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THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 1
The Professional Identity of the Nurse Practitioner: A Mixed Methods Study
Soohee Karamichos
MSN, University of Massachusetts- Boston 2010
BSN, University of Pennsylvania 2006
Dissertation Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Philosophy
Oklahoma City University- Kramer School of Nursing
April 12, 2023
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 2
Table of Contents
Abstract …………………………………………………………………………………………..7
Chapter 1 Introduction …………………………………………………………………………...8
Background and Significance …………………………………………………………...10
Problem Statement ……………………………………………………………………....13
Purpose of the Study ………………………………………………………………….....14
Research Question ……………………………………………………………………....14
Definition of Terms ……………………………………………………………………..14
Assumptions …………………………………………………………………………….16
Summary ………………………………………………………………………………..16
Chapter 2 Literature Review ……………………………………………………………….……17
Sources of Literature ……………………………………………………………………………18
Professional Identity …………………………………………………………………………….18
Nurse Practitioner Role and Professional Identity ……………………………………………...19
Meleis’ Transition Framework and Transition to the Nurse Practitioner Role …………………22
Situational Transition……………………………………………………………………24
Organizational Transition ……………………………………………………………….25
Parse’s Human Becoming and Professional Identity ……………………………………………28
Freely Choosing Personal Meaning and Value of the Nursing Discipline ……………...29
Cocreating a New Rhythm in the Practice Environment ………………………………..31
Cotranscending the Hierarchical Medical Model to a Transdisciplinary Model ………..34
Summary of Literature …………………………………………………………………….……..35
Hypothesis ……………………………………………………………………………………….37
Chapter 3 Methodology …………………………………………………………………….…....38
Design …………………………………………………………………………………...39
Data Integration ……………………………………………………...…………40
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 3
Interpretation and Reporting …………………………………………...……….41
Advantages and Disadvantages of Mixed Methods ……………………………………..41
Population and sample ……………………………………………….…………………………..42
Inclusion and Exclusion Criteria ……………………………………………………...…42
Ethical and Legal Consideration ……………………………………………………….…..…….43
Instrument ………………………………………………………………………………….…….43
Setting …………………………………………………………………………………………....44
Data Collection Plan ………………………………………………………………………....…..44
Chapter 4 Results ……………………………………………………………………….………..46
Quantitative Findings ……………………………………………………………………46
Questionnaire………………………………………………………………………..…...46
Instrument reliability ………………………………………………..…46
Data Collection …………………………………………………..…….47
Data Analysis …………………………………………………..………47
Categorical Data ………………………………………………………..………47
Continuous Data ………………………………………………………..………48
Research Question ………………………………………………..……49
Test of Hypothesis ……………………………………………………...………49
Additional Findings ……………………………………..………..……50
Summary of Quantitative Findings …………………………………...…...……51
Qualitative Analysis …………………………………………………………………..…51
Study Method …………………………………………………………………...51
Management of Researcher Bias …………………………………..…..52
Study Procedure ………………………………………………………….....…..53
Participants …………………………………………………………....……..….53
Qualitative Findings …………………………………...………………………..54
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 4
Thematic Findings………………………………………………………………55
Theme 1: Value of Caring ………………………………………...…...55
Subtheme: Relationship with Patients ……………….....……..55
Subtheme: Relationship with Nurses…………………...…...…56
Subtheme: Relationship with Physicians ……...………...…….56
Subtheme: Relationship with Administrators ………......……..57
Theme 2: Attitude of Confidence and Caring ………………..……...…58
Subtheme: Autonomy and Trust …………..….……………….58
Subtheme: Mentorship ………………………..….………...….60
Theme 3: Belief that Nursing is the Core of NP Identity ………..….....60
Subtheme: Holistic Care………………….………...………….61
Subtheme: Transcending the Medical Hierarchy……..….…....62
Qualitative Summary ………………………………………………...…………63
Mixed Methods Findings………………………………………………………..……….64
Integration of Data ………………………………………………...……………64
Summary of Mixed Methods Findings ………………………………...…….…65
Chapter 5 Discussion ………………………………………………………………………....….67
Mixed Methods Study Review ……………………………………………….………….67
Demographic of Quantitative Participants ……………………………...………68
Demographic of Qualitative Participants ………………………….…....………69
Quantitative Findings ………………………………..................................................…..69
Qualitative Findings ……………………………………………………………...….…..70
Value Theme ……………………………………………...……………....…….72
Attitude Theme ………………………………………………………...……….74
Belief Theme ………………………………………………………...……….....76
Mixed Methods Findings ………………………………………………………….…….78
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 5
Limitations ………………………………………………………………………….……..……..81
Implications and Recommendations ……………………………………………………….……81
Recommendations for Future Research …………………………………...…………………….82
Conclusion ………………………………………………………………………………………82
References ………………………………………………………………………………….……85
Appendix A: Explanatory Sequential Design…………………………………….…...….………94
Appendix B: Quantitative Survey……………………...………………………………...……….95
Appendix C: Cronbach Alpha Analysis.……………………….……………...………...………..96
Appendix D: Cronbach Alpha for the MCPIS-9.……………………………………...…….……97
Appendix E: Categorical Demographic Data.……………………………………...……………..98
Appendix F: MCPIS-9 Frequencies.…………………………..……………………….….…….101
Appendix G: Test of Normalcy.……………………………………..…………….……….……102
Appendix H: Kruskal Wallis Results.………………………….…………………….……….....103
Appendix I: Pairwise Comparison.…………………………………………………….………..104
Appendix J: MCPIS-9 Total and Years of Experience Graph.………………………..….….….105
Appendix K: Spearman’s Rho for MCPIS-9 and Years of RN Experience...……………….….106
Appendix L: T- test Score for Gender and MCPIS-9.……………………………………….….107
Appendix M: Between Subject Data.……………………..…………………...……………..….108
Appendix N: Qualitative Interview Guide.………………………….……………….………….109
Appendix O: Qualitative Value Theme………………………………………..……….……….110
Appendix P: MCPIS-9 Question Correlation Qualitative Question……………..………..…….111
Appendix Q: MCPIS-9 Frequencies………...…………………………………….…………….112
Appendix R: MCPIS-9 Qualitative Interview Guide and In Vivo Excerpt…..……...………….113
Appendix S: The Informed Consent Document Template – Adults…………..………………..118
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 6
Acknowledgments
I would like to thank my committee members Dr. Cheryl Frutchey, Dr. Dia Campbell-
Detrixhe and Dr. Danna Weathers for their time, effort, and encouragement. I am inspired by the
depth of knowledge and expertise these women possess.
I would also like to thank my family for supporting me through this degree. I am certain I
would not be who I am or where I am without you.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 7
The Professional Identity of the Nurse Practitioner: A Mixed Methods Study
Abstract
The study explored what is the level of professional identity of the nurse practitioners and what
values, attitudes, and beliefs make this profession unique. A stable professional identity has been
cited as beneficial in preventing burn out and to improve job satisfaction, yet the level and crucial
qualities of nurse practitioner remain undefined. The role transition of the nurse practitioner was
explored using Meleis’ Transition Theory and the transformation of the professional identity from
a nurse to a nurse practitioner was assessed using Parses’ Theory of Human Becoming. An
explanatory sequential mixed methods approach was chosen to explore the complex question of
professional identity. The quantitative portion was done through an online survey using the
Macleod Clark Professional Identity scale (MCPIS-9). The quantitative data was collected and
analyzed first. The qualitative component came after analysis of the quantitative section. The
qualitative participants were chosen from the quantitative pool. Guiding questions were
formulated from the MCPIS-9 to conduct a hermeneutic phenomenological study. The findings
indicate an overall positive professional identity. Contrary to previous studies, this study suggests
that the lowest period of professional identity occurs in nurse practitioners between 11 and 15
years of experience rather than in students or nurse practitioners with less than five years of
experience. The data from the qualitative interviews supported findings in previous studies by
Faraz (2016) and Han (2018). Extrinsic factors of administrative support, collegial relationships
and practice authority could be sources of support or hinderance. The nurse practitioner does not
align to the hierarchy but acknowledges the existence of a medical hierarchy. The nurse
practitioner report viewing an even field where physicians and nurses are colleagues, and no
profession is superior. The professional identity of the nurse practitioner is consistently identified
as a clinical provider who offers holistic, and patient centered care. The nurse practitioner
continues to feel rooted in the nursing discipline and use medical knowledge in addition to, not in
place of nursing discipline.
Keywords: nurse practitioner, nursing, profession, professional identity, interprofessional relationships, transdisciplinary, nursing theories, practice authority, scope of practice,
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 8
Chapter 1 Introduction
The Professional Identity of the Nurse Practitioner: A Mixed Methods Study
Professional identity (PI) is not the same as professionalism. Professionalism is the
expected behaviors of a professional while PI is one’s own decision and adoption of those
expectations (Katz, 2013). The PI of a person includes the internalization of “the attitudes, values,
knowledge, beliefs and skills” shared within a profession (Adams et al., 2009, p. 56). PI develops
before the education period and is constantly reshaped through the career implying an ability to
reinforce and advance the PI (Kristoffersen, 2021). Kristofferson also notes that PI is considered a
breakdown of one’s unique individuality and embracing the non-conformed PI within a
profession’s ideology resulting in a change of self -identity (2021). Professional identity
development is influenced by the education and work environment of the nurse (Gigger &
Godfrey, 2014); it is context-dependent and evolves with changes in knowledge and the
workplace (Fitzgerald, 2020). The formation of the nurse practitioner (NP) PI incorporates
transition as identities move from an individual state to a collective state that reflects the NP
profession.
The struggle to define a PI is not unique to nursing practice. The goal of a profession is to
distinguish itself from other professions through a defined identity (Janke et al., 2021). Janke et
al. (2021) argued that healthcare professionals share similarities such as compassion, sk ill, and
critical thinking, but a profession needs to identify what makes it unique. In pharmacy, it is the
ability to optimize medication use. In law, lawyers attempt to define their PI by solving the
discourse between the ethical expectation for candor and a need to develop a defense strategy.
Law PI is distinguished by the ability to deliver an ethical defense of their client (Katz, 2013).
School principals have a PI which is defined by the political and academic influence to improve
student outcomes (Cruz-Gonzalez et al., 2021). The common theme throughout the description of
PI, regardless of profession, is that a person’s identity is ever-changing and in a state of transition
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 9
and is defined and developed with society’s input (Adams et al., 2009 ; Cruz-Gonzalez et al.,
2021; Janke et al., 2021; Katz, 2013).
The NP PI has a common expectation in skills and knowledge, but these do not help
define the attitudes, beliefs, or values of the NP. The technical aspects of the PI are defined by the
International Council of Nurses [ICN] as a registered nurse generalist or specialist who has
developed expert knowledge and skills through advanced education (at least a master’s degree) to
practice as an advanced registered nurse practitioner in the specialty in which they are
credentialed (2020). Examples of such credentialing include certified nurse midwives, clinical
nurse specialists, certified nurse anesthetists, and nurse practitioners. For this study nurse
practitioners will be referred to as NPs.
The American Nurses Association [ANA] describes NP skills as the ability to treat and
diagnose, advise the public, and manage chronic diseases. NPs are also expected to remain
current on evidence-based practice changes through continued education. These individuals
are initially licensed as registered nurses (RN) and have attained at least a master’s degree
(American Nurses Association [ANA], n.d). The National Council of State Boards of Nursing
[NCSBN] also describes the role of the NP as a nurse with a master’s degree who can
diagnose, treat, order tests, and prescribe (National Council of State Boards of Nursing
[NCSBN], 2022). The Merriam-Webster dictionary defines the NP as “a registered nurse who
is qualified through advanced training to assume some of the duties and responsibilities
formerly assumed only by a physician” (Merriam Webster, 2022).
The limited description of skills and education – bring to light an unusual problem
within the NP profession; what makes the NP’s attitude, beliefs, and values unique? What is the
PI of an NP who remains inclusive of the knowledge, roots, norms, and morals, which
represent the traditionally understood role of the nurse (Lowe, 2016, Paragraph 1) yet practices
the skills traditionally reserved for physicians?
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 10
Background and Significance
According to the American Association of Nurse Practitioners [AANP], there are more
than 325,000 nurse practitioners in the United States alone (American Association of Nurse
Practitioners [AANP], 2021. Updated May 2021). This number does not include the other
advance practice degrees such as certified nurse midwives, certified nurse anesthetists, or clinical
nurse specialists. Despite increasing numbers of NPs in practice or expected to graduate from
their respective program, the expected need for practitioners will still fall short of the available
supply of NPs by as much as 20% by the year 2025 (Sargen et al., 2011). This occurrence has
been attributed to a higher attrition rate in practicing NPs (12.6%). This is twice the attrition rate
of physicians (Han et al., 2018).
Professional identity (PI) is important because the loss of NPs by attrition impacts
society and risks suboptimal outcomes in patient care, and negatively impacts the quality of life
(Kapu et al., 2021). One area that may significantly influence NPs' attrition rates is the
development of a PI. A benefit of a stable PI would help unify the NP profession on how to
practice and represent the profession to a healthcare team. NPs deliver care at a similar level
to their physician counterparts but are dismissed by nurses who do not understand the role
(Kippenbrock et al., 2019). Intrinsic factors such as autonomy, ability to deliver quality care,
accomplishment, and a sense of challenge were positive factors for satisfaction; while extrinsic
factors like policy, practice environment and compensation tend to contribute to higher
dissatisfaction (Han, 2018). The personal internal factors reflect the attributes, beliefs, and values
of the NP. The extrinsic factors are more organizational or societal. Both personal and societal
transitions are needed to accomplish a fully developed PI.
Previous research suggests that a strong PI is a good predictor of job retention in the
nursing profession. Research also supports that the development of PI may influence job
satisfaction and retention (Wu et al., 2020). PI development involves the internalization of the
values and norms of a profession (Janke, 2021). Much of the available research is focused on job
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 11
satisfaction and retention while not addressing the root of the problem (Han et al., 2018).
Education, experience of the transition into NP practice, interprofessional relationships, and
various practice rights expose the NP to the values and norms of the role.
Professional identity (PI) is important to the NP role, yet no study has shown the current
state of PI among NPs. What research that has been conducted on PI and NPs has been limited to
the use of the PI as a dependent variable to study job satisfaction and turnover rates (Auffermann
et al., 2020), the reflection of responsibility, trust, and accountability (Jakimowicz et al., 2017),
professional socialization (Zarshenas et al., 2014), integration into a healthcare team (Poghosyan
et al., 2017) and role transition (Kelley & Mathews, 2001). All the studies assume an established
PI reflected in the different variables of role transition, job satisfaction, responsibility, and
professional socialization. Researchers assume that NP PI is stable based on years of experience
due to increased career mobility, job satisfaction and job retention among more experienced NPs
(Auffermann et al., 2020). There is also a belief that NP PI simply increases with the years of
experience because of increased skill proficiency (Kelley & Mathews, 2001). However,
understanding the role of the NP does not equate to understanding the PI of the NP. There is no
such research to show the status of PI among NPs; whether it is low or high and when this level
varies or stabilizes. PI as an independent factor can show how other variables can improve or
stunt the change and to what degree.
There are established scales available to measure PI such as Macleod Clark Professional
Identity Scale (MCPIS-9). Adams et al. (2009) explored the concept of professional identity as an
independent variable leading to the development of the MCPIS-9 which measures a professions’
identity; however, the focus was on nursing and other health care fields, but not on the NP. This
scale can be used to explore the current degree of professional identity experiences by practicing
NPs. However, such research has not been undertaken.
The concept of role transition is central to professional identity. The NPs identity changes
from the previous RN role by virtue of a transition in level of education, responsibility, and
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 12
patient care. The transition period, which begins at the start of the education into the advanced
practice role continues beyond graduation. Transition are ongoing processes with no set ending.
Though there is no designated endpoint, the greatest period of transition and turmoil is the first
two years after graduation (Barnes, 2015). Transitions reflect a shift in both the professional role
of the NP, but also society’s view of the NP.
The quality of personal and societal transition can impact the PI in both a negative and
positive manner. A negative transition can lead to a lack of PI and leave the NP profession open
to burnout and increased attrition rates. Other professions such as teaching, have shown
correlations between burnout and professional identity. According to Chen et al. (2020),
individuals with high PI had a clear understanding of the work, and acceptance of the nature of
the profession which allowed them to maintain a positive outlook thus achieving a decreased rate
of job burnout. Negative transitions also lead to increased tension within professional
relationships. The transition impacts their previous relationships with physicians, allied health
team members and even other NPs. In some instances, NPs notice an initial opposition to their
roles from allied team health, but the resistance from their nursing colleagues can garner feelings
of betrayal in the NPs (MacLellan et al., 2016). The resistance from their nursing colleagues
increases the sense of departure from the nursing discipline. Negative transitions widen the
schism between NPs and the nursing discipline.
