Asssigment

Exploring the Factors that Influence Nurse Practitioner Role Transition

Hilary Barnes, Ph.D., CRNPa

Hilary Barnes: [email protected] aPost-doctoral Research Fellow, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104-4217, Office: 215.898.4908, Mobile: 215.801.1833, Fax: 215.573.2062

Abstract

The transition from registered nurse (RN) to nurse practitioner (NP) is often a stressful career

change. Data are lacking on the factors affecting NP role transition. This study examined the

relationships between NP role transition, prior RN experience, and a formal orientation. From a

sample of 352 NPs, only a formal orientation contributed significantly to the regression model

indicating a positive relationship with NP role transition (b = 6.24, p < .001). Knowledge of the

factors that explain NP role transition is important to inform the discipline how best to support

NPs during entry into practice.

Keywords

nurse practitioner; role transition; workforce; Meleis; Transitions Theory

The transition from registered nurse (RN) to nurse practitioner (NP) is a significant career

role transition. It is often difficult and can be stressful across various settings.1 During this

time, there is a shift from an experienced, often expert status in the RN role to an

inexperienced, novice status in the NP role.2 This can result in an alteration in professional

identity, loss of confidence, and impaired NP role development. Employment continuity and

the decision to remain in the profession can be affected when role development is

undermined.3 Successful role transition is important in order for NPs to become efficient

and effective providers as quickly and positively as possible.3

© 2014 Elsevier Inc. All rights reserved.

Author byline: Hilary Barnes, Ph.D., CRNP ([email protected]) is affiliated with the Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA. She was a doctoral student at Widener University School of Nursing in Chester, PA at the time this research was completed. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.

The content is solely the responsibility of the author and does not represent the official views of the National Institutes of Health.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

NIH Public Access Author Manuscript J Nurse Pract. Author manuscript; available in PMC 2016 February 01.

Published in final edited form as: J Nurse Pract. 2015 February ; 11(2): 178–183. doi:10.1016/j.nurpra.2014.11.004.

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Background

Nationally, NPs have received increased attention in recent years. Through The Patient

Protection and Affordable Care Act (ACA),4 the United States (U.S.) government has

directly called for an increase in the number of healthcare providers to care for the expected

millions of Americans, who will become eligible for health insurance. Currently, there is a

shortage of physicians in the U.S., which is expected to increase.5 NPs are being viewed as

key providers in the collaborative efforts to address these workforce needs.6

However, employment turnover rates for NPs are twice those of physicians.7 Seminal

research on NP role transition3,8–10 has identified many difficulties that NPs can experience

during this time; and provider outcomes, such as lower job satisfaction and feelings of

discontentment, have been associated with increased intent to leave and high turnover.11,12

These findings suggest that poor transition experiences result in NPs leaving positions.

During NP role transition, there are different personal and environmental factors that are

thought to promote the transition, and two of these factors include experience and receiving

a formal orientation.2 No studies were identified that directly examined NP role transition in

relationship to experience, specifically prior RN experience, or receiving a formal

orientation. The purpose of this study was to explore NP role transition in relationship to

prior RN experience and receiving a formal orientation in the first NP position.

Experience is believed to be important for skill acquisition and developing competency in

nursing practice.13 However, the available literature does not explicitly define experience in

relationship to NP role transition as prior RN experience or experience in a similar role.

Prior RN experience is reported to provide a foundation and help facilitate the transition to

the NP role,1,9,14 and NPs with less RN experience are thought to require more time to

transition into the new role.3 One study found no significant correlation between years of

prior RN experience and NP clinical skills after graduation.15

Within nursing, formal orientations are recommended as beneficial to role transition for

RNs,16,17 clinical nurse specialists,18 and NPs.12,19,20 Orientations have been found to

relieve stress and help promote a sense of confidence, competence, and satisfaction.12,16

Although extensive training and orientation time are provided to new RNs, similar measures

are lacking for NPs, and a lack of structured support has been found to affect NP role

transition negatively during the first year of practice.3

Theoretical Framework

Meleis’s Transitions Theory21 was used to guide this research. This framework defines

personal and community level transition conditions that are predicted to either promote or

inhibit the transition, and NPs can experience a successful or an unsuccessful transition. A

successful transition is characterized by a subjective sense of well-being, increased

confidence and competence, mastery of skills, and autonomous practice.2 An unsuccessful

transition is characterized by negative emotions, a lack of confidence, turnover, and limited

support.2,22 In this study, prior RN experience was examined as a personal level transition

condition, and receiving a formal orientation was examined as a community or

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environmental level transition condition. These variables were examined as possible

promoters or inhibitors of NP role transition.

