Exploring the Transition Experiences of Registered Nurses to Nurse Practitioners in Rural Healthcare Settings

Monday, 30 October 2017

Rhoda A. Owens, PhD
College of Nursing and Professional Disciplines, University of North Dakota, Grand Forks, ND, USA


The purpose of this study was to explore registered nurses' perceptions of their experiences during their role transitions from registered nurses to nurse pracitioners in rural healthcare settings. In addition, this study explored if and how nurse practitioners develop a professional identity through their rural health experiences.

Research Questions:

  1. How do registered nurses experience their role transition process and development of their nurse practitioner professional identities during their first year of primary care practice?
  2. What are the factors that attract nurse practitioners to work at rural healthcare facilities?

Significance and Literature Review:

Recent changes in the United States health policy, the growth of the total and aging population, and the increased need to manage complex chronic diseases are placing stress on the healthcare system leading to the need for additional primary care providers (Graves et al., 2016; Perloff, DesRoches, & Buerhaus, 2016; Schiff, 2012). By 2020, the United States will face a shortage of more than 45,000 primary care physicians (Kirch, 2012). Fewer medical residents are choosing to practice in internal and family medicine specialties (Kirch, 2012; Poghosyan, Lucero, Rauch, & Berkowitz; 2012). However, nurse practitioners make up the most rapidly growing primary care workforce and are being utilized to provide primary care in diverse settings (American Association of Nurse Practitioners, 2016; Poghosyan et al., 2012). According to the American Association of Nurse Practitioners (2016), nurse practitioners (NPs) are a vital part of the U.S. primary care workforce with 89% of the nurse practitioner population prepared in primary care and over 75% of NPs are actively practicing in primary care. New models of care delivery that emphasize greater interprofessional collaboration between physicians and other clinicians such as NPs are being encouraged (Graves et al., 2016; Perloff et al., 2016; Schiff, 2012). Furthermore, NPs tend to care for rural and underserved populations. Approximately 66% of NPs work in communities with populations of less than 250,000, with 35% practicing in communities of less than 50,000 (Rutledge, Haney, Bordelon,, Renaud, & Fowler; 2014). As a result, NPs will increasingly be called upon to meet the demand for primary care provider positions in rural areas (Rutledge et al., 2014; Schiff, 2012).

During role transition from the expert registered nurse identity to the inexperienced novice nurse practitioner identity, feelings such as inadequacy, role ambiguity, isolation, anxiety, stress, and being overwhelmed have been reported leading to feelings of incompetence (Barnes, 2015; Poronsky, 2012). Successful professional identity formation occurs for an individual when he or she develops the attitudes, beliefs, behaviors, and learns the knowledge and skills that support the role and responsibilities of being that professional (Johnson, Corwin, Wilson, & Young, 2012; Trede, Macklin, & Bridges, 2012). Furthermore, successful role transition and professional identity development results in increased retention and work satisfaction for individuals (Sabanciogullari & Dogan, 2015: Trede et al., 2012).

However, there is limited research with the registered nurse's transition to the role of nurse practitioner at rural healthcare settings. Successful role transition has been connected with professional identity development necessary to establish confidence and competence in one's new professional identity as well as work satisfaction and retention.

Operational Defintions and Theoretical Framework:

Operational definitions for rural nursing and role transition were established prior to implementing the study. Long and Weinert (1989) define the concept of rural nursing as “the provision of health care by professional nurses to persons living in sparsely populated areas” (p. 114). Nurses and other health care providers in rural areas must deal with a lack of anonymity and role diffusion (Lee & McDonagh, 2013; Long & Weinert, 1989). Role can be defined as a character assigned or assumed; a socially expected behavior pattern determined by an individual’s status in a particular society, or a function or part performed especially in a particular operation or process (Meleis, 1975). Role transition can be defined as a change in an individual’s self-identity within a certain context that occurs through the development of new knowledge and skills, as well as a change in behavior, role relationships, interactions, expectations, and abilities (Meleis, 1975).