Positive transitions and stable PI can lead to an appreciation of the NP role. A qualitative
study by Thompson and McNamara (2021) showed NPs are viewed as valuable because they are
a permanent fixture within the organization, where doctors may transition to other locations
throughout their residency, and NPs offer quality care. Positive role transition also supports an
NP’s autonomy and confidence and allow the practitioner to help with the transformation of the
healthcare system. The NP role is marginalized as not a nurse or physician and thus not fitting
into a hierarchal model. Delvin et al. (2018) argues that this is the ideal position for the NP who
can view the innerworkings of the healthcare system but stay relevant to society and the
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 13
underserved population which is equally marginalized by the current system; NPs can bridge this
gap. This aspect of promoting social justice through equal access to care is rooted in nursing’s
philosophy of health equality (Delvin et al., 2018). Positive transition helps reflect the nursing
discipline within the NP role.
PI is challenged by transition in role from registered nurse to NP. Improving the quality
of transition into the NP role will help with job satisfaction, retention and translation to patient
care access and safety (Owens, 2019). The quality of the transition will also influence
interprofessional relationships by better defining the role. The lack of uniformity in the NP
identity, makes the NP role seem diffuse and unclear lowering its acceptance among healthcare
teams (Ljungbeck et al., 2021). Lower acceptance of the NP role hinders the ability to justify
expansion of practice authority and scope of practice. Professional identity, which has a
component of knowledge and skill is used to gauge the ability of the practitioner and thus the
autonomy to practice. Practice authority (level of autonomy) is a predictor of ANP job
satisfaction and yet legislators, the public, hospital administrators, and even NPs cannot agree on
how to define autonomy (Peacock & Hernandez, 2020). To increase retention and improve
patients’ access to care, it is helpful to understand the PI of practicing NPs and how the various
aspects of PI are perceived by NPs.
Problem Statement
Literature states PI is important to job satisfaction and retention of the NP thus patient
access to care (Delvin et al., 2018; Han et al., 2018; Kristoffersen, M., 2020; Lowe et al., 2011),
yet there lacks an exploration of the current state of NP professional identity and the perception of
the NP identity. We do not know the current state of the NP PI. This leads to misunderstanding
and underutilization of the NP (Andregard & Jangland, 2015). The lack of information then limits
how organizations and universities can help or support the PI development in NPs. The NP feels
unsupported and underappreciated which increases risk of attrition which worsens patients’
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 14
access to care. To break this cycle, there must be a firm PI to define the professions’ abilities,
education, and contribution to society.
Purpose of the Study
The purpose of the study is to explore the current state of PI of practicing NPs and to
explore the NPs perception of the PI after transition from registered nurse to NP. PI will be
explored using Parse’s Theory of Human Becoming and measured with the MCPIS-9 scale.
The framework of Dr. Meleis’ transition model will explore the role transition.
Research Questions
What is the current state of PI among practicing nurse practitioners? Do NPs perceive a
defining PI?
Definition of Terms
Nurse Practitioner (NP). NP is a category of advanced practice nurses defined as
“one who has acquired, through additional education, the expert knowledge base, complex
decision-making skills and clinical competencies for expanded nursing practice, the
characteristics of which are shaped by the context in which they are credentialed to practice”
(International Council of Nurses [ICN], 2020, p. 9). Nurse practitioners are one of four
recognized categories within the advanced practice nurse including the clinical nurse specialist
(CNS), certified registered nurse anesthetist (CRNA), nurse mid wives and the nurse
practitioner (International Council of Nurses [ICN], 2020). This study focused on the nurse
practitioner role also known as the NP.
Professional Identity (PI). PI is defined as “the attitudes, values, knowledge, beliefs
and skills” shared within a profession (Adams et al., 2009, p. 56).
Transition. The concept of transition is defined as a “passage or movement from one
state, condition, or place to another” (Shumacher & Meleis, 1994, p. 119). Schumacher and
Meleis identified four types of transitions which are developmental, situational, organizational,
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 15
and health-illness. There was a focus on situational and organizational transitions which apply to
the change from RN to NP.
• The situational transition encompasses professional and educational passage and reflects the
individual NP’s transition.
• Organizational change is systemic and includes political and administrative changes, which align
with the social transitions.
Society. Society is defined as a group of people who share laws, traditions, customs,
and values often living in the same country, having the same interests or beliefs, or sharing a
profession (Merriam-Webster, 2022).
Nursing Discipline. A discipline is “distinguished by its domain of inquiry, a specific
area of study, and defined by its social relevance and value orientation” (Woods, 2020, p. 51).
Nursing discipline is defined as a concern with the relationship among humans, health, and the
universe (2020).
Practice Authority. Practice authority (PA) is a legislative concept reflecting the ability
of a profession (in this case NPs) to practice knowledge, skills, and judgment to the fullest extent
of their education and training regarding the level of oversight (American Nurses Association
[ANA], 2020). Full practice authority allows NPs to practice independently without physician
oversight, reduced practice requires physician collaboration while restricted practice required
physician oversight.
Scope of Practice. Scope of practice (SOP) is defined by the American Nurses
Association [ANA] (date) as a qualified service that can be performed by a group of professionals
(in this case NPs), to practice nursing whenever there is a patient in need of nursing services
because nursing has a social obligation to promote positive patient outcomes (n.d.).
Transdisciplinary. Transdisciplinary is defined as a holistic view that “subordinate
disciplines, looking at the dynamics of a whole system” and includes non -medical disciplines
(Choi & Pak, 2006, p. 355).
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 16
Assumptions
This research study included several assumptions:
• Nursing discipline remains the root of the nurse practitioner profession.
• A previous professional identity is changed during the transition into a new role leading to a
new professional identity as an NP.
• Transition precedes changes to professional identity.
• PI is fluid and ever-changing because transitions are occurring constantly.
Summary
PI is important to NPs job satisfaction and retention. NPs’ PI is not well
understood. The misunderstandings may be organizational, societal, variability in education and
practice authority, or the stress of the role transition. The PI and the perception of PI among
practicing NPs was explored to see if there are identifiable and modifiable variables to develop
PI.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 17
Chapter 2 Literature Review
Professions have an obligation to society and require “scholars, investigators , and
researchers who work to continuously advance the knowledge of the profession to improve
practice” (McEwen & Willis, 2019, p. 2). A profession consists of people educated in a
discipline following the rules of regulating bodies (such as the Board of Nursing) and practicing
within the scope of state and federal guidelines (Rizzo Parse, 1999). The NP profession has a
standard for credentialing and education that helps regulate and protect the profession, the title,
and the quality of care to the public (International Council of Nurses [ICN], 2020). Despite the
accepted definition of the profession, the professional identity (PI) remains inconsistent.
PI is a unique variable because it reflects a person’s ability to relate to a profession’s
“attitudes, values, knowledge, beliefs, and skills” (Worthington et al., 2013, p. 187). PI is a
unique and subjective variable because it reflects a person’s ability to relate to a profession’s
“attitudes, values, knowledge, beliefs and skills” (Worthington et al., 2013, p. 187). The
landmark study from Adams et al. (2006), discussed the development of a MCPIS-9 based on
the Social Identity Theory which believed that people can occupy multiple identities, but that
professional identity can be the most defining. The conflict in PI for NPs exists with which
attributes of PI to ascribe to as the practitioner transition from registered nurse (RN) to NP.
The process of transition triggers a change in PI. Nurse practitioners must use the skills of the
medical model to diagnose, treat and assess patients, while simultaneously continuing to
practice the nursing discipline. This utilization of medical skills is at odd with the nursing
profession which is more focused on the person (Trotter, 2019).
The available research on nursing PI indicates a stronger PI translates to increased job
satisfaction and better psychological wellbeing (Joseph et al., 2021). Conversely, a lack of PI
can decrease the perceived value of a profession and weaken practice specific paradigms leading
to a focus on the profession’s ability to fill gaps rather than the ability to represent a discipline
(Matthews et al., 2019). However, there is no research showing a measured level of PI among
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 18
NPs. Without understanding how PI varies among practicing NPs, interventions cannot be
tailored to improve job satisfaction and retention. The research aimed to fill a gap on what
practicing NP perceive as their PI. This is an important first step to identity key features that are
common to practicing NPs. The data can be used to guide education and practice to help new NPs
define a PI upon graduation. The NPs can then use the identifying factors to educate society on
why the NP role is unique and necessary.
The act of role transition was investigated using Meleis’ transition framework. Upon
transition, the PI of the NP is changed. The NP must then learn to navigate this new identity and
how it connects to the nursing discipline, other healthcare colleagues and the hierarchal medical
model. Transitions trigger a PI change, but it does not guarantee a stable PI. The concept of PI
and how the NP perceives the change was explored using Parse’s theory of Human Becoming.
Sources of Literature
The review of the literature was done through PubMed, OVID, CINHAL, Google
scholar, various books and library article searches on the internet using the terms: professional
identity, nursing discipline, nurse practitioner, nursing, nurse practitioner, transition, and role
change. Articles were limited to five years (2016-2021) with exceptions made to landmark
articles or articles which were referenced often within the current literature. A thematic approach
was taken to the literature review.
Professional Identity
Professional identity (PI) is a component of social identity and contains “the attitudes,
values, knowledge, beliefs and skills” shared within a profession (Adams et al., 2009, p. 56).
Adams et al. (2009), believes that multiple social identities can coexist, but PI is the most
significant and salient identity. Kristoffersen (2021) explains identity as oneness or uniqueness in
value or belief that is shared within a profession. Both Adams and Kristofferson highlight those
multiple identities coexist, but PI is defined by shared skills, values, and uniqueness within a
profession. PIs are affected by political, cultural, and historical realities that surround them and
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 19
are influenced by societal expectations (Fitzgerald, 2020). Changes in role and PI not only
impacts the NP, but has a ripple effect prompting changes to policy, culture, and society.
The PI changes when the RN transitions to the NP role, but the personal identity of
being a nurse first should remain steadfast. The NP PI changes during the education process
because new, medically oriented skills are introduced. It is the perception of many nurses that
the role of NP medicalizes the nursing discipline while physicians perceive that NPs encroach
in their traditional medical domain and question the ability of the NP to deliver quality care
(Delvin et al., 2018). A PI that highlights the nurse within the NP role can guide practice.
These skilled providers are nurses first.
The PI was measured using a validated tool. The chosen scale was the Macleod-Clark
Professional Identity Scale (MCPIS-9) which was developed by Adams et al. (2009) to address a
gap in knowledge on when to introduce professional identity formation topics in education. The
tool evaluated health and social care students’ connection to their chosen profession . The
MCPIS-9 scale identified a disconnect between the ideal and practiced version of a profession
among students. Though other tools to measure PI exist, the MCPIS-9 was chosen for the short
length which would increase the chances of completing the scale by practicing NPs with limited
time. A review of psychometric properties of various PI scales by Matthews et al. (2019),
indicates the MCPIS has been widely used in the health professions and thus has a large body of
evidence to support its use. The MCPIS-9 was specifically validated for use in the nursing
profession by Worthington et al. (2013).
Nurse Practitioner Role and Professional Identity
Nurse practitioner (NP) role is often defined through the skills, knowledge base, and
clinical competencies (American Nurses Association [ANA], n.d.; International Council of
Nurses [ICN], 2020; National Council of State Board of Nursing [NCSBN], 2020). Though the
professional definition of the NP role is uniform among most organizations, these definitions
do not define how the transition in role challenges the intangible factors like attitudes, beliefs,
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 20
and values. Interestingly, previous years of RN experience has not shown to be a significant
factor for success in an NP program (Barnes, 2015; El-Banna et al., 2015). It is not known if the
RN experience does not translate to the NP role because the roles are different or if the new
NP does not know how to utilize the nursing experience in a medical model. Do NPs still share
in the nursing discipline root upon graduation?
The NP profession must remember that it is guided by the discipline of nursing. The
discipline of nursing encompasses the phenomenon of interest which is the human-universe-
health process (Rizzo Parse, 1999). Discipline-specific knowledge helps allows the nursing
profession to have a unique identity rather than an extension of medical science (Rizzo Parse,
1999). Nursing specific values of “human dignity, integrity, autonomy, altruism and social
justice” aim to guide the character development of nurses (Fahrenwald et al., 2005, p. 46). These
nursing core concepts are an essential portion of the NP nurses' professional identity and can
be reinforced or weakened by the NP education. However, the NP’s introduction to the
professional identity role is often medically oriented (Andregard & Jangland, 2015). Newly
practicing NPs develop an allegiance to the medical model way of thinking while rating nursing
models as less important than medical models for practice (Wilson et al., 2015). The NP does not
only look at the heart or the lungs, but looks at the whole person (Trotter, 2019). The respect of
the whole person is what makes the NP service invaluable to the public. There is an opportunity
to reinforce the core identity of nursing during the role transition to prevent the loss of the nursing
discipline in favor of the medical model.
To understand the NP role, it is important to highlight that the NP role was created to
improve patient access to care. The NP role was designed by Dr. Loretta Ford (1997) to be an
autonomous primary care provider who practiced holistic care in congruence with nursing
philosophy. The NP profession was developed to address a shortage of primary care physicians
(Lowe et al., 2011). The NP role unintentionally created a threat to the medical profession's
scope of practice and market. The NP’s connection to nursing discipline exposes it to a conflict
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 21
in a traditional medical hierarchy. Traditional hierarchical models value physicians at the top
and nurses at the bottom. NPs are often considered “mid-level” providers who practice at a
level above the role of the staff nurse, but below physicians. This misnomer leaves the NP
feeling less than and increases the misunderstanding of the role within society (Dirubbo, 2019).
This also causes confusion among colleagues on how to categorize the NP role. Misunderstanding
of the role risks the NP being underutilized and undervalued which perpetuates the cycle or poor
PI leading to low retention. Healthcare providers such as NPs “must understand their own role
before they can work successfully together” (Meyer et al., 2015, p. 803).
The NP profession must demonstrate the value to the health care consumers (public). NPs
functioning as primary care providers have comparable interventional outcomes and are just as
safe and effective in providing care as their physician counterparts. In addition, care provided by
NPs’ is cost-effective, and patient satisfaction is reported to be as good as or better than care
provided by physicians (Kippenbrock et al., 2019). Yet, the public does not immediately bestow
the same level of trust on NPs as they do physicians and nurses because the roles of the NPs are
less understood (Jakimowicz et al., 2017). This lack of trust from health care consumers reflects
society’s adherence to the hierarchal model of the provision of medical care. The public
understands what nurses do and what physicians do but cannot define a nurse that has diagnostic
and prescriptive authority.
The public perceives the NP as a nurse and nurses traditionally cannot perform medical
skills. The public health consumer often misunderstands the abilities and the advanced level of
education of NPs. A part of PI is the knowledge and skills of the profession, but this is
complicated by the varying and state dependent levels of practice authority and scopes of
practice. Jakimowicz et al. (2017) suggests that a unified definition and description of the NP
scope of practice (SOP) would improve the public’s comprehension of the role and thus improve
public acceptance as primary health care providers.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 22
Meleis’ Transition Framework and Transition to the Nurse Practitioner Role
The transition framework was developed based on the Transition Theory of Meleis and
Schumacher (1994). Shumacher and Meleis (1994, p.119) defined transition as a “passage or
movement from one state, condition, or place to another”. The authors believe that transitions are
complex processes and multiple transitions can occur simultaneously (Shumacher & Meleis,
1994). Shumacher and Meleis (1994) identified four types of transitions: developmental,
situational, organizational, and health-illness. Schumacher and Meleis (1994) report common
concepts of a healthy transition are mastery and fluid integration of the new roles. The properties
of transition which characterize a transition event is or has taken place are awareness,
engagement, change and difference, time span and critical points or events (Meleis et al., 2000, p.
18). The NP role change involves a situational and organizational transition. Situational
transitions are defined by educational and professional changes while organizational transitions
are political and societal changes (Shumacher & Meleis, 1994). Both situational and
organizational changes trigger the change in PI from RN to NP. For transition to occur, the
change must happen over time and flow from one state to another resulting in a transformation of
the participants (Shumacher & Meleis, 1994).
There is a difference in the role from RN to NP as individuals begin to perceive
themselves as “providers of care rather than only as RNs (Owens, 2019). Transitions and PI are
evolving concepts as neither action has a terminal point. The transition theory has been widely
applied or references in nursing and role change. Past research into nurses’ transitions indicates a
successful transition resulted in work satisfaction and retention, but there is a lack of research on
vulnerable points of transition among NPs (Poronsky, 2013). But NPs have different roles and
responsibilities than RNs so it would be important to explore similarities and differences in the
transition between the NP and RN professions (Owens, 2019). According to Owens (2019),
learning the skills, knowledge, and responsibilities of the NP role was central to a successful
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 23
transition. Poronsky (2013) found that literature supports the nonlinear motion of transitions, and
skill acquisition was not the sole indicator of successful transition.