Methods

This study used a descriptive, cross-sectional survey of practicing NPs. Data were collected

via a paper-and-pencil questionnaire from a convenience sample of 352 participants at a

national NP conference. Based on a prior power analysis using a level of significance of p

< .05, a power of .8, and a medium effect size of .13, the projected minimum sample size for

this study was 88. A medium effect size of .13 is suggested for multiple regression

analysis,23 which was included in the data analysis. Participants were recruited through

flyers and posters that directed them to the data collection site. They were given a

questionnaire along with a letter explaining the study and their rights as research

participants. Completed surveys were returned anonymously in a secured box. Inclusion

criteria included NPs, who are currently practicing in direct patient care within the U.S.,

hold a graduate degree to practice as an NP, are able to speak and read English, and have

been working as an NP for at least six months, as role transition after graduation and into the

first position can, at a minimum, last this long.9 Finally, participants were required to have

started practicing as an NP after 1990; this is when NP preparation shifted from being

primarily certificate-based to requiring a graduate degree.24 Institutional Review Board

approval was obtained prior to data collection.

Measures

In this study, NP role transition was the dependent variable. The 16-item, 5-point Likert

Scale Nurse Practitioner Role Transition Scale (NPRTS) was used to measure participants’

perceptions of their own NP role transition experience.22 Participants were asked to rate

their agreement (1 = “strongly disagree” to 5 = “strongly agree”) with statements regarding

concepts such as feelings of support vs. isolation; understanding of their role by patients,

physicians, and other staff; and feeling prepared to manage patients and time. A higher total

score indicated the perception of an easier role transition experience.22 The possible range of

scores was 16 to 80. Permission was obtained from the instrument’s first author to use the

NPRTS for this study.

Content validity and reliability of the NPRTS were previously established in a sample of

182 practicing NPs across a variety of settings.22 Through exploratory factor analysis, the

authors found three dimensions that explained NP role transition: developing comfort and

building competence in the role; understanding of the role by others; and collegial support.

Internal consistency reliabilities for the three subscales were high at .88, .83, and .79,

respectively; no reliability coefficient was provided for the total 16-item instrument.22 In the

present sample (N = 352), reliabilities for the instrument’s subscales were similar at .85 for

developing comfort and building competence in the role; .78 for understanding of the role by

others; and .73 for collegial support. Internal consistency reliability for the total 16-item

NPRTS was .87. Further development of the instrument and evaluation of its psychometric

properties continue providing encouragement for future use.22

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The independent variables of prior RN experience and receiving a formal orientation in the

first NP position were measured using single-item questions. The item on RN experience

asked: “How long did you work as an RN prior to working as an NP?” The item on formal

orientation asked: “Did you receive a formal orientation in your FIRST NP position?”

Given that there are a limited number of orientation programs for new NPs and the body of

research describing and evaluating these programs is small and varies across healthcare

settings,19,20,25 a common definition of what constitutes a formal orientation is lacking. The

question asking about receiving a formal orientation aimed to assess whether the participants

felt they were provided with the necessary structure and support during entry into practice.

Data Analysis

Data were double entered to reduce the chance of errors and assure data quality. Descriptive

statistics were used to describe participants’ characteristics and study variables. Pearson’s

correlations between the variables were evaluated, and an independent t-test was used to

compare the mean scores on the NPRTS between those participants, who reported receiving

a formal orientation and those, who did not. A multiple regression analysis was used to test

if prior RN experience and a formal orientation explained NP role transition. Finally, using

Cook’s distance and Mahalanobis distances, no outliers or influential cases were identified,

and all assumptions of multiple regression analysis were analyzed and met.26 Data were

analyzed using IBM® SPSS® Statistics 20.

