An Educational Intervention to Enhance Nurse Practitioner Role Transition in the First Year of Practice

Role transition is a natural process that occurs when the registered nurse (RN) pursues additional education and training in preparation to become a nurse practitioner (NP). This role transition is complex with multiple yet distinct phases, beginning with entrance into the educational program and continuing as long as two years’ post-graduation (Brown & Olshansky, 1997; Cusson & Viggiano, 2002; Heitz, Steiner, & Burman, 2004). The journey of practicing from the “side of the bed to the head of the bed” (Cusson & Viggiano, 2002, p. 21) generates anxiety, insecurity, and increased stress in the graduate, ultimately causing role confusion and disruption in role identity, thereby leading to a longer adjustment period. Graduate NPs feel an unreasonably high expectation to be clinically competent immediately after graduation in order to have “mastered” the new role of the practicing NP (Cusson & Viggiano, 2002). Moreover, graduate NPs tend to blame themselves for experiencing these emotions and internalize these feelings, further exacerbating the sense of isolation and incompetence (Hill & Sawatzky, 2011). A compounding factor is the employer and new NPs expectation that they “hit the ground running” (Brown & Olshansky, 1997). This pressure combined with insufficient opportunities during the NP program for socialization results in graduate NPs feeling like “imposters” (Hill & Sawatzky, 2011).

There are a few qualitative and cross-sectional studies that have investigated strategies to facilitate the role transition of NP graduates. Nonetheless, current findings support formal orientation programs, informal and formal mentoring, as well as professional networking and socialization activities as positive influences on NP role transition (Bahouth & Esposito-Herr, 2009; Barnes, 2015; Cusson & Strange, 2008; Duke, 2010; Fleming & Carberry, 2011; Hart & Macnee, 2007). To date, there are no published quantitative studies that evaluate outcomes of role transition programs on graduate NP transition to practice. There is a gap in knowledge regarding strategies to support professional NP role transition during this critical time period. Therefore, purpose of this study is to investigate whether an evidence-based role transition webinar provided to graduate NPs would result in improved integration into practice.

The study design is a non-randomized, pretest-posttest, single-group study utilizing a convenience sample. The target population consists of nurse practitioners within the first year of practice willing to participate in the study. The Nurse Practitioner Role Transition Survey (NPRTS) was used to measure the role transition of the study participants. The NPRST is a 16-item survey with a 5-point Likert scale consisting of three components: Developing Comfort and Building Competence, Understanding of the Role by Others, and Collegial Support. The response options are: (1) Strongly disagree, (2) Disagree, (3) Neither disagree or agree, (4) Agree, and (5) Strongly agree. The potential range of scores is 16 to 80, with higher scores equating to a more successful transition. The content reliability and validity for measuring NP role transition with the 16-item NPRTS of this study population was 0.77 using Cronbach’s alpha internal consistency.

The intervention was a recorded evidence-based webinar on NP role transition components across the spectrum, with Brown and Olshansky (1998) Limbo to Legitimacy serving as the theoretical foundation. The webinar is divided into four sections that mirror the NP role transitional phases identified in this model. The webinar provides education on the issues known to impact role transition within the first year of practice including nurse practitioner transitional phases, the regulatory issues of licensure, certification, prescriptive authority; role conflict resolution strategies; organizational components of practice such as privileges, practice agreements, and credentialing; as well as business management concepts like billing and coding.

Participants were recruited through email invitation utilizing the Coalition of Advanced Practice Nurses of Indiana (CAPNI) membership list-serve and Nurse Practitioner program directors for the state of Indiana and the surrounding Midwest. Participants engaged in the webinar one to three weeks after the pre-survey and two to three months before taking the post-survey.

A total of 30 participants completed all components of the study. The mean pre-survey score was 54.72 at a 95% confidence interval with a standard deviation of 6.7, a slightly negative skew, and positive kurtosis indicating a slightly above average degree of confidence in NP role transition prior to participation in the educational intervention. The study participants were exclusively female (100%), 90% white, with 75% being in the age range of 31-59. Only 7.5% of participates graduated within three months of participation, (45%) graduated 4-6 months prior to participation, and 15% graduated within 7-9 months. Over 60% had 6-15 years RN experience before entering their NP program. The highest program participation was from Indiana University Purdue University of Indianapolis (25%), followed by Indiana Wesleyan (15%), and Indiana State University (7.5%). Over 25% of participants were from NP programs in Ohio and Illinois.

The lowest mean scores for participants were in the areas of NP program preparation (=3.10/5), understanding of the NP role by the public (=2.73/5), and ease of transition from nurse to NP (=3.06/5). The highest mean scores were being treated as a professional by colleagues (=4.32/5), understanding of the NP role with nurse colleagues (=3.90/5), and having the skills to deal with NP role transition (=3.70/5). There was no statistically significant difference observed regarding years practicing as RN (P=0.731), time from program completion (p=0.145), or NP program (p=0.888), and NPRTS scores.

There was a positive association seen between age range of the participant and higher NPRTS scores in the post-test (p<0.000). This is the first study to demonstrate that there are possibly age-related differences in NP role transition, indicating perhaps more life experience equates to improved coping skills and in general enhances NP role adjustment.

The educational webinar was shown to have a statistically significantly positive influence on the participant’s reported perceptions of NP role transition as it relates to confidence (item 6) (P <0.019) and smooth transition (item 7) (p <0.026), but not on the NPRTS comparison scores as a whole (pre-survey u= 54.7/80, post-survey u=54.0667, P= 0.616).

Several indicators showed improvement in mean scores after completion of the webinar including comfort level with patients, skills to deal with role transition, and the requirement of less time for responsibilities. Improvements in these factors have important practical applications to NP practice since facilitators of NP role transition can lead to shorter and possibly less complicated adjustment period. And although it is unknown if the improvement is directly associated with the educational intervention, it is encouraging nonetheless and warrants further investigation to understand the significance fully.

The most problematic barrier identified with this study is the timing of the study implementation to the time of NP graduation. Due to the study implementation being in the fall, almost half of the study participants (47.5%) had graduated the previous December, or more than nine months prior to the study launch. Another 45% graduated 4-6 months preceding the study in May. Unfortunately, 7.5% of the study participants graduated within three months of program implementation when the webinar content would have been most applicable. As a result, over half of the study participants were outside of this ideal window of opportunity and may not have benefited as much from participation.

In conclusion, it has been recognized that NP students devote most of their energy during their NP program to the clinical aspects of NP practice, leaving little time for professional NP role development (Hamric & Hanson, 2003). This phenomenon contributes to a slower and more difficult NP role transition (Duke, 2010; Hart & Macnee, 2007; Latham & Fahey, 2006). Having practical and assessable educational interventions to optimize NP role transition can result in positive affirmation of the NP role and should help to solidify NPs contributions to healthcare to consumers and other healthcare providers. Determining the factors that contribute to the success of NP role transition, including optimal timing would be prudent. Therefore, steps need to be taken to facilitate successful transition so that graduates can transform into effective providers as soon as possible.