Transitions can have positive or negative results. An example of a positive transition
would be feelings of being supported and well prepared for practice upon graduation which
reflects mastery of the NP role. Stable collegial relationships and good rapport with patients or
other providers reflect fluid integration of the role. Nursing interventions are necessary to support
positive transitions. In the case of the NP, this would come from good educational foundation,
solid root in nursing theory, access to mentorships organizational change to fully utilize the NP
role.
Transitions can be negatively impacted by lack of organizational support. The article by
Poghosyan (2017) reported that the NP role was well understood by colleagues, but not by
administration leading to negative images of the NP role within the medical team. Physicians also
have poor understanding or views of the NP role and believe NPs incapable of both autonomy
and accountability (Jakimowicz et al., 2017). Negative transitions increase tension with
healthcare teams and limit the NP from fully integrating and mastering the new role. The
negative transition prevents the NP from fully embracing his/her new PI.
Interprofessional tensions rises when organizations do not understand the NP role and
situational transitions do not promote the nursing core values during the NP education. The
quality of transition is important to preventing interprofessional tension which can increase the
risk of burn out and lead to higher rates of attrition. To weather the situational changes,
professionals must anchor into the values which reflect their PI, making one less vulnerable to
situational factors that challenge their profession (Fitzgerald, 2020). Transitions begin the change
in PI so both situational and organizational transitions will be explored further to understand how
each type of transition influence NP PI.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 24
Situational Transition
Situational transition begins when the RN decides to enroll in an NP program and begins
the PI transformation. The first year of situational change is the most critical and stressful
(Owens, 2019). The new role will involve a balance between the previous RN role and the
expansion into the NP role (Dillion et al., 2016). Despite the purposeful initiation of the
situational transition process, the NP student may be unaware of how to balance the change
leading thus requiring a longer adjustment period. Increasing awareness of the expectations of the
role change through faculty guidance and mentorship during and after the education period can
shorten the adjustment period and improve transition quality (Poronsky, 2013).
Recommendations by the National League of Nursing [NLN] (2017) indicated that PI is a
core expectation of nursing and NP education, it remains up to the organization on how to
implement this. The International Council of Nursing [ICN], reports “the NP is fundamentally a
nursing role, built on nursing principles aiming to provide the optimal capacity to enhance and
maximize comprehensive healthcare services” (International Council of Nurses [ICN], 2020, p.
11). The same guidelines report a need to research the value of the NP to support the legitimacy
of the role (ICN, 2020). Both the NLN and the ICN recognize a need to root the NP PI into the
nursing discipline through education. NP curriculum should include development of PI and
opportunity for interdisciplinary education to decrease the stress of transition for new NPs (Faraz,
2016). Faculty and mentoring of NPs can help with the greatest challenges of situational
transition which are navigating a new provider role, integrating into a healthcare system,
increasing their skills/proficiency, rebuilding professional relationships, and educating society
and the organization on the NP role (Dillion et al., 2016). Mentorship guidance can improve the
quality of transition, which can increase job satisfaction and retention rate of the NP work force
(Barnes, 2015).
Situational transitions of the NP are complicated by the various available degrees. For the
NP there are many starting paths such as family nurse practitioner, adult/gerontology nurse
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 25
practitioner, psychiatric nurse practitioner, acute care nurse practitioner and/or pediatric nurse
practitioner. These are just the choices for the nurse practitioner track of the NP and do not
include the other advanced practice degrees of certified nurse midwife, certified nurse anesthetists
or clinical nurse specialist. This offers a lot of opportunity for the NP to choose a path that fits
their interest, but it makes it difficult to explain the subtle variations in each degree. Family
practitioners can see any age patient, but adult/gerontologists can only see people aged 12 and
over. Hospital settings prefer and, in some states, require, an acute care degree which limits
family practice and adult/gerontology providers to outpatient settings. To patients and healthcare
colleagues, this makes it hard to understand why one NP can do certain things, but another
cannot. Nurses and physicians have a more uniformed path to their degrees. Nursing has a
common test known as the NCLEX and those that pass are considered registered nurses. Nurses
are not limited to inpatient or outpatient settings. Medicine has a common path known as the
MCATs then medical school with differentiation during residency.
The variations in qualifying degree for NP and the difficulty getting preceptorship or
mentorships in each specialty highlights one of the major issues in the education of NP which is
the lack of uniformity. An attempt to resolve the variability in education is to move all programs
to Doctor of Nursing practice (DNP) which would offer more protection to the nurse practitioner
title (Goolsby & Budd, 2019). A DNP does not unify the various degree paths. A family practice
degree with differentiation after graduation through residencies or fellowships would clarify the
skills of the NP to the public and other healthcare providers. Uniformed expectations in education
gives the public, medical colleagues, and administration a clear understanding of the
qualifications an NP holds.
Organizational Transition
The situational transition sets the stage for an organizational transition. Dillion et al.,
(2016) indicates that organizational support is statistically significant in the six months of
transition to minimize the stress. Studies continue to report connections between organizational
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 26
support and NP transition with Barnes (2015) reporting that organizational factors were more
influential than personal factors in successful transitions. Organization includes administrators,
politicians, and regulating bodies like boards of nursing and patient. Organizational transitions
are inevitable as the role of the individual changes from RN to NP. A PI cannot be formed
independently of society because a profession needs to be recognized by society to have
significance (Fitzgerald, 2020).
An example of organizational transition can be seen in how hospital administrators view
the NP. A negative relationship with administrators led to limited control over their work
environment and lower satisfaction (Schirle & Dietrich, 2020). Lack of information on the NPs’
education and skills lead to misunderstanding of the NP role. Examples of the misunderstandings
are thinking that NPs equal to residents, medical assistants, or physician extenders. Employers
can help decrease role ambiguity by educating the other health care professionals on the scope of
practice of the NP (Faraz, 2016). Organizations can help the NP role by promoting
interprofessional interactions, but this cannot be done if the organization does not understand the
NP identity.
Interprofessional collaborations can improve understanding of the NP role by creating
bridges into other disciplines through mutual appreciation of different professions. These
collaborations are not always natural and require some organizational oversight to form. The
Veterans Affairs in Connecticut developed a center of excellence in primary care education
program (CoEPCE) to facilitate understanding of professional roles among NPs and physicians.
The group consisted of NP fellows, first year post graduate residents and second year
postgraduates in a 36-month program where they worked alongside each other, shared patients
and learning experiences. Initially, all participants had a misconception of the ability and skill of
the other members, but by the end of the program the was a cohesive mix of professional with
individual identities who functioned as a team to deliver patient care (Meyer et al., 2015).
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 27
Interprofessional collaborations are a tool in cocreating a supportive scaffolding for new NP
graduates to model their behavior and practice.
It is financially beneficial for organizations to invest in the NP PI development and
improving quality of transition as NP turnover is costly and disruptive to patient care. Hospitals
with poor retentions spent an average of $3.6 million more than those with better retention of NPs
(Dillion et al., 2016). According to Auffermann et al. (2020, p.2), “recruiting and training
healthcare workers can be upwards of 100% of the yearly pay for the worker” . This is a huge
financial burden to society if you consider that over 20% of the turn overs occur in the first one to
two years (Auffermann et al., 2020). This is only a financial loss and does not consider the
negative impact to patient access to care. The quality of organizational transition has a positive
correlation to improving professional and job satisfaction if there is increased support and
confidence with the profession leading to more successful transitions (Dillion et al., 2016).
Conversely, there was a significantly negative correlation to job retention when there was lower
organizational communication or leadership quality (Dillion et al., 2016).
Further examples of poor organizational transition can be seen in the lack of support for
the NP role. NPs were expected to see the same number of patients as physicians but were given
less access to medical assistants which shifted additional responsibilities of rooming the patient,
vital signs, or labs to the NP, but physician are not expected to perform these tasks (Andregard &
Jangland, 2015). NP role is given less respect than physician colleagues and seen as the same as a
nurses or medical assistants. Role ambiguity positively correlated to higher turnover rates so
improving the PI would help clarify the NP role and lower this occurrence (Auffermann et al.,
2020). Andregard and Jangland (2015) report the NPs have no representation within committees,
or recognition as an independent discipline due to organizations’ inability to differentiate RN and
NP roles. Faraz (2016, p. 1539) notes NPs voiced similar issues with extrinsic factors such as
“practice environment, colleague negativity and having to defend the NP role to others” and lack
of role acceptance along with interprofessional conflict as cited reason for changing employment.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 28
An organization with good leadership can attempt to understand the NP role to improve
interprofessional relationships and lead to better NP retention (Andregard & Jangland, 2015).
Parse’s Human Becoming and Professional Identity
Exploring the role transition without understanding how the change in PI may impact the
NP and society is incomplete. Situational and organizational transition lead to a change in the PI
of the NP. The change in NP PI leads to a paradigm shift in how he/she relates to the nursing
discipline, interprofessional relationships and hierarchal medical model. The NP needs to be an
active participant in the development and representation of the PI. Parse’s theory of Human
Becoming was applied to view the NP PI. The theory was chosen because it explores a shift in the
person- universe relationship when faced with an acute change in the status quo such as the
situational and organizational transition that occur when the RN becomes an NP.
The first of three assumptions in the theory anticipated that a person’s view of what is
important will change when an impactful event occurs. For the NP, the situational transition shifts
the PI from RN to NP. The NP must evaluate how important is the preservation of the nursing
discipline to the PI when faced with an influx of medical skills. Conversely, the NP can focus on
only the skills of diagnosing, treating, and prescribing and drift further from the nursing root.
Education and mentorships can influence how the nursing discipline will be reflected in the NP
PI.
The second assumption indicated changes in priority will force the person to create a
new environment that supports this shift also known as cocreating a rhythmical pattern of relating
(Parse 1992). The change to NP PI will challenge the current organizational situation. Previous
relationships with patients, healthcare colleagues and society based on an RN identity do not
apply since the NP PI is different. The NP must re-establish interprofessional connection after
the PI change. The new connections cannot be made if society is not willing or understanding of
the NP role. Nurse practitioner’s PI shows he/she can use medicine’s tools but transcend mere
technique by anchoring themselves into the nursing discipline (Trotter, 2019). This ability to exist
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 29
in both the medical and nursing realm offers holistic care where patients can have both the caring
nature of nursing and the diagnostic expertise of medicine. To create this change, practice
authority (PA) and scope of practice (SOP) must change to fully utilize the NP role.
The third assumption anticipated that the PI change will become ingrained into the NP
role and supported by the environmental changes leading to a cotranscendence to a new reality.
NP’s role is not defined by the profession boundaries of either nurses or physicians, but the
current inflexible hierarchical model forces the NP to fit in as a nurse or a physician. A more fluid
transdisciplinary model will allow the NP and the organization to redefine healthcare roles and
help support a positive PI.
Choosing Personal Meaning and Value of the Nursing Discipline
Owens believes “individual learning experiences, and socialization can contribute to
developing and/or changing of an identity (2019, p. 159-160). Owens (2019) also notes that
transition and change in identity happen during education and the first six months to two years of
practice. NPs connection to the nursing disciplines is challenged by the evidence practice views
rather than the theory-practice curricula seen in nursing schools (Donohue-Porter et al., 2017).
Roberts et al. (1997) similarly highlights an NP program with an increased focus on clinical skills
over holistic nursing care models risks losing the nursing identity and regresses the students’
confidence. It is the obligation of the NP program to continue to demonstrate meaningful ways to
incorporate nursing discipline into new skills the NP will acquire. The NP must be competent in
the new skills, but educators must show the NPs that the skills should not define your whole PI.
The use of conceptual and theoretical frameworks throughout NP education programs can help
preserve and protect the nursing distinction and uniqueness in the NP position (Wilson et al.,
2015).
In an ideal setting, the education process will lay the nursing theoretical background.
There is a need to solidify clinical content, but also “another cornerstone, not as prominent but
highlighted as necessary, is to include nursing theories and research methodologies to support the
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 30
development of professional and clinical competencies” (Ljungbeck et al., 2021, p. 8). Nurses
search for identity through interaction with others (patients, other nurses, physicians) and when a
nurse cannot show themselves as nurses, they lose a sense of usefulness and lower their
dependence and devotion to their profession (Zarshenas et al., 2014). Mentor-mentee
relationships are impactful to PI development in new NPs. It is crucial to have NPs with clear PI
leading the profession and serving as mentors to establish a cycle of positive NP PI. A study of PI
can help identify periods of greatest identity stability to seek resources for orientation programs.
A formal orientation was more influential in promoting NP transition than previous RN
experience (Barnes, 2015). Forms of orientation include residencies, mentorships, and
fellowships post-graduation. Residencies are positive tools which support NP clinical skills and
can enforce nursing theory during this post graduate period. An on-boarding program which
expects new NPs to immediately function at a high and complex level increases stress and results
in turnovers (Bryant & Parker, 2020). Collegial mentorships and formal orientations improve
role transitions for NPs (Faraz, 2016). An orientation programs with a nursing discipline focus
can show the NP how to use the clinical skills within a nursing framework.
Post graduate orientation for NPs shows positive gains in role transition, clinical
confidence, autonomy, but are a controversial issue by the AANP which feels the need for post
graduate residency programs indicates a lack of educational rigor (Finneran & Kreye, 2021). On
the contrary, the other medical professions with which the NPs practices have a version of post
graduate support such as nursing with orientation to specialty practice and physicians with
residencies and fellowships. The existence of a post graduate program like a residency or
fellowship does not diminish the NP education, but acknowledges that all new practitioners,
regardless of specialty, need support. NPs gain confidence from further training and the boost in
confidence is noticeable to patients and colleagues (Jakimowicz et al., 2017). Mentorships have a
positive influence on job satisfaction and increase retention (Auffermann et al., 2020).
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 31
PI is most influenced by mentors and experiential learning which is a mixture of explicit and
tactical lessons. PI development is not linear and have periods of progression and regression
(Cruess et al., 2019). The fluctuations in PI present recurring opportunity to enforce nursing
discipline regardless of the years of experience.
Cocreating a new Rhythm in the Practice Environment
The interprofessional relationships between the NP and other healthcare colleagues
change when a nurse transitions to a NP. This transition will promote change in that individuals
PI. The interprofessional relationship encompasses the rapport among NPs, nurses, physicians,
administrators, patients, and legislators. The NP no longer identified with the PI of the RN.
Nurses view NPs as undermining the experiential learning of the nursing discipline by over
emphasizing educational or clinically heavy skills leading to overt or covert hostility (Anderson
et al., 2019). Upon graduation, NPs notice opposition to their roles from allied health, but the
resistance from their nursing colleagues garners a feeling of betrayal from NPs (MacLellan et al.,
2016). The NP may identify as a nurse, but nurses may not see this. A PI shows that medical
skills are tools used to expand the nursing role, not replace it can help rebuild the
interprofessional connection.
Relationships with physician colleagues also change. Physicians understand the nursing
PI and qualifications but misunderstand those of the NP believing it more akin to medical
residents or physician extenders and thus not medically competent to deliver independent care
(Andregard & Jangland, 2015). The PI change of the NP is perceived as a threat to the
professional boundaries of nursing and medicine and causes a fracturing of previously stable
interprofessional relationships. Policies are used to preserve the uniqueness of the nursing and
medical professional identities from the NP.
The practice environment is influenced by scopes of practice (SOP) and practice
authority (PA). The change in role leads to a PI change from solely nursing to a blend of nursing
and medical identities. This changes the level of care the NP provides to patients. Early NPs
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 32
struggled to characterize a nurse who performed tasks previously reserved only for physicians
and had to endure a competition of professional ownership between physicians and nursing
bodies (Trotter, 2019). Confusion in the NP abilities stunts the PI development through practice
restrictions. Practice restrictions give the control of the PI development to the nurses and
physicians who make the policies by limiting the full utilization of the skills and knowledge of
the NP. The NP must be an active participant in creating a change in the environment or risk
being defined by the misconceptions of other health care disciplines.
The view of the NP education as less than, rather than different from, the physician
hinders the ability to expand PA to full authority and open SOP. The PA reflects the legal
oversight of the NP practice by physicians and the SOP is state regulated reflection of
qualifications and education for the NP profession and impact daily practice. SOPs are also
variable among states as each state has a regulating board of nursing and can be influenced by the
practice authority of the state. There is a high prevalence of misunderstanding of the NP role
among physicians with almost 85% being unaware that NPs have graduate degrees and national
certifications, 50% are unaware that NPs are autonomous providers in some states and 40%
believing that medical by laws states NPs must be supervised by physicians (Bryant & Parker,
2020). The perception of incompetence is used as a justification to continue restrictions on PA
and SOP of the NP.
