NURSE PRACTITIONER GRADUATE TRANSITION TO PRACTICE

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NURSE PRACTITIONER GRADUATE TRANSITION TO PRACTICE

• Funding
• Council of Ontario University Programs in Nursing
• Ontario Ministry of Heath and Long Term Care
•  

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• Co-Principal Investigators
• Dr. Betty Cragg
• (University of Ottawa)
•  
• Dr. Patricia Bailey
• (Laurentian University)
•  
• Co-Investigators
• Dr. Frances Legault
• (University of Ottawa)
•  
• Jennie Humbert
• (University of Ottawa)
•  
• Suzanne Doucette
• (University of Ottawa)
• Masters of Nursing Student
• Célyne Laflamme

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Objectives

• To describe the role transition of NP graduates
  from their perspective and from the perspective
  of a co-participant (employer, physician, NP
  colleague) working in the same setting, nominated
  by the NP
• To explore the support requirements of NP
  graduates during the first year of practice
• To make recommendations for NP practice,
  education, and policy

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Theoretical FrameworkAdapted from Brown and
Olshansky (1997)

• LIMBO TO LEGITIMACY
• Laying the Foundation - 0-1 month
• Recuperating from school
• Negotiating the bureaucracy
• Looking for a job
• Worrying
• Launching -1-3 months
• Feeling like an imposter
• Confronting anxiety
• Getting through the day
• Battling time
• Meeting the Challenge - 6-12 months
• Increasing competence
• Gaining confidence
• Acknowledging system problems
• Broadening the Perspective - 12 months
• Developing system savvy
• Affirming oneself
• Upping the ante

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Research Process

• Descriptive qualitative design (Thorne et al.,
  1997 Thorne et al., 2004) informed by Focused
  Ethnography (Morse Richards, 2002 Muecke,
  1994) and Narrative Analysis (Bailey, 2001, 2002,
  2004)
• Sample
• Purposive sample 15 - 20 NPs in the first year
  of NP practice
• Anglophone and francophone graduates of COUPN
  PHCNP program in Ontario
• Nominated colleague for each NP
• Semistructured interviews
• At 3, 6, 12 months of employment with NPs
  co-participants
• Document reviews
• Job descriptions
• Organization charts
• Policies organizational and provincial
• Reports and reviews of NP programs and practice
•  

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Demographics
Anglophones 17 NPs 15 Co-participants Francophones 6 NPs 6 Co-participants
NPs Age Range 29 61 Mean 42.8 SD 9.7 Range 27 46 Mean 37.7 SD 6.5
Years of Experience Range 6 - 37 Mean 19.23 SD 11.14 Range 3 - 23 Mean 14.3 SD 7.03
Co-participants Professional background MD x 5 NP x 4 Administrators x 6 MD x 3 NP x 3
Previous experience with NPs 6 5
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(No Transcript)
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Full-time vs. Part Time Work
N.B. Six (6) Francophone Participants were
included Seventeen (17) Anglophone Participants
were included
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Work Settings

• Anglophones
• Clinics
• Community Health Centres
• Family Health Teams
• Primary Care Centers
• Emergency Departments

• Francophones
• Hospital
• Clinics
• Emergency
• Patient populations
• Community Health Centres

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Population Profiles Diverse

• All ages (individual, family, groups, community)
• Geriatrics
• Aboriginal (urban and on-reserve)
• Homeless
• Clients with mental illness addictions
• Francophone communities
• Multicultural populations
• Womens health

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Themes

1. Transition to NP Role
2. Contextual Factors Impacting NP Role Transition
3. Interprofessional Relationships
4. Provincial Policy and Politics
5. Educational Preparation

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Theme 1 Transition to NP Role

• Role Adjustment
• NPs had high expectations of themselves from the
  beginning
• Transition reflected Brown Olshanskys stages
• Other factors complicated the transition lack
  of familiarity with NP role, organizational and
  professional unfamiliarity with NP needs
• Co-participants frequently not aware of the NPs
  struggles
• Those with previous experience more aware of need
  for support

