontario experienced similar transitions over the first year of practice to those found in Brown and Olshansky’s research.1 However, their transition was complicated by the health care environment being ill-prepared to receive them owing to rapid changes in PHC. New NP graduates will have successful transitions to their role when interprofessional relationships and supports are in place before they enter their new place of employment. Strategies for mentorship and for the integration of new NPs into PHC settings are available and need to be implemented by health professionals and administrators.
Acknowledgments
This research was funded by the Council of Ontario University Programs in Nursing through funds from the Ontario Ministry of Health and Long-Term Care. The views expressed in this paper are those of the authors and do not necessarily reflect the views of the Ontario Ministry of Health and Long-Term Care.
Notes
EDITOR’S KEY POINTS
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Nurse practitioner (NP) graduates in Ontario experience a common transition to practice. Successful transition to the role is facilitated when interprofessional relationships and supports are in place before new NPs enter the place of employment.
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In some cases the health care environment is ill-prepared to support new NPs’ transition to practice, owing to recent rapid changes in primary care.
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Strategies for mentorship and for the integration of new NPs into primary health care settings are available. Use of these tools would assist health professionals and administrators as they strive to ease the transition process for newly graduated NPs.
POINTS DE REPÈRE DU RÉDACTEUR
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Le passage à la pratique est le même pour toutes les infirmières praticiennes (IP) diplômées en Ontario. La réussite de cette transition est favorisée lorsqu’il existe de bonnes relations interprofessionnelles et de l’aide avant leur arrivée au lieu de travail.
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En raison des récents changements rapides dans les soins primaires, il arrive que le milieu de travail soit mal préparé pour faciliter le passage à la pratique des IP.
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Il existe des stratégies pour fournir un mentorat et pour intégrer les nouvelles IP au milieu de soins primaires. Le recours à ces stratégies aiderait les professionnels de la santé et les administrateurs dans leurs efforts pour faciliter le passage à la pratique des IP nouvellement diplômées.
Footnotes
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This article has been peer reviewed.
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Cet article a fait l’objet d’une révision par des pairs.
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Contributors
All authors participated in the development of the original research proposal. Interviews were conducted by Ms Sullivan-Bentz and Ms Laflamme, and all authors participated in data analysis and in writing or reviewing the manuscript. All authors approved the final version for publication.
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Competing interests
None declared
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