Cocreating also requires the other party (society) to be willing to engage in the change by
lifting restrictions. The National Academies of Science, Engineering, and Medicine [NASEM]
released a report on the Future of Nursing for 2020-2030. In this report, the NASEM recommends
the removal of barriers that prevent nurses from practicing to the full extent of their education and
training including reimbursement disparities for telehealth and insurance services by NPS,
allowing federal authority (where all NPS are independent practitioners with full practice
authority) to supersede states regulations and scope of practice restrictions where applicable (The
National Academies of Science, Engineering and Medicine [NASEM], 2021). The
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 33
recommendations were made to address issues of poor access to healthcare. The PA (level of
autonomy) is the most significant predictor of NP job satisfaction and yet legislators, the public,
hospital administrators, and even NPs cannot agree on how to define autonomy (Peacock &
Hernandez, 2020). The NP must first understand the unique qualities of the PI to educate others
about why the profession is necessary.
There are three different levels of PA and more restrictive PA leads to worse healthcare
access. Full PA allows NPs to practice independently without physician oversight, reduced
requires collaboration while restricted required physician oversight. Reduced and restricted
practice authorities limit an NPs ability to deliver cost effective care to underserved populations
since he/she is dependent on availability of physician partners which may be geographically or
financially limiting. NASEM (2021) noted that access to care was impacted by level of practice
authority restriction with 63% increased access to care in states with full practice authority
versus 47% in reduced and 34% in restricted showing the negative impact of PA restrictions.
Like PA restrictions, limitations to SOP have a negative impact on access to care. States with
full SOP have more efficient and cost-effective primary are services and better mix of providers
(Mark & Patel, 2019).
Lifting of practice restrictions is an essential need as millions of eligible patients lack
access to care due to PA restrictions leading to worsening health outcomes and ultimately more
healthcare costs (The National Academies of Science, Engineering and Medicine [NASEM],
2021). The harmful effects of policy limitations were noted during the COVID pandemic where
states such as Florida, Kentucky, Louisiana, New Jersey, New York, Tennessee, West Virginia,
and Wisconsin had to loosen restrictions to increase access to care for patients due to overload of
the healthcare system (The National Academies of Science, Engineering and Medicine
[NASEM], 2021). NPs helped increase access to care and improved patient outcomes without
issues during a pandemic. Reinstating restrictions is not logical if the only excuse is that NPs
cannot deliver the same quality care as physicians because the level of education is “lower”.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 34
Studies have shown NPs provide the same or superior care quality compared to physicians and
patients reported the NPs listened and respected their perspective more than other providers.
(Mark & Patel, 2019). Nurse practitioners proved they are capable providers during the Covid
pandemic.
Cotranscending the Hierarchal Medical Model to a Transdisciplinary Model
Hierarchal models encourage professional boundaries by creating power struggles where
each profession attempts to maintain dominance. Physicians can control prescribing and
diagnosing while nurses control care delivery. Professional boundaries are difficult to cross since
each profession is deeply rooted within their own culture. In a hierarchal system, the NP is forced
to fit as a nurse or a physician. The need to “fit” the NP into a preexisting role creates
interprofessional tension and dilutes the PI of the NP as either nurse or physician. To fully
appreciate the NP PI, the model must change to a more fluid transdisciplinary approach.
Organizational leaderships can impact team functioning and help challenge traditional hierarchies
which places nurses below doctors (Andregard & Jangland, 2015).
The other existing medical models of multidisciplinary and interdisciplinary practice
cannot develop the NP PI because they have a limited application. The multidisciplinary teams
are defined as different healthcare providers whose skills do not overlap, providing
coordinated care to a patient (Social Care Institute for Excellence, 2018). As previously
mentioned, NPs skills are an overlap between nursing and medicine. In a multidisciplinary model,
the NP role risks being viewed as redundant by nursing and physician members of a team.
Interdisciplinary has more potential to have inclusivity for the NP role as a synthesis of multiple
disciplines to develop a new integration of knowledge (Choi & Pak, 2006). Even the
interdisciplinary model has a risk of excluding the NP role by organizing the care plan around
nursing and medical roles and discounting the holistic care the NP can offer. Transdisciplinary
models are the most capable models to fully integrate the NP PI into a healthcare team.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 35
The transdisciplinary model was first purposed by quantum physicist
Basarab Nicolescu’s (Nicolescuian) and relates to the NP role because it acknowledges another
way of knowing such as interpretations, meaning making, intuition and knowledge construction
as seen within the art of nursing (Lynch et al., 2021). This type of knowledge is not given
credence in a hierarchical system as it is often immeasurable and not aligned with medicines
positivist view of absolute truth (Lynch et al., 2021). Transdisciplinary care in practice can be
difficult as it calls for disciplines to abandon their specific silos and acknowledge what is
between, beyond, across disciplines and each member is granted expert status with the team (Van
Bewer, 2017).
The Nicolescuian model of transdisciplinary was difficult to translate into practical use
and led to the Zurich approach to transdisciplinary care (Mode-2) which focused on pragmatic
“participatory innovation, active cross-discipline dialogue, inclusion of sectors beyond academic
discourse and a focus on complex problems” with a goal of creating knowledge (Lynch et al.,
2021, p. 640). Physicians may view a patient’s situation with physical solutions aimed at curing,
nursing would offer supportive and person-oriented care, but individually, the two disciplines will
still view the patient from their own lens. NPs can embody the transdisciplinary approach by
bridging, not replacing, medicine and nursing’s view of a situation by seeing how the physical
ailment would impact a patient’s social, psychological, and quality of life. Transdisciplinary
aims to put the dynamics and the goal of care as the primary goal and subordinates’ disciplines to
allow any team member’s input, even non-medical members like patients, to have equal influence
(Choi & Pak, 2006). The NP PI has begun transcendence, but society is still trying to maintain the
hierarchical status quo. Nurse practitioners are a large and valuable healthcare resource, and a
better understanding of the NP PI can clarify the value of this profession.
Summary of Literature
The PI of the NP is rooted in the nursing discipline, but the NP is professionally different
from the RN due to a transition in role. Role transition and PI cannot occur independent of each
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 36
other, and one can influence the other. There is a large body of research on NP role transition, but
less so on the resulting PI. Literature indicates transitions are continuous events but are more
tumultuous and stressful in the first two years of change. The situational transition of the NP is
dependent on completing the educational program and passing the national certification for
licensure. Organizational transitions are more complex and depend on practice restrictions,
interprofessional relationships and social acceptance of the NP role. There are indicators of
successful transition when there is mastery of the new role, and the new identity is embraced by
the professional. The level of PI can be influenced by the positive or negative quality of the
transition.
Situational and organizational transitions trigger PI change, but there is a gap in
knowledge on the status of PI and if there is a higher PI for those who are past their first two
years of practice. Literature shows that the NP role is defined by skill and education, but missed
the subtle aspects of values, beliefs and attitudes that define the PI. Education focuses on the
necessary skills to practice but misses the opportunity to reinforce the nursing discipline and
theories which will ground the new NP into a stable root. Skills can be learned, but the character
of a profession must be developed. Development of the characteristics which reflect a PI can be
exemplified through mentorships, preceptorships, and incorporation of nursing theories into the
NP programs. Organizational policy restrictions and commitment to hierarchical medical models
limit full utilization of the NP’s skills and knowledge constraining the advancement of the PI.
Transition is an essential concept the PI of the NP as there is a change in role from RN to
NP. The RN expands in skill and changes in role by accomplishing a master’s degree in nursing
but is thrusted into an unstable PI. Available studies focus on the PI as a reflection of job
satisfaction, retention, stress with additional studies showing ambiguity of the NP role and
interprofessional stress with colleagues (nursing, physician, and administration) as negatives to
successful NP transitions. Unified PI can improve the public perception and acceptance of the
role by improving understanding of the role. If administration and other healthcare colleagues are
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 37
confused by the role of the NP, then it is expected that the lay person will not understand the
profession. If the PI is well established, the NP can reflect the value of the profession and thus
justify expansion in practice authority to improve access to quality healthcare for the public.
Hypothesis
The null hypothesis: PI is not impacted by the years of NP experience. The directional
hypothesis: PI will be higher in NPs with more years of practice.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 38
Chapter 3 Methodology
Mixed Methods (MMs) is considered the third major research paradigm with the
hallmark of MM being the integration of quantitative and qualitative data to generate data beyond
what each individual method could produce alone (Guetterman, Babchuk, et al., 2019). The
overall goal of mixed methods research, of combining qualitative and quantitative research
components, is to expand and strengthen a study’s conclusions (Schoonenboom & Johnson,
2017). Mixed methods allowed the qualitative data to enrich the rigorous approach of quantitative
study and data analysis to approach complicated questions (Creswell, 2015).
Best practices in MM research identified the following steps:
1. Identification and development of a clear theory or philosophy, clear description of the full study
design with figures on integration.
2. Justification of the MM approach by describing why a quantitative or qualitative approach alone
is insufficient to address the topic. Timing, technique, and responsibility of integration are
necessary. Integration of qualitative and quantitative findings with a clear aim and theoretical or
conceptual underpinnings are strengths in a MM study (Creswell et al., 2011)
The purpose of a MM approach in this study was to capture a full picture of the NP PI. A
MM approach addressed the limited generalizability of the results from the qualitative portion of
the study and the limited depth of understanding typical of findings derived from quantitative data
by combining techniques from both approaches (Green et al., 2015).
The question of PI levels can be evaluated with a tool, but the tool cannot capture what
makes the NP participant believe he or she is a part of the profession. The deficit to a purely
quantitative approach to the PI of an NP is that it will only reflect the varying degrees of PI. Some
additional quantitative data can be found in statistical analysis of the demographics such as age,
gender, state of practice, type of specialty (family, adult/gerontology, pediatric, acute care,
psychiatry), years of RN experience, level of education (bachelors including current NP students,
masters in one of the NP specialties excluding post master’s certifications and doctorate both
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 39
Doctors of Nursing practice also known as DNP and Doctor of Philosophy also known as Ph.D.
Since there was no data in currently available literature showing a variability in PI among NPs,
the initial quantitative data helped set the groundwork. The quantitative data did not reflect the
attitudes, values and beliefs of the NP which are essential components to a PI. The qualitative
component derived from interviews conducted among the quantitative participants.
Design
The three common MM designs are explanatory sequential where quantitative data is
collected and analyzed before qualitative; exploratory sequential where qualitive is collected and
analyzed before quantitative, or convergent where both sets of data are collected and analyzed
simultaneously (Draucker et al., 2020). This study was conducted using the explanatory
sequential design where the quantitative was collected first then the qualitative. In general, an
explanatory sequential design is chosen when a researcher wishes to explore new research topics
and establish evidence related to incidence, relationships, or causation (Gray et al., 2017). The
design is considered sequential when either the qualitative or quantitative data is collected first.
Then the results from the first round are used to inform the subsequent phase (Gray et al., 2017).
The rationale for this MM approach was the use of quantitative data and analysis, via
statistics, provides a general understanding of the research problem. The qualitative data and
analysis refined and explained the statistical results by providing a more robust explanation of the
human experience beyond that statistical data gathered in the initial quantitative strand (Gray et
al., 2017; Guetterman, Babchuk, et al., 2019). In an explanatory sequential design, the
quantitative data (numerical) was collected and analyzed first (see appendix A for study graph)
and then the qualitative data (text) was collected and analyzed as part of the second sequence
(Gray et al., 2017; Guetterman, Babchuk, et al., 2019). As indicated by Green et al. (2015), it is
possible to have a mixed methods study with equal importance to both quantitative and
qualitative data. The qualitative data was used to explain or elaborate on the quantitative findings.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 40
To clarify, the quantitative data was collected first and analyzed to evaluate for PI
variations, then the qualitative individual interviews were conducted (Gray et al., 2017;
Guetterman, Babchuk, et al., 2019). The qualitative and the qualitive samples came from the
same participant pool (Creswell, 2015). The results of the first phase were used to purposefully
select participants to best address the qualitative research strand (Guetterman, Babchuk, et al.,
2019).
Following the collection of both quantitative and qualitative data integration began.
Schoonenboom and Johnson (2017) discussion dependency within a MM study where the fidelity
of the second half of a study (qualitative) depends on the results of the first portion of the study
(quantitative).
Data Integration
The way the qualitative and quantitative data is integrated is critical to maintaining
scientific rigor within the MM approach (Creswell, 2015). In addition, the method of integration
of quantitative and qualitative data can dramatically enhance the value of mixed methods research
study. According to Creswell (2015), integration occurs when data is merged and compared,
utilizing qualitative data to explain quantitative findings, using qualitative data to build a
quantitative study, or embedding qualitative component into a quantitative study.
There are four specific approaches to data integration: connecting, building, merging,
and embedding (Fetters et al., 2013). Connecting occurs when the researcher connects the data
through the sampling frame for both aspects of the qualitative and quantitative strands. With
building, one data base informs the data collection in another data base. When merging, two
databases are brought together for analysis. When embedded, data collection and analysis occur
at multiple points. Integration occurs at the point of interpretation and reporting level via
narrative, data transformation, with a joint display of data (Fetters et al., 2013).
Integration can happen at the study design level, during data collection, analysis of
reporting of experimental results (Creswell, 2015). In this study, data integration occurred in two
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 41
parts. First, at the study design level by connecting the sampling frame for the quantitative and
qualitative strands (Fetters et al. 2013). The quantitative data was connected to the qualitative
data through purposeful selection of qualitative participants from the qualifying pool of
quantitative participants. Connecting these two pieces was an integration step which allowed the
researcher to build the qualitative interview questions to gain the most meaningful information
from the groups.
Integration also occurred through merging of data (Fetters et al.,2013). Merging of data
occurs when the researcher brings together data from the quantitative questionnaires and
interviews for analysis and comparison. This step occurred following the statistical analysis of the
quantitative data and textual analysis of the qualitative data (Fetters et al., 2013). In this study, the
merging of the data occurred after the statistical analysis of the numerical data and qualitative
analysis of the textual data. This allowed the researcher to compare the variations in the PI scores
among NPs with different years of experience with the qualitative themes and noted common
themes among those reporting high or low PI.
Interpretation and Reporting
A narrative integration technique with a weaving approach was used to explained
connections between the two strands. This approach allowed the researcher to write about both
qualitative and quantitative findings by correlating themes and data together rather report each
strand data separately (Fetters et al., 2013).
Joint display of the quantitative data and the qualitative data was used to represent the
data in a concise visual format. As recommended by Fetters et al. (2013), a joint display will
allow correlation with the quantitative MCPIS-9 questions and themes that correlate to the
questions.
Advantages and Disadvantages of Mixed Methods
MM research is not without its advantages and disadvantages. The greatest advantage of
a MM approach was in the combination of both inductive and deductive research approaches
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 42
using both quantitative and qualitative methods to explore a complex research question. This
research method was appropriate if there was a clear and logical integration of both strands
(Green et al., 2015).
The disadvantage results from the complexity of an MM approach. Because it was a
combination of two very different methods of research, the integration and display of data could
have been problematic if the researcher was unfamiliar or lacks guidance in using this research
method (Bressan et al., 2016). Despite its disadvantages, the MM methodology was a very
meaningful technique to simultaneously explore multiple questions and to address complex
healthcare research (Bressan et al., 2016). A lack of discussion in integration strategies and poor
qualitative method descriptions were common weaknesses and points of criticism (Guetterman,
Sakakibara, et al., 2019). Scientific rigor of the quantitative and qualitative arms had to be clear
and show integration.
Population and Sample
The target population was practicing NPs and current NP students. The participants were
divided into five categories based on years of practice as described in the 2020 American
Association of Nurse Practitioners [AANP] nurse practitioner profession survey. The quantitative
sampling was a convenience sample.
Inclusion and Exclusion Criteria
Inclusion criteria was actively licensed and practicing as an NP regardless of full time or
part time, but not retired. For students, the participants had to be new to the NP profession
meaning current registered nurses studying for their first NP degree. The participant had to be
able to speak, read and write English fluently.
The MCPIS-9 survey instrument and demographic data must be completed in its entirety
by the participant for inclusion in the study. To participate in the qualitative interview, the
participant had to have completed the survey, demographic form, and the full face-to-face
interview in its entirety. Any individual was excluded who fails to meet any portion of the
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 43
inclusion criteria or has the inability to fluently read, write, or speak English. For the student
component, exclusion was post masters certificate students.
Ethical and Legal Consideration
The participants interested in participating in the qualitative interview were asked to
provide their email on the MCPIS-9 form. Consent for interview will be assumed if the email is
provided. The survey did not contain any foreseeable triggering questions related to trauma,
substance abuse, or legal matters.
According to Groves et al. (2009), a concern that confidentiality will be breached was a
large reason that surveys are not completed or returned, but that long legal forms also deterred
participation. IRB approval was sought and forms declaring a pledge to safeguard confidentiality
were signed.
Instrument
Study instruments included a tool for collection of demographic data and MCPIS-9
survey. Demographic data was collected includes age, gender, state of current practice, type of
NP degree (or student), years of RN practice and years of NP practice. The MCPIS-9 was used
as the tool to quantify the PI of the nurse practitioner and nurse practitioner students.