Results

Description of Participants

A summary of the demographic data and characteristics of participants’ first NP position are

presented in Table 1. The present sample was primarily female (88.6%), white (81.8%), and

had a mean age of 47. A majority (86.6%) held a Master of Science in Nursing (MSN) as

their highest nursing degree. Years of NP experience ranged from six months to 23 years,

with a mean of 7.67 years. The most frequently cited population focus was Family (47.9%),

and almost 60% of the sample reported practicing in an outpatient/private practice office

setting.

Study Variables

A summary of the descriptive statistics for the study’s variables can be seen in Table 2. Prior

RN experience ranged from zero to 38 years with a mean of 13.75 years. This variable was

positively skewed; however, as previously discussed, no outliers or influential cases

impacted the analysis. Of note, these descriptive statistics for prior RN experience should

not be confused with years of NP experience. Data on NP experience were collected using a

separate questionnaire item and was used to establish study eligibility and describe the

sample. Prior RN experience had a non-significant relationship with NP role transition (r =

−.08; p = .12). Additional analyses using various cut-points within the RN experience

variable revealed no significant relationships with NP role transition.

In the first NP position, 33% of participants received a formal orientation (Table 2).

Receiving a formal orientation was positively correlated with NP role transition (r = .29; p

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< .001). An independent-samples t-test revealed that, on average, participants, who received

a formal orientation had higher scores on the NPRTS (M = 53.11, SD = 9.44 vs. M = 46.85,

SD = 10.02). This difference was significant t (350) = −5.62, p < .001. Overall, the

participants reported a moderate transition experience based on a mean NPRTS score of

48.92 (SD = 10.25).

Multiple Regression Analysis

Multiple regression analysis was used to test if prior RN experience and receiving a formal

orientation explained NP role transition. The results of the regression indicated the two

variables explained 9% of the variance (R2 = .09, F(2, 349) = 17.05, p < .001). However, as

seen in Table 3, only a formal orientation was significantly associated with NP role

transition.

Discussion and Recommendations

The aim of this study was to examine NP role transition in relationship to prior RN

experience and receiving a formal orientation. As this is the first study that directly explored

these relationships, it provides the preliminary work for future research on the concept of NP

role transition. As predicted by Transitions Theory,21 receiving a formal orientation was a

promoter of NP role transition. Those NPs, who received a formal orientation, reported

better transition experiences. Both the Institute of Medicine27 and provisions in the ACA4

recommend establishing programs for advanced practice nurses during entry into practice.

Additionally, nurse researchers argue that NPs, who receive structured orientations, have

easier and quicker transitions and are more satisfied with the role.12,19 This result aligns

with the increased interest in structured orientations and support for new NPs across

healthcare settings,12,19,20,25 and may help to support efforts to develop orientation

programs for NPs.

In contrast, prior RN experience was neither a promoter nor inhibitor of NP role transition.

Of note, caution is needed when making conclusions about this finding, as there is

conflicting results in the literature on the influence of prior RN experience. For example,

previous NP-focused research highlights the importance of RN experience and suggests that

it is beneficial to NP role transition.1,3,28 However, studies have reported that new NPs

found NP clinical experience to be beneficial during role transition.8,9 This finding adds to

the body of NP role transition research and may be of use in informing and helping to frame

the discussion on providing the appropriate experiences to NPs.

Alternatively, the relationship between prior RN experience and NP role transition may not

be solely explained by the amount of RN experience but also the type of RN experience

gained. NP role transition may be influenced by similarities or differences between the

practice settings of an individual’s RN role and subsequent NP role, such as transitioning

from an inpatient RN role to an outpatient vs. an inpatient NP role. Perhaps exploring these

specific relationships would reveal different results in future research.