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Theme 1 Transition to NP Role

• "It certainly isnt the lack of support that I
  have had. Its a confidence issue with me and
  that this is the first week Ive actually had
  where there has been three days where I can say,
  You know what? I really did well. A
  tremendous blow to my ego and pride is going from
  expert to not. That has been tremendously
  difficult to overcome. I hate being a novice. I
  hate it." (NP10 3 months)
• "Its amazing how the baby steps work, you know.
  Youre nervous but you can handle it." (NP10 - 6
  months)
• "Much improved. Very. I get more and more
  confident. More continuity with patients, more
  trust in yourself, more confident in my
  decisions, less consulting with physicians. I am
  doing really, really well. Its been a long
  road." (NP10 12 months)

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Theme 1 Transition to NP Role

• Time management
• First 3 months much overtime
• New patient assessments
• Inappropriate length of bookings
• Introduction of electronic health records
• Generally not pressured by co-participants to see
  more patients, but lack of perception of amount
  of overtime worked
• By 1 year
• Little overtime
• Expectations clearer for NPs and staff

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Theme 1 Transition to NP Role

• Mentoring
• Key factor
• Experienced co-participants very aware of need
  for mentoring and support
• Some NPs had to seek own supports and explain
  role while they were still learning it.
• There is certainly a responsibility of us when a
  nurse practitioner comes, to mentor her through.
  It doesnt matter if theyve been working for
  awhile, you still have a new practice population
  and they still have to learn the ins and outs of
  things. (Co-part 12 6 months)

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Theme 1 Transition to NP Role

• Previous experience
• Very experienced nurses, many with ICU and
  Emergency backgrounds
• Much life experience
• Many known in workplaces because of previous
  employment as RN or as NP student placement
• Able to draw on experience to deal with start up
  organizations, lack of appreciation for role and
  their needs, and conflicts.

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Theme 2 Contextual factors impacting role
transition

• Many changes in the Primary Health Care system in
  Ontario during this period
• Family Health Teams forming
• Pilot projects in Emergency Departments and other
  settings on effect of hiring NPs
• New NP positions in specialized clinics

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Theme 2 Contextual factors impacting role
transition

• Many employers had funding, but not
  infrastructure to support NP practice e.g. job
  descriptions, organizational charts, space,
  support staff
• "The biggest challenge is space I dont have an
  office. I dont 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. Well
  naturally, you know how things are. Moving
  buildings, its going to be another year." (NP 2
  -12months)

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Theme 2 Contextual factors impacting role
transition

• Hiring
• Word of mouth or student placement
• Few needed to move to find employment
• Fit with agency important to co-participants
• Alternative positions available for those who
  were dissatisfied with current NP employment
• Orientation Much variation, often with the NP
  identifying own needs and plan own program
• Evaluation Often responsibility unclear, with
  lack of job description and expectations.
• Continuing education Many anglophones had to
  fight for time reimbursement

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Theme 2 Contextual factors impacting role
transition

• Opportunities to shape practice and define own
  roles
• The nurse practitioner had been attending some
  meetings. We just ceased that now as she has been
  seeing patients. Because we were taking her
  advice and her input on how we should be forming
  and associations we should have. So she was very
  helpful in helping us to formulate where we are
  going. (Co-part 1 3 months)

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Theme 3 Interprofessional Relationships

• Professional Colleagues
• MDs - family, emergency, specialists
• RNs family practices/health teams, clinics,
  emergency
• Support staff receptionists, lab techs
• Relationships dependent on
• Culture and experience of agency with NPs
• Organizational position of NP
• Employee status
• All employees
• NP hired by MD
• Independent practice with consultation

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Theme 3 Interprofessional Relationships