The MCPIS-9 was chosen to evaluate the dependent variable of professional identity (see
appendix B for MCPIS-9 questionnaire sent to participants) (Matthews et al., 2019). Other scales
were considered but not chosen due to lack psychometric evaluation and the overall length of the
questionnaires, potentially leading to lower completion rates. The MCPIS-9 is a Likert based
scale composed of nine questions. The scale attributes range are five-points from strongly agree
(score=1) to strongly disagree (score=5). Reverse coding where strongly disagree (score =1) and
strongly agree (score=5) are used for three negatively worded questions of “I am often ashamed
to admit that I am studying for this profession”, “I find myself making excuses for belonging in
this profession” and “I try and hide that I am studying to be part of this profession” .
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 44
The MCPIS-9 has been used in research with other nursing and medical populations.
Worthington et al. (2013), used the MCPIS-9 specifically toward nursing students, the scale has
been applied to pharmacy students (Mylrea et al., 2017) as well as paramedic students (Johnston
& Bilton, 2020). Further validations were done using exploratory factor analysis by Worthington,
et al. (2013) on student nurse population to evaluate attrition rates during the program based on
professional identity. Worthington et al. (2013) found that students with higher PI scores per the
MCPIS-9 had higher drop rates than those with higher PI.
Though the scale has been applied to students of various medical fields, it had not been
applied to practicing professionals. The exploration of PI and development should not stop when
individuals graduate form the respective professional programs as the concept of PI is a
continuously ongoing process that is part of personal development. As seen in the study by
Adams et al., (2006) and Worthington et al., (2013), the MCPIS-9 has good predictability to
determine if students will complete their health science study. Both studies by Adams et al.
(2006), and Worthington et al. (2013), indicated attrition from their perspective medical programs
were lower with higher ranking PI. The MCPIS-9 may have the same predictability for attrition
among practicing NPs.
Setting
The study was conducted in the United States with no restriction on state, type, degree,
urban or rural practice.
Data Collection Plan
An online survey platform was used to distribute the MCPIS-9 survey and collect the
data. According to Nayak & Narayan (2019), there are advantages and disadvantages to an online
survey method. Online surveys tended to be more acceptable to participants. Online surveys
seemed to have larger participant participation rates than paper survey. In addition, the data
generated through online surveys appeared to have fewer mistakes, with fewer skipped questions.
The largest disadvantages pertained to cost issues through the administering of the survey through
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 45
survey platforms (IE: survey monkey). In addition, some individual found surveys more difficult
if they are poorly educated or if they dislike the depersonalization of online surveys (Nayak &
Narayan, 2019). Despite the challenges, the online survey method was the most convenient way
to reach many NPs across the United States.
Qualtrics.com (2021), reported an average of a 20-30% response rate to surveys. Based
on this response rate, at least 172 surveys (30% above the power total of 132 participants) was the
minimum target. Survey monkey was used and a target population of 250 was purchased.
Storage and safeguarding of the data and personal information of the participants was
vital to this research. The data will be stored for three years from the end of the
dissertation/experiment. This three-year period was chosen after review of the NIH Grants Policy
Statement which requires researchers to keep study information stored for three years in case of
review (National Institute of Health, 2020). The surveys were all transferred to a flash drive and
kept in a safe. There were six paper survey submissions - which were also scanned and
downloaded onto the flash drive. The original papers were placed in the safe with the flash
drives, The qualitative interviews were conducted and recorded via zoom and transcribed using
Nvivo. Transcriptions and video interviews were downloaded to a flash drive and delivered to the
same safe.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 46
Chapter 4 Results
This chapter contains the analysis of findings. The main purpose of this mixed methods
study was to describe the relationship between PI and of years of NP experience. The results of
the qualitative exploration were then used to study the qualitative aspects of the NP PI. The
results are presented in the following three sections as quantitative, qualitative, and mixed
methods. The project was approved by the IRB committee at the Oklahoma City University
Quantitative Findings
The purpose of the quantitative findings is to measure the relationship between PI scores
using MCPIS-9 and the years of experience as an NP. The study was completed using a survey
format.
Questionnaire
The MCPIS-9 questionnaire is a Likert-like scale that included nine items with responses
scaled from one to five, which measured the professional identity of the participants. On the
scale, one indicates strongly agree and five indicates strongly disagrees. The survey included
three negatively worded questions. These negatively worded questions were reversed coded as
part of standard statistical analysis procedures. The questions centered around a feeling of
belonging, relating and sense of pride the participants felt as nurse practitioners.
Instrument Reliability. Cronbach’s alpha was calculated to measure the internal
consistency of the survey instrument (Tavakol & Dennick, 2011). This survey contained nine
survey questionnaire items that measured. The survey was found to have acceptable internal
reliability coefficient with a score of 0.84 (see Appendix C for Cronbach alpha results).
Acceptable range of Cronbach alpha scores are between 0.7 to 0.95 (Tavakol & Dennick, 2011).
The item total statistic of each of the nine MCPIS-9 scale questions showed individual questions
rated below 0.7, but that deletion of any of the questions did not decrease the Cronbach alpha
score below 0.82 (see Appendix D).
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 47
Data Collection
The survey involved a recruitment of a sample of practicing NPs or NP students to
participate in the study. A power analysis using G* power was performed to estimate sample size.
Using the ANOVA fixed effects with a large effect size, alpha of 0.05, power of 0.80, degree of
freedom of 5 (k-1 where the k equals the six groups) was 86. Study participants were recruited
through snowball sampling and convenience survey sampling. The snowball attempt yielded 15
samples. Survey Monkey was used to send the survey to a convenience sample of participants.
Survey Monkey yielded an additional 1037 participants. Out of the 1037 returned online surveys,
only 125 surveys were completed without missing data, and the participants met the inclusion
criteria. The total response was 1052 which included the 1037 Survey Monkey samples and the
15 snowball samples. The total participants who met inclusion criteria and enrolled in the study
was 140 which included the 125 participants from the Survey Monkey and the 15 NPs from the
snowball sample.
Data Analysis
The software IBM SPSS® Statistics version 29 was used for data analysis. Of the 1052
total number of participants, 13.3% (n = 140) responded to all questionnaire items. Continuous
variables were summarized using means, medians, standard deviations, minimum and maximum.
Categorical variables were summarized with frequencies and percentages. Categorical variables
in this study included: age, gender, ethnicity, state of current practice, type of NP degree, years o f
NP practice and years of RN experience. The continuous variable in this study was the total
MCPIS-9 score.
Categorical Data. The categorical data (See Appendix E) showed that most of the
participants (36%) were between 25-34 years old. The next most frequently reported age was 35
to 44 years old (25%). The remaining age ranges were 18 to 24 (9%), 45 to 54 (18%), 55 to 64
(9%) and 65 and over (2%). The most frequently reported gender was female (70%) with rest
reporting as male (30%). Ethnicity showed dominance toward Caucasian (66%) with the next
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 48
most frequent race of Hispanic or Latino (13%). The other races were Black of African American
(9%), Asian or Asian American (9%), American Indian or Alaskan Native (1%) and other races
(1%).
Participants were certified as NP in several areas including Family NP degree (46%),
Acute Care Adult/Gerontology (10%), Adult/Gerontology (13%) and Pediatric (16%) and less
were Certified Nurse Anesthetists (6%), certified Mid-Wives (6%) or Psychiatry (1%).
Most participants had five or less years of NP experience (41%). The remaining
experience was spread among students (17%), six to 10 years (19%), 11 to 15 years (14%) with
less in 16 to 20 years (6%) and 21 years or more (3%).
The majority of the participants reported five or less years of RN experience (48%)
before transitioning to the NP role. The remaining categories of years of experience was six to 10
years (26%) and the 11 to 15 years (24%). The least participants reported over 15 years (1%) of
RN experience.
Most participants practiced in restrictive authority states (44%). With the next most
prevent full practice authority (32%) and the last group of reduced authority (24%).
Continuous Data. The continuous data obtained from the MCPI-9 scores are reported in
chart form (see Appendix F). These scores were based on the MCPI’s 9 items which were each
measured on a Likert-like scale ranging from 1 to 5 with lower scores indicating better PI. The
range had the potential to vary from 9 to 45 with 27 indicating complete neutrality in scoring. The
most frequently occurring score was 9 (n=15) and the next most frequently occurring was 18
(n=12). Several scores occurred infrequently with 5 or less participants reporting these scores.
These scores are: 14 (n=5), 17 (n=5), 23 (n=5), 25 (n=5), 22 (n=3), 31 (n=2), 24 (n=1), 26 (n=1),
28 (n=1) and 33 (n=1). The remaining scores are: 10 (n=10), 11 (n=9), 12 (n=6), 13 (n=7), 15
(n=7), 16 (n=9), 19 (n=8), 20 (n=10) and 21 (n=8). Analysis of the MCPIS- 9 scores with mean,
standard deviation, minimum and maximum scores indicates that minimum score of nine and
maximum score reported was 33. The means score was 17.04 with a standard deviation of 5.91
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 49
indicating most scores fell between 11 and 23 (M=17.04, SD=5.91). (Table 1). The data suggests
that most participants scored high on the PI scale.
Table 1
MCPIS-9 Total Scores
Statistics
Mean Standard deviation Minimum Maximum
17.04 5.909 9 33 Note. This table shows the mean, standard deviation, minimum and maximum of the continuous
data (MCPIS-9) total scores.
Research Question
The quantitative research question was is there a difference in MCPIS scores with
different years of NP experience? The null hypothesis was that the years of NP experience does
not influence the MCPIS-9 scores and the directional hypothesis that the more years of NP
experience resulted in higher MCPIS scores.
Test of Hypothesis. The hypothesis tested the dependent variable of total MCPIS-9
scores and the independent variable of years of NP experience. The Kruskal-Wallis was used
instead of an ANOVA because the assumption of normalcy in the independent variable was not
met (see Appendix G). The assumptions for the Kruskal-Wallis are that there are three or more
mutually exclusive independent groups of variables for comparison regardless of normal
distribution (Kellar & Kelvin, 2013).
This study used an alpha level of 0.05 to indicate significance. There was statically
significant difference (p= 0.34) in the MCPIS-9 scores among the different NP experience levels
thus rejecting the mull hypothesis (see Appendix H). The post hoc test was done with Dunn’s Q
test (see Appendix I) showing statistically significant difference among participants with 21 or
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 50
more years of experience and less than five (p=0.02). There was also a statistically significant
difference among those with 21 or more years and 11 to 15 (p=0.02), six to 10 years and five
years or less (p= 0.02) and six to 10 years and 11 to 15 years (p=0.02).
Based on the MCPIS-9 scale, the lower the score the stronger the individual’s
professional identity. There was a noted improvement in MCPIS-9 scores in participant groups
with less than five years of NP experience to those with six to 10 years NP experience. The data
suggests a worsening of MCPIS-9 scores among NPs with six to 10 years and 11 to 15 years of
experience (see Appendix J for the graph). The reason for this decline is not clear with the
quantitative portion of the study.
Additional Findings. Additional statistical analysis was run to see if there were any
statistically significant correlations between the other variables and MCPIS-9 scores. An analysis
of MCPIS-9 scores, age and years of RN experience was conducted with a Spearman’s Rho
correlation coefficient. The data met the assumptions for the Spearman’s Rho correlation
including two independent and random samples of ordinal, interval, or ratio measurements, with
at least two variables to compare, with a monotonic relationship (Kellar & Kelvin, 2013). The
alpha was 0.05. The results show a statistically significant negative correlation between age and
MCPIS- 9 scores (p value = 0.003) whereas age increases, the MCPIS score decreases indicating
stronger PI. Also, a statistically positive correlation between age and years or RN experience was
noted (see Appendix K). This positive correlation shows older participants tended to have more
RN experience as well.
Statistical analysis of the gender and MCPIS-9 scorers using a t-test showed no statistical
significance (Appendix L). An N-way ANOVA was run on the remaining variables of ethnicity,
type of NP degree and states of practice with the MCPIS-9 scores and an alpha value of 0.05 and
analysis showed no statically significant difference (see Appendix M).
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 51
Summary of Quantitative Findings
Overall, NPs tended to have positive PI with an average score of 17 and a small standard
deviation of 5.9. The quantitative analysis showed that there is a difference in MCPIS-9 scores
with years of NP experience supporting the directional hypothesis and rejecting the null. Most of
the participants were female, but this reflects the occupations gender disposition as there are more
female nurses than males. Most participants transitioned quickly into the NP role with most
having less than 10 years of experience with clustering to the five years or less. Similarly, most of
the NPs had less than 15 years of NP experience and most indicated five to 10 years.
Previous research by Barnes (2015) indicated that the first two years of NP practice are
the most tumultuous, but the data showed that the period of greatest strain on PI is between the
years of 11 to 15 while the five years or less group had only slightly worse than median MCPIS-9
scores. The reason for this fall in PI between years 11 and 15 was unknown based on the
quantitative data alone.
Qualitative Findings
The purpose of the qualitative portion was to study the intangible phenomena of the NP
PI such as the values, beliefs, and attitudes. The qualitative portion was used to further explore
the intangible aspect of PI such as the values, beliefs, and attitudes of the practicing NP. A special
attempt was made to target NPs with 11 to 15 years of experience and those above 21 years since
these are the two extreme difference in MCPIS-9 scores, but all the years of practice was included
in the qualitative portion. The main qualitative questions included what the perception of the NP
PI is and whether the NP continues to connect to the nursing core. The practicing NPs and
enrolled NP students across the United States were asked to provide their unique experience. The
qualitative study explored the perception of the nursing discipline within the NP profession.
Study Method
The qualitative portion of this mixed method study was phenomenological.
Phenomenological approach seeks to understand a research topic through the experience of the
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 52
participants (Neubauer et al., 2019). As noted by Neubauer et al. (2019), there are different
theories that underpin phenomenological studies identified as transcendental or hermeneutic
phenomenology. Neubauer et al., explained the transcendental approach, as proposed by Husserl,
focuses solely on the individual’s participant’s perception (2019). Transcendental method expects
the researcher to bracket, or separate oneself, from the study.
The hermeneutic method, proposed by Heidegger, understands the researcher cannot
completely exclude oneself from the study (Neubauer et al., 2019). Hermeneutic methodology
includes the researcher as part of the world in which the phenomena is occurring and thus cannot
be removed. However, the researcher can still guide the study without directly influencing the
participant’s perception of the phenomena.
The In vivo coding method was chosen because it was more likely to reflect the inherent
meaning of a person’s lived experience (Stinger, 2014). A secondary method of value coding was
also included in the in vivo excerpts to enrich the codes. Value coding “reflects a participant’s
values, attitudes and beliefs, representing his or her perspective or worldview” (Saldana, 2016, p.
131). Saldana (2016) defines values as the importance a person attributes to a thing or idea,
attitudes as a way a person feels about thing or idea and belief is an incorporation of attitudes and
values that shape a person’s perspective of the world.
Both coding methods offered value in the qualitative findings of the NPs’ perception of
the profession’s identity. In vivo allowed the lived experience of the participants to be undiluted,
while the value coding allowed those experiences to reflect a view of the values, attitudes, and
beliefs.
Management of Researcher’s Bias. Since the approach chosen for this study was
phenomenological the challenge to this methodology was the researcher’s personal experience
and potential for bias and how personal experience and bias may influence the interpretation of
the phenomena. A way to limit the effect of researcher biases is the use of bracketing. The
purpose of bracketing was to ensure that the researcher’s lived experiences are not the lens in
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 53
which the participants’ experience was viewed. However, hermeneutic theory acknowledges that
the researcher cannot remove his or her own experience thus bracketing would not resolve bias.
The goal in the hermeneutic approach to phenomenological research is to be aware of this bias.
The researcher did a self-reflective session using the interview guide to identify her own
views of this phenomenon. The researcher, as a practicing NP, made herself aware of what her
own perception of NP PI was by answering the guiding questions. This allowed the researcher to
identify similarities and difference in the PI perception and supported a deeper exploration of this
unique concept.
The self-reflection session also used journaling to separate the researcher’s views and that
of the participants. Journaling was especially helpful in instances where the researcher’s
perception of the question differed from the participants’ responses. Through journaling, the
researcher acknowledged the difference and analyzed the participants’ response without the
influence of her own opinion. The purpose of the self-reflection portion was to identify
preexisting biases which may influence participants.
Study Procedure
The study procedure used one-on-one interviews conducted through Zoom or in person.
The study was limited to practicing NPs or currently enrolled NP students. The study was
conducted in whatever environment the participants were most comfortable. The interviews were
recorded for documentation and transcription purposes. A guiding set of questions was used in a
semi structured manner (see Appendix N for example of interview questions).