The theoretical framework for this study was based on Illeris’ (2014) Transformative Learning and Identity theory. Illeris’ (2014) Transformative Learning and Identity theory adds the concept of identity formation to previous Transformative Learning theories. Identity is created, developed, and changed through transformative learning (Illeris, 2014). Illeris (2014) defines the concept of identity as “…identity is about being a person in the world, who one experiences being, and how one relates to and wants to be experienced by others” (p. 1). Finally, establishment of one’s identity involves the three dimensions of learning (content, incentive, and interaction) in society and depends on the learner’s characteristics as well as present and past experiences (Illeris, 2014). Content is what is learned. Incentive involves the motivation and engagement of the learner to learn. Interaction with other individuals is experienced by the learner in a particular setting in society (Illeris, 2014). Learning is an individual process for individuals because their new learning builds upon their relevant prior learning and experiences that can be different for each individual and based on their linkage of new to the already developed skills, knowledge, abilities, understandings, competencies, attitudes, and so on (Illeris, 2014).

Use of Illeris’ (2014) Transformative Learning and Identity as a theoretical framework is appropriate for this study. The framework provides a lens to further explore the nurse practitioner’s role transition and professional identity development at a rural healthcare setting as it takes into account critical factors for role transition and professional identity development not previously studied for this population.


A qualitative phenomenological approach described by Moustakas (1994) was used for this study. The aim of phenomenology is to determine in depth what an experience means for an individual who has experienced the phenomenon and able to provide a comprehensive description of it, and the individual’s perceptions of the experience are the source of knowledge (Moustakas, 1994). The phenomenon to be explored in this study will be the nurse practitioner meanings of their experiences as they role transition from their nurse identities to their nurse practitioner identities in their first year of practice at rural healthcare settings.

Approval for this study was obtained through the university’s Institutional Review Board. Participants included nurse practitioner program graduates from a Midwestern university that serves a large rural region. Other inclusion criteria for participants included being employed in their first year of primary care practice at a facility considered rural as indicated by the Rural Health Information Hub (2016). Emails were sent to these graduates by the principle investigator explaining the study’s purpose, selection criteria, time commitment, and participation requirements. Participants were located at multiple states and rural healthcare facilities. Following written informed consent, two audio-recorded face-to-face semi-structured interviews in person or using skype for business were conducted with each participant. The first interview was conducted at approximately 6 months of employment and the second interview was completed around 1 year of employment. Interviews were transcribed per verbatim. Interviews were conducted until data saturation was achieved. The use of multiple in-depth individual interviews as a main method of data collection is appropriate in phenomenology studies as it provides a means to address the research purpose from different perspectives and gain a greater understanding of the phenomenon (Creswell, 2013; Glesne, 2011; Moustakas, 1994; Roulston, 2010). For example, questions examined participants’ perceptions and meanings of their role transition and identity development experiences; and their perceived need for support, learning, and further professional development. Participants were asked to answer the questions in a present and retrospective view.

Moustakas’ (1994) phenomenology research method approach will be used as a guide for the ongoing analysis of each participant’s verbatim interview transcripts, field notes, and a reflective journal. Member checking will be conducted continuously as interviews are transcribed and analyzed to eliminate inconsistencies and inaccuracies involved in data analysis. Lincoln and Guba (1985) have identified member checking as “the most credible technique for establishing credibility” (p. 304). Using a content analysis approach, common themes will be developed by grouping significant statements, and textural descriptions of the participant’s experiences (Moustakas, 1994). Another experienced qualitative researcher will be asked to review the data analysis and interpretation to ensure it is logically consistent.


Data results and analysis will be completed by the conference date and will be reported at that time.


It is proposed that findings will result in implications for nursing program leaders to use in developing and revising curriculum for their nurse practitioner programs that will better prepare nurse practitioners to enter and transition into rural primary care practice. The study results can be utilized by educators and preceptors to develop curriculum and practice experiences for NP students to improve safe, high quality care in rural settings. In addition, findings will aid rural healthcare facility administrators and leaders in providing necessary support, orientation, and life-long professional development to nurse practitioners. The findings are useful to promote successful role transition and identity development for NPs in rural settings.