The multiple regression model did not explain much of the variance in the dependent

variable (9%), and only a formal orientation contributed significantly (Table 3). Therefore,

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the possibility that 91% of NP role transition is explained by other unidentified factors must

be considered. The available literature recounts similar NP role transition experiences,8–10,28

and these experiences are reported during transitions to outpatient1 and inpatient3,14 settings.

However, in the present sample, family NPs were primarily represented, and the majority of

participants practiced in the outpatient setting (Table 1). Exploring the transition experiences

across the different population foci and practice settings, in which NPs are trained and

employed, may help to identify additional factors that promote NP role transition. These

factors could include the number of precepted clinical hours, curricular content, the amount

of mentorship provided, orientation length, the availability of resources, and collegial

support.

Implications

The results of this study could have implications for NP practice, education, and

administration. The Consensus Model for APRN Regulation: Licensure, Accreditation,

Certification, and Education29 addresses the growing number of practicing NPs and their

value in the healthcare system through efforts to align NP education, accreditation, and

licensure. With the knowledge of what affects role transition for individuals with varying

amounts of experience, NP educators could tailor clinical requirements and placements in

preparing NPs for practice. This is particularly timely as schools of nursing currently admit

students into MSN30 and Doctor of Nursing Practice31 programs with no prior practice

requirements.

Additionally, knowledge about the positive relationship between a formal orientation and

NP role transition may encourage administrators to explore hiring and orientation policies

and could provide the necessary support for wider development of these programs.

Implementation of orientation programs could lead to the establishment of environments that

are best suited to support NPs during role transition and may drive highly-qualified

candidates to specific institutions and positions.20 Whether these environments include

hospitals, private practices, or community-based health clinics, helping NPs transition into

practice more smoothly and effectively could improve NP satisfaction with the role, as well

as increase the retention of highly-qualified NPs.12

Limitations

This study used cross-sectional, self-report data; thus, causal relationships among the

variables cannot be established. Also, NP role transition was measured at one time point,

and measuring samples of NPs at various times during the transition may reveal different

results. Participants in this study had varying years of NP experience. With increasing years

since the transition, some participants may not accurately remember their NP role transition

experiences and may have forgotten the positive or negative aspects of the transition.28

Finally, the sample did not include all practicing NPs. Only NPs, who were in attendance at

the conference and were motivated to complete the questionnaire, were included for

participation.

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Conclusions

This is the first study to provide empirical data on NP role transition in relationship to prior

RN experience and receiving a formal orientation in the first NP position; it provides a

foundation for future research on this topic. The results are unexpected and interesting as NP

role transition had a non-significant relationship with prior RN experience, and the two

independent variables explained only 9% of the variance of NP role transition. Future

research is needed to examine these relationships further in order to separate out the details

of these variables, as well as identify additional factors that provide the best support to new

NPs. With different pathways to entry into practice, it can be expected that there will be

NPs, who will enter the role with limited or no prior RN experience. Understanding the

difference of the transition to the NP role in an individual, who has had RN experience

versus someone who has not had any RN experience, is important, because these NPs may

differ in their needs for support during the transition period. Determining those factors that

may account for the remaining unexplained variance is prudent as it is expected that NPs

will play an increasingly larger role in the nation’s healthcare system.

Acknowledgments

Funding Sources: This study was partially funded by Sigma Theta Tau International, Eta Beta Chapter, Widener University School of Nursing, Chester, PA. Manuscript preparation was supported by the National Institute of Nursing Research, National Institutes of Health under award number T32NR007104, Advanced Training in Nursing Outcomes Research (Aiken, PI). Neither funding source influenced any aspect of this study or manuscript submission.

The author thanks the American Association of Nurse Practitioners for assisting with the data collection. The author appreciates comments and edits provided by Dr. Matthew McHugh and Myra Eckenhoff. This study was supported with funding from Sigma Theta Tau International, Eta Beta Chapter, Widener University School of Nursing, Chester, PA.