Participants
To protect participants’ identity, the NPs were assigned a random name of a Greek
goddess. The participants were purposefully selected from those that qualified in the quantitative
portion of this study. The purpose of this selection method was to get a reflection of a person’s
experience and expand on the data generated from the quantitative portion of this study. After
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 54
multiple weeks of reaching out to participants, a total of six participants agreed to be interviewed.
All six participants were women with an age range of 35 to 64 with a mean age of 45.
Of the NPs who agreed to participate in the qualitative interviews, most of the individuals
(n=5) practice in restrictive practice authority states, Out of this group of five participants, two
were Veteran’s Health Administration (VHA) employees and thus had full practice authority.
Another participant practiced in a full authority state as a non-VHA employee.
This resulted in three (n=3) NPs with full practice authority and three (n=3) with
restrictive authority. Five of the NP had a certification in family practice and one individual was a
certified adult/gerontology NP. The ethnicities of the participants were split between Asian (n=3)
and Caucasian (n=3).
Qualitative Findings
Phenomenological research uses interviews to explore the lived experience of the
participants (Gray et al., 2017). Once all the data was collected through interviews, all the files
were uploaded into NVivo software for transcription, analysis, and coding. NVivo is a qualitative
data analysis application that allows researchers to collect, organize, analyze, and
visualize unstructured or semi-structured types of data. The transcriptions were compared to the
original recordings for accuracy.
Once each interview was transformed into an audio source file with the NVivo software
the actual data analysis or coding began. Coding is the process of putting together extracts from
the transcripts that are related to each other into basins called nodes. Specifically, transcripts were
thoroughly read, and nodes were created during the process to house relevant excerpts from the
transcripts. Audio files were listened, and relevant audio excerpts were coded to new and or
existing nodes. Content of the nodes were constantly reviewed as part of the analysis process and
the emerging themes were separated into three tree nodes based on values, attitudes, and beliefs
(Value in relationships, Attitude of confidence and caring, and Beliefs in nursing as the core NP
identity (See Appendix O). In addition, eight subthemes were identified. Saturation of data was
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 55
reached as recurring themes emerged. The themes were organized into three main themes of
value, attitude, and beliefs with subthemes identified within each .
Thematic Findings
The themes were divided into value, attitude, and beliefs. The value themes were
reflected on relationships the NPs had with patients, nurses, physicians, and administration. The
attitudes were centered on how the NPs viewed their practice. The NPs reported confidence in
their practice abilities and caring as central themes. Lastly, the NPs reported the belief that
nursing remains the root of their NP identity. The NPs also believe that nursing and medicine
have equally significant contributions to their practice and patient care.
Theme 1: Value in Relationships
The NP participants repeatedly mentioned relationships as something valuable and
important. The participants felt that their relationships with physicians, nurses, administrators,
and patients changed with the transition to the NP role. The change was not negative or positive,
but it was a common challenge experience by the NPs. The NPs needed to set new boundaries
and educate those around them about their role to find a new balance.
Subtheme: Relationship with Patients. The relationships with the patient changes from
someone who executed physician orders to someone who now makes a care plan. Patient also
needed to be educated on the abilities of the nurse practitioner. For example, participants said:
(Hera) “Some of the patients who are educated, they understand nurse practitioner. But some of
them, you really need to let them know that I’m not a nurse. I went back to school and I’m a nurse
practitioner, so it’s mixed”.
(Hestia) “They have no clue, and it irritates me when you have to say we’re like a PA. We are,
but we aren’t, but sometimes people can’t get it unless you um, put it in terms that they know”.
(Artemis) “I think a lot of people still question what we actually do. They think that we’re nurses
and not a provider until they are educated and then they’ll be like, ‘Oh, so you’re a doctor?’”
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 56
The relationship with patients centered around letting the patients be active participants in
their care. The NP understood that dictating a medical plan without a patien t’s input would risk
noncompliance. In additions, participants stated:
(Aphrodite) “We build relationships and then we know, we give overall care, not only focused.
And we spend a lot of time to understand the patient’s need. And I think that all comes back to the
basics of nursing”.
(Hestia) “Nursing 100% is being able to establish a relationship person to person…. Medicine,
it’s a lot of telling people what to do. We don’t tell people what to so. We ask them what they’re
ready to do first”
Subtheme: Relationship with Nurses. As previously mentioned, RNs can be resistant
in accepting the NP role, leading to a sense of betrayal for the NP (MacLellan et al., 2016). While
the NP can complete routine patient care duties their responsibility is now to provide patient care
in a different role. For example, one participant noted:
(Hera) “I mean we have a good relationship and sometimes, the nurses have had to have a clash
with them because they forget. They keep thinking, I’m a nurse”. “Why can’t you do it? Because
you still have your RN license”.
The result of Hera establishing boundaries was an improved relationship with nursing
staff. She helped the nursing staff understand that her priorities have changed as an NP, and this
does not mean she does not value the nursing roles.
The participants also believed that perception of the NP role by other medical professions
(mainly nursing) depended on their previous interaction with the individuals in those roles. One
participant, Hestia emphasized being a part of a team.
(Hestia) “It depends on whether they’ve worked with someone that was a quality provider, part of
the team versus someone who is coming in and trying to tell them what to do yet again”.
Subtheme: Relationship with Physicians. Physicians were generally accustomed to the
RN role and understood what an RN can and cannot do. Many physicians remain unaware of the
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 57
NP education and role functions. This can impact working relationships and acceptance of NP as
members of the healthcare team. The participants voiced a perception of hostility from
physicians because they perceive that NPs are encroaching on their medical domain.
(Artemis) “They’re a little bit possibly more reserved… because they might feel threatened by
how we want full practice authority and how we want to work independently and so there’s some
friction there”.
(Hestia) “Physicians have told their patients they need to get a real doctor”.
Not all physician relationships were negative. Hera and Athena believe that they have a
good relationship with their physician counterparts built on communication. They perceived the
MDs were confident in the NPs ability to care for patients.
(Hera) “I think that there is a good camaraderie and rapport as far as nurse practitioner and
doctors. An, I feel like that they are confident, and more comfortable with nurse practitioner to
take care of patients”.
Physicians could also negatively or positively impact the NPs relationship with patients.
(Athena)” I think just education and when they do see their physician, that when they say ‘oh,
you’ll see the nurse practitioner’ that they introduce them in a way that sheds some light to the
role and importance. That it’s just not like my back up person and that’s just going to take notes
and I’ll see you later”.
Subtheme: Relationships with Administrators. The NPs in the study voiced that
administrators were overall very accepting of their role because they generated revenue. The
relationship with administration depends on the ability of the NPs to be financially viable member
of the team. The ability to generate revenue is dependent on the practice authority of the state .
(Hera) “They (administrators) would do anything for us because they see our productivity”.
Hera practiced in a federal facility (where they are independent providers) exp ressed
satisfaction with administrators because their financial contributions were clear. Athena was also
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 58
in a full PA state but worked in a primary care organization reported a different view of
administrators.
(Athena) “I feel like right now a nurse practitioner, although we can do so much, and we make
such a big impact; I think overall we’re still seen as cheap labor”. Additionally stating “I’m not
sure if they have the same type of, I guess, respect for nurse practitioners as they do for like an
MD”.
Theme 2: Attitude of Confidence and Caring
NP reported their confidence to practice was improved through a trusting relationship
with role models and other physician colleagues. Trust, mainly trust between NPs and
physicians, was a recurring theme. Mentorship also influenced attitudes of the NP. Mentors
modeled the PI to the NPs and taught them how to practice, but also the attitudes that reflect the
profession and its values.
(Athena) “I had good role models who were nurses who encouraged me to pursue a career in
nursing”.
(Aphrodite) “My father was a surgeon, and my mom was a nurse and so they were missionaries
in South American. And so, I’ve just seen that modeled for pretty much throughout my life”.
Subtheme: Autonomy and Trust. The participants reported being drawn to the NP
profession because of autonomy and independent practice. Nurses are vital healthcare members
but are not independent care providers and they are bound by their scope of practice. Participants
said:
(Athena) “I want to do a little bit more than be the typical eyes and ears of the doctor and
following orders. But being able to make decision on my own and diagnose and treat”.
(Hera) “I was so interested that I could practice independently and take of patients”.
(Hestia) “One was autonomy”.
(Demeter) “Looking at the nursing job, then being in that role and being in health care for this
long. I enjoyed being in the nursing facility, helping patients and being there for them. I wanted
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 59
to take a step back and see a lot of things that happened in the clinics and hospital. I wanted to be
in the other part of the role as a provider. So basically, I took my time to do that nurse
practitioner school. And I wanted to learn a lot more in the provider aspect because you’re
constantly not treating patients on your own as a nurse. Do, providers’ role, being able to
prescribe, being able to delegate to others and so on”.
Full practice authority is a restricted luxury in some states. Until there is legislative
change, trust between the NP and the supervising physician can improve autonomy in restrictive
PA settings. Even those individuals with full PA stated a trusting relationship with physician
colleagues improved their ability to deliver care to patients. Trust translated to more autonomy
since physicians felt confident in the decisions made by the NP.
(Athena) “They also trust me and my judgement, and so also allows me to have my autonomy to
also practice the way that I like to practice”. Athena further states “I said, I’m fortunate enough
to work with two great doctors who communicate well, and I do feel like we have a good team in
regard to primary care. Which is important”.
(Hera) “So, my chief, she didn’t even look into the chart to verify. She just approved it. I think
she’s gained her trust with me working with her for so many years”.
(Aphrodite) “My current position is absolutely my favorite job so far. Somewhere I can see
staying. The patients love me. My surgeon I work for is only in clinic one day a week, so I’m very
independent. My autonomy is huge”.
Another participant identified open communication as a critical tool to building trust.
(Demeter) “They did trust us, but a lot of times it’s scary because at night you’re on your own.
You have residents to rely on. So that’s what we constantly call… If we communicate, we didn’t
communicate with them constantly then and we just will do what we wanted, I’m sure the
physicians would have had trouble with us. So, that’s why just letting them know and updating
was a big thing for me. And that’s what I did, and they truly appreciated that”.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 60
Subtheme: Mentorship. The NPs voiced the uniqueness of their role was the ability to
provide holistic patient centered care. Mentorship helped shape how the NP fit into the
healthcare team and perceived the PI. Mentors who valued their profession and demonstrated
caring passed this trait to their mentees. Mentors facilitated the acceptance of the NP into the
healthcare team.
(Athena) “It’s nice having that support from other nurse practitioners who already carved out the
roles and responsibilities of a nurse practitioner in primary care”.
(Aphrodite) “I think that people that have been a nurse practitioner for, you know, anywhere
from one year to, you know, pretty, much a lifetime, took me under their wing and showed me
what, you know, what that particular role that they did as far as being a nurse practitioner”.
The mentors were not always other nurse practitioner. Another NP identified physician
mentors who provided guidance, more so than other NPs.
(Artemis) “I guess some of the doctors really were my people that I trained under. I had a nurse
practitioner, but she already had… she had been with them for a couple of years. She had her
own clinic. She was out doing dialysis rounds or rounding in hospitals, so I was kind of just
thrown out there”.
Theme 3: Belief that Nursing is the Core of NP Identity
The NPs reported that nursing remained the core of their PI. They did not feel their role
change resulted in a departure from the nursing discipline. They felt the role change allowed them
to practice their nursing skills in a different way.
(Athena) “I have an extra degree where I can actually manage medication, prescribe, and
diagnose. But you know the core root of what I do is nursing”.
(Hera) “I’m in this profession, so I think that’s really laid a foundation, and I still think when I
talk to my patients and all, that TLC is there… So, I think I pretty much maintain my nursing
core”.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 61
(Hestia) “Being able to utilize medical knowledge, but never letting go of that nursing ability to
say, how does this affect you?”.
(Artemis) “I still use my nursing background. You know, the lab results and how we communicate
with doctors and collaborating with other physicians. I think all of that is geared toward my
nursing education”.
Subtheme: Holistic Care. A recurring theme present in the study was the delivery of
holistic patient centered care by the NP. The NPs felt this ability was a result of their nursing
background. The nursing root also allowed the NP to transcend the existing medical health care
model. This practice is fundamental to nursing and is essential to the NP profession. This ability
set the NP profession apart from medicine and anchored them back to the nursing root.
(Aphrodite) “You can look at the person as a whole and be able to, you know, treat them as an
individual instead of a body system”.
(Athena) “it’s not just like health conditions and ailments, but also their psychosocial history and
things like that also influence their overall care. And so, I think nursing focuses on that more than
the traditional plain medicine”.
The participants also believed that the NP profession could deliver quality care to
patients. Holistic care was also reported to be a reason patients opted for NP care over other
healthcare providers. Participants stated:
(Aphrodite) “They’re going to be well taken care of because they’re (NPs) well versed in, you
know, as far as all the medical disease processes, but also the, just in other conditions and
situations”.
(Demeter) “We tend to talk to patients more, spend time with patient more and are more open.
Have an open relationship or open communication with the patient versus a closed ended
question or are trying to get them out of their clinic and really communicating and following up
as needed. And, we see a big difference. Even patients themselves tell us as a nurse practitioner,
how great we do versus when they see MDs and PAs”.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 62
(Athena) “I’ve heard repeatedly over and over how some people would rather have a nurse
practitioner because I think as a whole, nurse practitioners spend more time talking to the
patient, trying to figure our what’s going on? What are their issues?... But I’ve gotten positive
feedback as far as wanting a nurse practitioner to take care of them because of those results”.
(Hera) “I ask them, always, do you want to follow up with an MD? And they always say no, I’ll
continue with you. So, I think once you maintain the relationship and explain, I think they really
like nurse practitioners”.
One participant reported that she had identified holistic care as a possible burden to NP
providers. She found that accepting the status quo was less stressful than challenging the system
and risking possible burn out. External factors like insurance and prescriptive authority were
reported by the participants as having a negative impact on their ability to provide holistic care.
(Athena) “I’ve accepted there are some holes in our healthcare system and in a way, it’s a way
for me to protect my own sanity and mental health so I don’t get burned out because of
disappointment”.
Another participant agreed with the perception that external factors impacted their ability
to provide holistic care.
(Artemis) “Maybe it’s more insurance, here’s my problem, b iggest problem is getting things
approved. Pain medication is a huge issue right now. You know, my doctor has to prescribe
everything. We don’t have that prescriptive authority”.
Subtheme: Transcending the Medical Hierarchy. The NPs participants did not see
physicians as superior, but rather a resource to their practice. They acknowledged the education
of the MD degree but did not feel this education made them better providers. The NPs continued
to identify as nurses thus do not see nurses as inferior providers.
(Demeter) “I think it (NPs) fit. I mean, I think a lot of times we can be equals. But they do have
more training and knowledge, especially when it comes to a specialty”.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 63
(Hera) “Sometimes the negative role is like some of the patients are really complicated and I
don’t have that confidence. I mean, at least, I send them to an MD for a second opinion and many
times, I wish I had more experience of them”.
(Aphrodite) “I think it’s very positive from a, especially in this American society that we live in. I
feel like they do get the respect, especially when being in MD perspective. There’s no, there’s no,
I don’t see, especially at the area that we work at. I don’t see like, OK, these are going to be in
this higher class or, they (NPs) are in this middle area and, yeah, nurses there in the lower. I feel
like we all treat each other the same”.
Qualitative Summary
The themes of the qualitative study show that there is a shared identity among NPs. The
participants all felt their nursing roots gave them the ability to face challenges that came with role
transition. The change from RN to NP changed the relationship the participants had with patients,
nurses, physicians, and administrators. The NPs felt that their nursing background gave them the
ability to educate those around them of their role which re-established relationships and set new
boundaries.
Nursing was central in their NP education. The NPs did say their confidence in their NP
role grew with time as their skills were refined. Mentors were valued by NPs. The NPs shared a
common identity that their nursing background instilled in them the ability to care about others.
Lastly, the participants felt nursing remains the root of their NP identity. They do not feel
they have left nursing, but rather they practice nursing with different skills. Practice restrictions
were not a hinderance to the NP because of their ability to form trusting relationships with
physicians. They showed their skills as providers and physicians trusted their decisions, so this
helped bypass the PA limitations. The NPs did not feel the physicians were better or above them
and nurses below. They did not acknowledge the traditional hierarchy. The uniqueness of NPs is
their ability to bridge nursing and medicine to deliver holistic care.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 64
Mixed Method Findings
The purpose of the mixed methods (MM) study was to explore the perception of the NP
PI among practicing NPs and NP students. The approach was an explanatory sequential model
where the quantitative data was collected first using the MCPIS- 9. Then the qualitative data was
collected using a phenomenological approach and semi-structured interview. Data was collected
in this method to identify the intangible aspect of PI value, attitudes and belief of the NP as seen
by students and practicing NPs. The qualitative question was what is the PI perceived by NPs and
NP students? The quantitative hypothesis was that the PI is affected by the years of NP
experience and the null was that there would be no affect. The mixed method research question
was: do NPs with different years of experience have different view of their PI?