• NP role confusion
• "There had been lots of conversation about what
  can a nurse practitioner do? One of the first
  things I did was download, the brochure off the
  NPAO website and had copies left around in
  the clinic. So the staff have learned, the
  patients have learned, and the physicians have
  learned." (NP 4 - 3 months)
• "They physicians expect that you can manage
  everything and again, with medications,
  prescriptions, they cant understand, Why do I
  have to co-sign for this?" (NP 10 - 6 months)
• "The physicians had basically been told, they
  claim that they were told, that were nurses, so
  we therefore dont require nursing support." (NP
  9 - 3 months)

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Theme 3 Interprofessional Relationships

• 9 NPs changed jobs during the period of the
  study.
• 7 anglophones and 2 francophones
• 7 job changes were because of interprofessional
  conflicts.

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Theme 4 Provincial Policy and Politics

• Regulations limit scope of practice, prescription
  rights, medical directives required in hospitals
• Some government agencies and insurance companies
  accept NP referrals and forms some do not
• "Certain insurance companies wont 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 - 6
  months)

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Theme 4 Provincial Policy and Politics

• Insecure funding for new positions
• "We were funded for a full year but we were
  worried about funding for the year and we were
  afraid we were going to lose her so we actually
  put her on staff. The posting went up before we
  heard from the ministry. But we do have full
  funding for a full year." (Co-part 15 12
  months)
• MD funding mechanisms led to competition with NPs
  and restrictions on practice
• "Not being able to refer to specialists because
  of billing issues. Its within my scope to be
  able to refer to a dermatologist or whatever, but
  because they physicians cant get paid the
  same, I cant do it. Thats frustrating." (NP 2 -
  3 months)

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Theme 5 Educational Preparation

• 12 month program provided in 2 languages by
  consortium of 10 Ontario Universities
• Post baccalaureate, moving to Master's level
• Recommendations from participants
• Role transition preparation
• More clinical
• More preparation for "business aspects"
• Budgets, contracts, government forms
• "Most of the nurse practitioners I know are
  struggling with not having a clear
  understanding of the financial side of things."
  (NP 2 - 12 months)
• Info re particular client groups
• Influencing policy government and agency

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Factors Influencing Success

• Age personal confidence
• Experience as RN in areas like Emergency, ICU
• Mentorship and support from NP colleagues
• Availability of MDs and NPs for consultation,
  especially in early months
• Adequate resources and support roles
• Organizations that were familiar with role, scope
  of practice, and expectations of NPs
• Francophone NPs precious resources

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Factors Hindering Success

• Organizations with new positions for NPs
• New structures for organizations and practices
• Team adjustment to the new practitioner
• Few position descriptions, infrastructure plans
• Contracts temporary with unclear continuation
  of position
• Policies and funding limiting scope of practice

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Recommendations

• New NPs
• Look for work in agencies familiar with role
• If impossible, negotiate supports and mentorship
• Mentorship
• All newly graduated NPs need formal mentorship
• New NPs seek and establish links with experienced
  NPs
• Hiring organizations
• Provide orientation to agency and role
• Job description, role definitions, and
  organization chart with clear reporting
  relationships pre hiring
• New organizations hire experienced NPs or arrange
  consultation for NP and agency

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Recommendations - continued

• Organizations
• Ensure supports of space, clerical and
  interprofessional staff and policies and
  procedures to promote full scope of practice
• Common repository of resources for NP hiring
  agencies, NPs and MDs
• Interprofessional protocols to facilitate NP
  referrals
• Funding
• Stable, predictable funding for new positions
  with timely notification of change
• Support for orientation, mentoring, team
  building, continuing education
• Reassess MD funding to avoid competition with NPs

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Recommendations - continued

• Policy
• Re-examine limitations on prescriptive authority
  and referrals to facilitate gate keeper role of
  NP
• Funding for independent practice
• Role clarification with professional bodies
• Education
• Role transition
• Complex situations e.g. co-morbidity,
  homelessness
• Business aspects of practice
• Pre-licensure interprofessional education for
  NPs, MDs, RNs, etc.

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Questions?

• bcragg_at_uottawa.ca