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12. Sargent L, Olmedo M. Meeting the needs of new-graduate nurse practitioners: a model to support transition. J Nurs Adm. 2013; 43(11):603–610.10.1097/01.NNA.0000434506.77052.d2 [PubMed: 24153203]

13. Benner, P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Upper Saddle River, NJ: Prentice Hall; 2001.

14. Fleming E, Carberry M. Steering a course towards advanced nurse practitioner: a critical care perspective. Nurs Crit Care. 2011; 16(2):67–76.10.1111/j.1478-5153.2011.00448.x [PubMed: 21299759]

15. Rich ER. Does RN experience relate to NP clinical skills? Nurse Pract. 2005; 30(12):53– 56.10.1097/00006205-200512000-00009 [PubMed: 16344710]

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22. Cusson, RM.; Strange, SN.; Conelius, J.; Duran, B.; Merkle, D.; Mokel, M. Development and testing of a scale to measure nurse practitioner role transition. Storrs, CT: University of Connecticut, School of Nursing; 2011.

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25. Bahouth MN, Esposito-Herr MB. Symposium. Orientation program for hospital-based nurse practitioners. AACN Adv Crit Care. 2009; 20(1):82–90.10.1097/NCI.0b013e3181945422 [PubMed: 19174640]

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Licensure, accreditation, certification, & education. Jul 8. 2008 https://www.ncsbn.org/ Consensus_Model_for_APRN_Regulation_July_2008.pdf

30. American Association of Colleges of Nursing. Schools Offering Master’s for Nonnursing College Graduates. [Accessed November 5, 2014] (Entry-level/2nd Degree Master’s) Programs. Fall. 2013 http://www.aacn.nche.edu/research-data/GENMAS.pdf

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Highlights

• This study examined factors believed to affect NP role transition.

• A positive correlation exists between a formal orientation and NP role transition.

• Registered nurse experience did not explain NP role transition.

• Future research is needed to identify more factors that influence this transition.

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Table 1

Demographic Data and Characteristics of the First NP Position (N = 352)

Demographic Statistic

Age (n = 350)

Mean (SD) 47.31 (10.05)

Range 25–70

Gender (n = 352)

Female (%) 88.6

Race (n = 351)

White (%) 81.8

Black/African-American (%) 9.4

Highest Nursing Degree (n = 352)

Master of Science in Nursing (%) 86.6

Doctor of Nursing Practice (%) 10.2

Years of NP Experience (n = 352)

Mean (SD) 7.67 (5.94)

Range 0.5–23

Characteristics of the First NP Position

Population Focus (n = 338)

Family/Individual Across Lifespan (%) 47.9

Adult-Gero Primary Care (%) 19.2

Adult-Gero Acute Care (%) 12.7

Pediatrics/Neonatal (%) 2.4

Women’s Health/Gender-Related (%) 1.8

Psychiatric/Mental Health (%) 1.2

Practice Setting (n = 343)

Outpatient/Private Practice Office (%) 57.1

Inpatient/Hospital/ICU/Neonatal ICU (%) 15.2

Emergency/Urgent Care/Retail Clinic (%) 9.9

Nursing Home/LTC/Rehabilitation (%) 5.2

Note. Some categories are not included in the table. NP = nurse practitioner; SD = standard deviation; ICU = intensive care unit; LTC = Long-term care.

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Table 2

Descriptive Statistics for Study Variables

Variable N = 352

Years of Prior RN Experience

Mean (SD) 13.75 (8.54)

Range 0–38

Formal Orientation

Yes (%) 116 (33.0)

No (%) 236 (67.0)

NP Role Transition (total NPRTS scores)

Mean (SD) 48.92 (10.25)

Range 23–77

Note. RN = registered nurse; SD = standard deviation; NP = nurse practitioner; NPRTS = Nurse Practitioner Role Transition Scale.

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al O

ri en

ta tio

n (y

es =

1 )

6. 24

1. 11

.2 9

5. 61

.0 00

Pr io

r R

N E

xp er

ie nc

e −

.0 1

.0 1

− .0

8 −

1. 56

.1 2

N ot

e. N

P =

n ur

se p

ra ct

iti on

er ; R

N =

r eg

is te

re d

nu rs

e.

J Nurse Pract. Author manuscript; available in PMC 2016 February 01.