Integration of Data
Data integration is the process of carefully and methodically combining or merging data
from different sources into a single unified view. This makes the data more useful and valuable
than a single form of data. When the data is merged the information f rom each data set is
combined based on common identifiers.
The quantitate data was collected first using MCPIS-9 survey and then analyzed. Then
the qualitative data was collected, analyzed, and integrated with the quantitative MCPIS-9 using a
joint display of the MCPIS and the interview question. The data integration was further expanded
to include direct quotes from participants that reflect the sentiments of NPs and NP student
perception of PI (see Appendix R).
The quantitative strand explored the hypothesis that more years of NP experience would
result in higher MCPIS-9 scores while the null would be that there would be no change in
MCPIS-9 scores with years of experience. Analysis of the MCPIS-9 scores using the Kruskal-
Wallis identified a significant difference (p= 0.34) in PI (see Appendix H for statistical results of
Kruskal-Wallis). This resulted in the rejection of the null hypothesis and the acceptance of the
directional hypothesis.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 65
This result was also reflected in the qualitative finding. Specifically, the six individuals
who participated in the interview had an average MCPIS-9 score of 11, which indicates a strong
PI rooted in nursing. All participants reported their perspectives and experience in developing PI
as NPs. Participants reported:
(Demeter) “Our background with nursing major made a major impact. And I feel like we
became more independent with our nursing background itself. Although we use to take on tasks
that was given to us as nurses; but now, now that we’re on the other side of it, we have been in
the setting for so long. We have seen our doctors talk to nurses and how we communicate. So,
using our nursing background, we are able to, I feel like it’s improved when I communicate with
my nurses. Improved communicating with tasks and so on. And, not looking down on them
because we have that (nursing) in the background”.
(Hera) “we build a relationship and then we know we give overall care, not only focused and we
spend a lot of time to understand patient’s need. And, I think that all comes back to nursing”
(Hestia) “nursing sets us apart from pure medicine”.
(Aphrodite) “Nursing brings, I think, the aspect of being able to look at every like the whole
person and is able to really kind of hone in on the, you know, the humanistic part, the quality, you
know, the part, the caring part, the caring about others. Not that the medical model doesn’t, but
they’re just more focused on facts”.
Despite the quantitative data suggesting a significant drop in NP PI at the 11 to 15 years
mark, the two providers Athena and Artemis remained consistent in their qualitative perception of
NP PI. These two providers were the only ones to express an extrinsic factor of insurance
limitations contributing to satisfaction in their role.
Summary of the Mixed Methods Findings
This chapter presented a review of the data analysis and findings from a mixed method
research project to determine the PI of NP. The data collected included the demographic survey,
MCPIS survey, and the semi-structured interview about the perception of NP PI.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 66
In this mixed-methods study, based on the statistical findings, of the quantitative data,
indicated that the participants identified themselves as having a high PI. The qualitative findings
reported three main themes. The themes were values in relationships, attitude of confidence and
caring, and a strong and shared belief that nursing remains the core of NP identity. All three
primary themes include subthemes including relationships with patients, other nurses, physician,
and administrators. Other subthemes revolved around autonomy, trust, and mentorship as well as
holistic care and transcending medical hierarchy.
Finally, the mixed methods findings found similarities in the participant PI in both the
quantitative and qualitative strands. Specifically, the quantitative results yielded general trends
and relationships which are often needed while qualitative results provide in-depth personal
perspective and experience of NP PI. The findings from both the quantitative and qualitative
strands imply that there is a shared strong PI among NPs and NP students centered around a
common nursing root. The qualitative data did not identify an obvious reason for the drop in PI
among practitioners with 11 to 15 years of NP experience noted in the quantitative strand. The
reason for this remains unclear.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 67
Chapter 5 Discussion
The aim of this study was to investigate the PI of the NP. The PI was explored using an
explanatory sequential mixed methods approach. The study was approved by the Oklahoma City
University IRB and the consent template was completed by the researcher and participants for the
qualitative portion. The Survey Monkey quantitative portion notified the participants of the study,
but did not get physical signatures since it was an anonymous online survey. Consent was
assumed when the participants completed the survey (see appendix S for a copy of the consent).
The concept of PI is complex, and a quantitative or qualitative approach alone would miss some
important aspects of this multifaceted topic. Professional identity not only includes the skills and
knowledge of a profession, but the values, attitudes and beliefs shared by its members (Adams et
al., 2009; Worthington et al., 2013). Professional identity involves an individual’s personal view
of the profession, views of colleagues working with someone in that profession , society’s
understanding, and value of the profession as well as the consumers who receive service by the
profession’s members. Certain characteristics of an individual’s PI can be quantitively measured
with instruments. These characteristics include professional knowledge and skills. However,
intangible aspects like values, attitudes, and beliefs can only be explored through qualitative
studies. To fully explore PI, the study used both quantitative and qualitative approaches.
Professional identity (PI) is often mistaken for professionalism, but these are not
interchangeable concepts. As noted by Katz (2013), professionalism is the expected behaviors of
a member of a profession. In contrast, PI provide definition and is based in the practitioner’s view
and perception of those behaviors.
Mixed Method Study Review
A MM approach was used with an explanatory sequential method to better explore PI.
Since there were no available previous studies showing variations in PI among NPs, this was
explored first with a quantitative approach.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 68
Demographic of Quantitative Participants
The quantitative portion was done through survey method. The survey had demographic
questions including, age, gender, ethnicity, years of RN experience, years of NP experience, the
NP degree, and states of practice. The demographic data collection was initially done through
snowball sampling which produced 15 participants. This was not sufficient to meet power, thus
the collection as expanded to include purposeful sampling using the survey engine Survey
Monkey which produces an additional 1037 participants. Totally participants including the 15
snowball samples was a total of 1052. Of the 1052 participants, only 140 (15 snowball samples
and 125 Survey Monkey participants) met inclusion criteria and were enrolled. The participants’
age ranged from 18 to 65 or older with most frequent age range at 36% being 25-34 years old (n=
50), mostly females at 70% (n=98), mainly Caucasian at 65.7% (n=92) with the next largest
ethnic group being Hispanics at 12.9% (n=18). Majority of participants at 46% were certified
Family NPs (n= 64) with 44% practicing in restrictive authority states (n=62). Majority of the
participants reported five or less years of RN experience (48%) before transitioning to the NP role
(n=67). Majority of the participants at 41% had five or less years of NP experience (n=58).
The quantitative survey used the MCPIS-9 to measure the PI of current NP students and
practicing NPs. The survey had nine questions which were calculated for a total MCPIS-9 score.
The Cronbach alpha for the nine questions was 0.84 indicating a good reliability among the
questions. Lower scores indicate stronger PI. The means score was 17.04 with a standard
deviation of 5.91 indicating most scores fell between 11 and 23 (M=17.04, SD=5.91). The most
frequent MCPIS=9 total score was nine (n=15).
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 69
Demographic of Qualitative Participants
The qualitative portion was done after completing the quantitative analysis. The
phenomenological qualitative study was done using the interview method to evaluate what
practicing NPs and NP students felt were the values, attitudes, and beliefs of the NP PI. The
Survey Monkey did not allow participants to enter personal data so they could not be contacted
for qualitative interviews. The 15 snowball participants did indicate if they wished to participate
in the qualitative interviews. Six participants agreed to the qualitative portion of the study. The
participants were all females (n=6) ranging in age from 35 to 64 with a mean age of 54. Majority
were family practice NP (n=5) with only one adult gerontology NP. The practice authority was
split evenly with three participants in full and three in restrictive territories. The ethnicities of the
participants were split between Asian (n=3) and Caucasian (n=3). The total MCPIS-9 scores
ranged from nine to 16 with a mean score of 11. The years of NP experience ranged from student
(zero years of experience) to 18 years with an average year of practice of 10.5 years. The
previous RN experience ranged from three to 25 years with an average year of practice of 10.5
years also.
Quantitative Findings
The quantitative study hypothesis was that the years of NP experience would exert an
influence on the MCPIS-9 scores. The null hypothesis was that that the years of NP experience
would have no impact on MCPIS-9 scores. The test of hypothesis was done using the Kruskal
Wallis statistical test. The analysis showed a statistically significant result of 0.034 (lower than
the p value of 0.05) which led to the rejection of the null hypothesis.
Further analysis suggested that the NPs indicated a strong PI with the most frequent
MCPIS-9 total score of nine, but that there was a drop in the PI for those who had 11 to15 years
of NP experience. The reason for the decline in PI scores during this period is unknown.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 70
A study conducted by Kacel et al., (2005) noted a fall in satisfaction with each year of
experience with a plateau of dissatisfaction occurring between eight to 11 years of experience.
The authors indicated a ceiling in pay raises and limited opportunities advancements with
increasing number of years of practice lead to lower NP satisfaction.
A study by Ryan and Whitaker Ebbert (2013) reported a higher level of satisfaction in
new NPs than those with 5 to 10 years of practice. From these results, one might conclude that the
newness of the experience and initial pay raise that occurs with the role change “wears off”
resulting a decline in satisfaction with the provider role can occur.
These two studies by Kacel et al., (2005) and Ryan and Whitaker Ebbert (2013) are not
limited to newly transitioned but were also not specific to the mid-career practitioner. This study
identified a period of low PI among those with 11 to 15 years of experience aligning with these
previous studies. It remains unclear, what is causing the drop in PI and satisfaction among NPs at
the midpoint of their careers.
The quantitative data established that there was a range of PI among NPs with different
years of experience, but could not explain the attitudes, values, and beliefs of the NP profession.
Aligning with previous studies by Barnes (2015), previous RN experience was not a statistically
significant influence on the MCPIS-9 scores. There were no significant correlations with the
ethnicity or gender of the participants and the MCPIS-9 scores, but it is unknown if this is a true
finding or skewed due to the population of the study being homogenously 65.7% Caucasian and
70% females.
Qualitative Findings
Nursing has been referred to as a science and an art, but Gadow (1995) stated that science
and art are epistemologically mutually exclusive. Science depended on positivist and clinical
observations and art of caring has theoretical concepts. An inability to measure the art of caring
and the skills of clinical practice left the nurse unable to quantify the level of expertise (Gadow,
1995). Bender and Holmes (2018) believed that nursing discipline was an embodiment of
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 71
objective (evidence-based knowledge) and subjective (artistic and instinctive) knowledge.
Nursing has traditionally been focused on the human-universe- health relationship (Rogers, 1970)
and the holistic approach to care and quality of life (Willis, et al., 2008). The qualitative study
was aimed at asking what the values, attitudes, and beliefs were of practicing NPs and NP
students.
A self-reflection session was conducted by the researcher in line with the hermeneutic
approach. The purpose of this session was to identify pre-existing bias the researcher may have
regarding this topic that may influence the participants. During this session, the researcher was
able to identify that she had embedded biases based on her own experience as a nurse
practitioner. The researcher believed that the nursing fundamentals of caring, education and
relationships were crucial components of the NP profession and education. To neutralize this
bias, the researcher kept the questions about nursing within the NP education and profession very
broad.
The experiences of the participants were similar to the researcher’s. There was a strong
sense that the participants continued to feel connected to their nursing background. The
participants reported a desire to be more independent as a decisive element in the transition from
RN to NP.
Jakimowicz et al. (2017) reported that confidence and skill increased with more years of
experience. The greatest change during the years of NP experience was increased confidence. The
NPs voiced their confidence to manage complex cases and time management increased with more
years of NP experience.
The researcher also had a misconception that the current hierarchy placed the NP at a
disadvantage and was surprised by the consistent sentiment of belonging in the hierarchical
model. The participants reported that they did not sense tension from physician and nurse
colleagues but did report this was likely influenced by individual work environment. The self -
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 72
reflection allowed the researcher to see parallels to her own views and how the other NPs see the
profession.
The findings of the qualitative data were coded using the In vivo method with an
additional coding method of value coding. The themes were divided into value, attitudes, and
beliefs with a total of eight subthemes. The PI of the NP was influenced by the value in the
relationships among physicians, nurses, administrators, and patients. A study by Hans et al.,
(2018) reported the strength of interprofessional relationships had the greatest influence on job
satisfaction but was highly dependent on the organization and available support. The relationships
were changed but not broken. The NPs voiced a need to clarify their abilities and scope of
practice to differentiate themselves from their former RN role. However, the NPs did not feel the
change in duties was seen as a departure from their nursing root.
Value Themes
The initial theme of value explored the changes in relationships with patients, physicians,
nurses, and administrators after the RN transitioned to the NP role. As Parse (1990) stated in her
theory of Human Becoming, the change in role made the NP evaluate what was important. They
voiced tension as they found their place among the medical team members, but overall expressed
positive relationships.
This theme had four subthemes. The NPs felt their relationships with patients was made
stronger because they were nurses. Patients were valued as active participants in the care plan.
This notion aligns with the study done by Mark and Patel (2019) showing NPs provide quality
care and patients have positive views of their interactions with this profession.
The second subtheme was the relationship between NPs and nurses. All the participants
reported positive relationships but did note tension when their role was not well understood.
Underutilization the NP role also bring negative feelings, job dissatisfaction (Ljungbeck et al.,
2021; Owens, 2019). Misunderstanding of the NP role also diminishes the societal value of the
role by not truly reflecting its contributions. There was a need to set boundaries with nurses, so
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 73
they were not relegated to their former nursing duties and left unable to practice as NPs. Nurses
did not accept delegated duties from NPs because they felt the NPS were still nurses and thus
could and should continue to perform nursing tasks. This caused tension between NPs and nurses
because there was a lack of understanding of what the NP role entailed. The NPs felt that clear
and firm clarification of their abilities and changes responsibilities helped establish a healthier
relationship with nurses and resolved the tension.
The third subtheme focused on the relationship between NPs and physicians. Overall,
NPs voiced positive relationships with physicians. Again, it was important to reinforce the
relationship through communication. This provided the physicians a chance to understand how
the NPs practice and opened the path to a trusting relationship. Communications also allowed the
physicians to feel a sense of control over the situation even when they were not present. One
participant quoted:
(Demeter) “They did trust us, but a lot of times it’s scary because at night you’re on your own.
You have residents to rely on. So that’s what we constantly call… If we communicate, we didn’t
communicate with them constantly then and we just will do what we wanted, I’m sure the
physicians would have had trouble with us. So, that’s why just letting them know and updating
was a big thing for me. And that’s what I did, and they truly appreciated that”.
The final subtheme was the relationship between NPs and administrators. As mentioned
above by Meleis and Schumacher (1994), organizational transitions occur because the NP role
and duties differ from that of a nurse. The NP had to re-establish these relationships in his or her
new role. The NPs felt their relationship with administrators depended on how much revenue they
could generate. The relationship between administrators and NPs were seen as positive if the
administrators saw NPs as financially valuable. As previously quoted by a qualitative participant:
(Hera) “They (administrators) would do anything for us because they see our productivity”.
Despite this, there continued to be sense that NPs were less than physicians as quoted by
one participant:
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 74
(Athena) “I feel like right now a nurse practitioner, although we can do so much, and we make
such a big impact; I think overall we’re still seen as cheap labor”. Additionally stating “I’m not
sure if they have the same type of, I guess, respect for nurse practitioners as they do for like an
MD”.
The lack of full practice authority (PA) adds additional challenges to the NP to
administration relationship. Underutilization of NPs by administrative has been cited in previous
research as negatively impacting NP job satisfaction (Faraz, 2016; Schirle & Dietrich, 2020). If
NPs cannot prove their financial value, they risk being used as physician support or extension of
the nursing labor force rather than a unique profession. The NPs in the study acknowledge the
existence of the PA restrictions and manage around this by developing strong and trusting
relationships with their supervising physicians.
Attitude Themes
The attitudes of the NPs reflected confidence and caring as important factors. There was
a shift in NP attitude because of a shift in role. Attitude reflects the situational change that occurs
when the RN becomes an NP. The NP had to cocreate an environment that could highlight their
unique PI. The NPs felt their confidence naturally increased over time, but that having mentors
helped them feel accepted. Mentors were vital to the development of the PI by showing the NPs
how they should behave as a professional and negotiate relationships within their workplace. The
NPs also noted that trust between themselves and physicians was essential to their practice.
The attitude’s theme had two sub-themes. The first sub-theme focused on the connection
between autonomy and trust. As previously mentioned, many of the NP practiced in restrictive o r
reduced authority states, but even those with full authority voiced a trusting relationship as vital.
The more trust the physicians had in the NPs, the more autonomy the NPs had to practice
independently. One participant stated:
(Hera) “So, my chief, she didn’t even look into the chart to verify. She just approved it. I think
she’s gained her trust with me working with her for so many years”.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 75
The existence of PA limitations leaves NPs highly dependent on their ability to form
relationships with physicians to have autonomy. However, if the NPs cannot connect to a
supervising physician, the restrictive PA could result in a huge disability to the service the NPs
can provide patients. Practice authority limitations can only be conquered through legislative
change.
The NPs feel there is a financial motive to continue to force collaborative agreements
especially since there are studies showing that NPS deliver the same or better quality of care than
MDs and physician assistants (Kippenbrock et al., 2019). Limitations on PA were felt to be
predatory and financially motivated rather than a true concern for patient safety. Physicians often
require NPs to sign agreements where a fee is paid for them to be available to sign prescriptions
and review charts. A study participant voiced:
(Hestia) “from the site perspective, it is a limit. It’s kind of a racket, in my opinion that it is still
the way it is. Because they’re (physicians) making so much money off of it. You can’t help but
think that that’s the reason that they restrict us from prescribing when we’re trained to”.
Mentorship was the second sub theme within attitudes. Many of the NPs voiced that their
initial introduction to nursing and caring was before they even started their careers. Early
influence and choice of profession have been connected in other research which indicate a
relationship between early experiences and influence which create a foundation for children
which can be further shaped by belief and expectations of the person (Akosah-Twumasi et al.,
2018, Nyamwange, 2016). The NPs had a recurring theme of having caring influences early in
their lives which attracted them to the nursing profession. Many participants voiced examples of
caring and nursing throughout their childhood such as:
(Athena) “I had good role models who were nurses who encouraged me to pursue a career in
nursing”.
(Aphrodite) “My father was a surgeon, and my mom was a nurse and so they were missionaries
in South American. And so, I’ve just seen that modeled for pretty much throughout my life”.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 76
The NPs continued to note that mentorship and the influence of other practitioners helped
shape their practice. According to Barnes (2015), the first two years is the most stressful in
transition and mentorship is a positive factor to ease the stress. The NPs felt their confidence
naturally increased over time, but that having mentors helped them feel accepted. Mentors were
vital to the development of the PI by showing the NPs how they should behave as a professional
and negotiate relationships within their workplace. Mentors are tasked with preserving the
nursing within the NP PI. Mentors are influential aspects of feeling accepted into the NP
profession and place of employment. This aligns with the study by (Barnes, 2015; Dillion et al.,
2016; Faraz, 2016) stating mentors are important. Organizations should invest in mentorship
programs which are not limited to new NPs. The PI of the NP can fluctuate (Poronsky, 2013) so
the mentorship program should be open to any practitioner regardless of years of NP experience
Orientation is an organizational process that helps NPs transition into their roles, but
mentorships are personal connections. Mentorship helped NPs ease into their roles even if there
was no formal orientation. Most of the participants voiced a lack of formal orientation when they
first started. However, these participants did not see a disadvantage to a lack of orientation. The
NPs were seasoned practitioners and felt that they “hit the ground running” and this made them
self-reliant. One participant stated:
(Atremis)” It definitely made me become more independent quicker. I had to kind of figure things
out on my own. But it also allowed me to have the confidence to ask for help or if I didn’t know
something, I had multiple resources and kind of learned, you know, there’s too much to know. So,
you have to branch out and ask from time to time.
Belief Theme
The NPs state that nursing remains the core of their NP PI. The NPs felt they were still
nurses but had a different set of skills. The NPs did not fully ascribe to the medical model
because of the nursing root. The study showed that the NPs feel they had good examples of
nursing within their NP programs helping them preserve the nursing root. The International
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 77
Council of Nurses [ICN] (2020) and the National League of Nurses [NLN] (n.d.) expect the NP
programs to continue to preserve the nursing discipline and the study is an example of this
objective in action.
The belief theme had two sub themes. The first sub theme focused on the holistic care the
NPs offer. This combination of medical skill and nursing root resulted in the unique ability to
care for a patient holistically. The NPs could see beyond a diagnosis and expand their care plan to
incorporate social, financial, and mental components. Participants stated:
(Aphrodite) “You can look at the person as a whole and be able to, you know, treat them as an
individual instead of a body system”.
(Athena) “it’s not just like health conditions and ailments, but also their psychosocial history and
things like that also influence their overall care. And so, I think nursing focuses on that more than
the traditional plain medicine”.
Transcending the medical hierarchy was the second sub theme within beliefs. The
participants felt the hierarchical system was not a challenge for them. They did not identify
transdisciplinary care, but voiced actions that reflect it. The main concept within transdisciplinary
care is the abandonment of professional silos that limit the sharing of experience, knowledge, and
respect (Choi & Pak, 2006). The NPs felt MDs were resources due to their expertise, but not
practicing above them. They felt respectful of nursing staff but voiced the need to establish
boundaries so they could practice as NPs rather than continue in nursing tasks. The NPs felt
patients observed the medical hierarchy in preferring physicians but were won over after seeing
the positives of holistic care that NPs can deliver. The NPs do not see the boundaries of their
profession and easily maneuver between medicine and nursing. Trust and communication
between physicians and nurses transcended the hierarchy and leveled the field the NPs practiced
in. The study shows strong interprofessional relationships and understanding of the NP role
allowed transdisciplinary care to supersede the medical hierarchy.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 78
Mixed Method Findings
The Mixed Method (MM) approach was chosen because PI is complex and requires a
qualitative component to explain the quantitative data in better detail. The researcher felt the
quantitative data would only reflect the numerical aspect of how strong the NP PI was but could
not elucidate the essence of the PI. It was important to understand what the perceived PI is among
NPs to see if there was a central identity. Understanding the PI of the NP allows the profession to
distinguish itself from medicine and nursing. It is important to have a distinguished PI so that the
NP can begin to highlight their unique contribution to society. The main question was do NPs
with different years of experience have different view of their PI?
The MM portion of the study was done through explanatory sequential method. As stated
above, the quantitative data shows a strong PI with greatest decline in MCPIS-9 score between 11
to 15 years of NP experience. The qualitative data indicated a strong roo t in the nursing
discipline, with positive interprofessional relationships and utilization of trust and respect to
transcend the medical hierarchy. Combined, the data indicated that NPs, regardless of NP
experience, reported a connection to the nursing discipline. Zarshenas et al., (2014) reported that
if nurses could not demonstrate their nursing core, they risked losing their purpose and identity.
Perhaps the ability of the NPs to remain rooted in their nursing core allows them to maintain a
strong PI despite transition from RN to NP.
The NPs (Atremis and Athena) who had 11 to 15 years of experience were more vocal
about the negatives of extrinsic factors such as PA limitations and insurance influencing their
practice. One participant reported:
(Artemis) “If um, you don’t have a position to sign certain things, you can’ get the patient what
they need. So, it limits our ability to provide care.” She also added “Maybe it’s more insurance,
here’s my problem, biggest problem is getting things approved. Pain medication is a huge issue
right now. You know, my doctor has to prescribe everything. We don’t have that prescriptive
authority”.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 79
Another mid-career participant voiced insurance limitations translating to limitations of
providing care. The need to meet patient’s needs is ingrained into the nursing core but can cause
mental stress to NP to strive to practice this core while delivering a different level of care.
Sometimes NPs “withdraw psychologically or physically in situations when they had unequal
power (for example physicians or administration) in order to be able to continue negotiating their
identities” (Chulach & Gagnon, 2016, p. 56). As states by Chulach & Gagnon (2016, p. 56), One
way to negotiate their identity as an NP is by “rediscovering their sense of self by incorporating
their nursing framework of care (their anchor identity) into a new professional world”.
(Athena) “I’ve accepted there are some holes in our healthcare system and in a way, it’s a way
for me to protect my own sanity and mental health so I don’t get burned out because of
disappointment”.
An assumption by the researcher was that more restrictive PA would limit the ability of
the NPs to practice resulting in worse MCPIS-9 scores. However, this was not the reported data.
The quantitative data did not indicate a statistically significant connection between practice
authority and MCPIS-9 score.
The quantitative study did not note a statistically significant influence of practice
authority (PA) on MCPIS-9, but the qualitative portion clarified a reason for this result. The
qualitative data did note limitations in PA was a barrier by practicing NPs. As stated by a
qualitative participant:
(Atremis) “ If um, you don’t have a position to sign certain things, you can’ get the patient what
they need. So, it limits our ability to provide care”.
Many NPs were able to overcome PA limitations with the support of the organization
they practice in and the relationships they build with their physician colleagues. Because the NPs
can adapt to a restriction does not justify existence of limiting practice authority. As stated by the
qualitative participants, these relationships take years to establish and heavily depend on extrinsic
factors like administrators understanding and supporting NPs. Full practice authority eliminates
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 80
the barriers for new NPs, who do not have the advantage of connections, to still practice without
this hurdle. Previous research indicates that restrictive PA limits access to care and decreases
quality of care (Mark & Patel, 2019; The National Academies of Science, Engineering and
Medicine [NASEM], 2021).
Previous studies have shown NPs deliver the same if not better-quality care as physicians
(Kippenbrock et al., 2019) and does not support the need for oversight. However, having a
mutually beneficial relationship with physicians is seen as a great resource. If patient safety, and
not financial motives, are the cornerstone of collaborative agreement, then there should be no
financial contract between NPs and physicians. Physicians do not charge other physicians for
advice on a complicated patient. The lack of statistical significance in the quantitative study may
be that NPs adapt to their restrictions and not necessarily that the restrictions are not impactful.
The NPs did not feel hindered by the existence of the medical hierarchy. The previous
notion that nurses are mid-levels is negative if viewed in the setting of a top (physicians) and
bottom (nurses). The hierarchy promoted professional tension where nurses feel NPs have left
nursing and physicians feel that NPs are not proficient to practice in their realm (Delvin et al,
2018). If the medical model was a level field rather than a tier, then each discipline would have a
unique place. Transdisciplinary practice allows the NP to practice as a unique profession rather
than an extension of nursing or as support staff to physicians requiring oversight (Chulach &
Gagnon, 2016). Again, the concept of communication and trust became vital in the NPs ability to
function despite limitations. Nurse practitioners engaged those around them to garner feedback on
their role and performance which allowed them to be more visible and integrated into the
healthcare team (Bennett, 1984). Teamwork has been cited to improve collaboration and PI of
different medical professions (Faraz,2016; Meyer et al., 2015). The NPs feel they are nurses that
can bridge nursing and medical knowledge to patients. The bridge is built on trust and respect
and represents a continuum, not a ladder with a top or bottom. The NPs have transcended the
hierarchy by staying rooted in nursing and being apt at medical skills.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 81
Limitations
The largest cohort of the qualitative participants were from an anonymous program done
though a Survey Monkey which limited the ability of the researcher to connect with participants
for the qualitative portion. The researcher was limited to the snowball sample of 15 quantitative
participants and of those only a small number of six agreed to participants. The participants were
all females and so the male NP perspective was missing in the qualitative portion. The qualitative
participants all had full or restrictive practice authorities, so the reduced practice authority
perspective is lacking. Another limitation is the ethnic diversity of the qualitative participants is
limited to Asians (n=3) or Caucasian (n=3) so other ethnic groups are not represented in this
portion. Most of the participants (n=5) were family degree NPs, and one was adult/gerontology
and so other specialties were not explored in the qualitative portion. The study was also limited to
the United States and may not reflect that PI of NPs in other countries.
Implications and Recommendations
The study suggests that that there is a difference in PI with differing years of experience.
The period of lowest PI was assumed to be among those with five or less years of experience
since previous studies by Barnes (2015), Barnes et al., (2020), Owens (2019) and Poronsky
(2013) suggested the greatest period of turmoil occurred within the first two years of transition
into the NP role. Surprisingly, the data from this study suggested that the lowest period of PI is
among those with 11 to 15 years of practice and not among those with five or less years of
experience.
Overall, the PI is strong, and NPs and student NPs feel connected to the profession. Most
studies focus on newly transitioned NPs and there are no studies specific to practitioners midway
to their careers. Studies that focus on attrition, job satisfaction, and burn out do not specify the
highest rate of attrition based on years of practice. Given the high attrition rate in the NP
profession, it would be beneficial to study NPs at this point in their career to see what factors may
be influencing their decision to stay or leave the NP profession. Another important point of
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 82
finding out the drop in satisfaction and PI among those mid-way into their careers is the fact that
dissatisfied NPs may discourage nurses from pursing NP education. These are experienced NPs
that are worth preserving.
Recommendations for Future Research
The study also shows an overall predominance of female Caucasians. A study that is
focused on ethnic minority NPs’ perspective of PI would be beneficial to see if there is a
difference. Is there a factor rooted in the PI of the NP and nursing that continues to drive the
homogeneity of this profession? Does the PI of either nursing or the NP profession not appeal to
the minority population? These are questions that were raised but could not be address in this
study.
The study was also conducted from the perspective of the practicing NPs and NP students
and does not capture the PI as seen by patients, physicians, administrators, or nurses. Additional
studies of the PI of the NP with the perspective of the community and society would help
enlighten how the profession is perceived.
Conclusion
As previously stated, the NPs increase access to care, deliver high quality care and
increase revenue for organizations (Kapu et al., 2021). The NP profession plays a critical role in
healthcare, yet the attrition rate for this profession remains higher than in physician counterparts
(Han et al., 2018). The financial cost of turnover is estimated to be 3.6 million dollars annually
(Dillion et al, 2016) with the cost to train another NP estimated at 100% of their one-year salary
(Auffermann et al, 2020). Having an established PI is a protective mechanism against burn out
and increases job satisfaction and retention (Chen et al., 2020; Joseph al, 2021). Yet, there is no
established PI for the NP profession. This study suggested there were common concepts within
the NP PI such as nursing core, holistic care, value in relationships and attitudes of confidence
and autonomy in trust.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 83
The transition from RN to NP triggers a situational and organizational change.
Situationally, the education of the NP is different than that of the RN. Organizationally, the NP
must be utilized in a different capacity than the RN. The NPs are tasked with establishing new
connections with peers, patients, coworkers, and other providers as a result this change. A new set
of skills and duties come with a change in roles.
The inevitable change in roles leads to the change in PI. The practitioner is now tasked
with viewing him or herself as an NP. The NP must evaluate the value of the nursing discipline in
a medically oriented role. The study results show that NPs continue to feel connected to the
nursing root. The NPs feel they are still nurses.
The new identity challenges the way the NP functions in the organization. The NP must
educate administrators, physicians, and nurses on their new scope of practice and changes in
priorities. If the NP does not clarify his or her role and set boundaries to protect their practice, he
or she risks being underutilized (Jakimowicz et al., 2017). As stated by Jakimowicz et al., (2017),
underutilization and misunderstanding of the NP role leads to job dissatisfaction.
Within the qualitative findings, the NPs felt that open and trusting communication with
physicians led to good working environments. The administration saw value in the productivity of
the NPs. This can be impacted by restrictive and reduced PA which financially incentivize
incidental billing under the supervising physician. Incidental billing diminishes the NPs financial
contributions. Full PA lets the NP be wholly present for patients by increasing access to care.
Full PA also allows the NP to bill independently thus quantifying their financial contribution to
an organization.
Lastly, the PI change means the hierarchy of medicine must evaluate where to place the
NP. The NPs feel they do belong in the current medical model, but their expression of their role
shows they function in a transdisciplinary way without being aware. NPs perform nursing roles in
an elevated state where they can communicate medical needs more clearly to physicians resulting
in smoother care coordination. They serve patients holistically including a medical care plan for
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 84
disease processes which blends medicine and nursing. Transdisciplinary is a new concept in
medical models and the NPs have likely found a way to carve out a place for their profession
without realizing they have already changed the field.
NPs are cohesive in their view of their profession. The PI, as seen by practicing NPs, is
one of holistic, patient centered care. The NPs remain rooted in their nursing core and practice
medical skills as an extension, not replacement of the nursing discip line.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 85
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Appendix A
Explanatory Sequential Design
In accordance with the explanatory sequential design of the mixed methods, initial data
collection will be a quantitative study using MCPIS-9. The data will be analyzed for variation in
PI levels. Participants for the follow up qualitative interview will come from the pool of
quantitative participants. After analysis of the qualitative data, the interpretations and mixed
method analysis will be done.
Quantitative data collected and analyzed
Follow up interviews
Qualitative data collection
and analysis Interpretation
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 95
Appendix B
Quantitative Survey
Example of the form to participants sent out during the quantitative portion of the study.
Thank you so much for your willingness to participate in a study focused on the professional identity of the nurse practitioner (NP).
• Age_______
• Gender________ [M/F/O (other)]
• States of practice ______________
• Type of NP degree ___________ (examples are family, acute care, adult/gerontology,
pediatric, certified nurse anesthetist, certified nurse mid wife)
• Years of nursing experience before becoming an NP ___________
• Years of NP experience ____________
• Ethnicity _________
Macleod Clark Professional Identity Scale 1. I feel like I am a member of this profession.
Strongly agree Agree Neutral Disagree Strongly disagree
2. I feel I have strong ties with members of this profession.
Strongly agree Agree Neutral Disagree Strongly disagree
3. I am often ashamed to admit that I am studying for this profession.
Strongly agree Agree Neutral Disagree Strongly disagree
4. I find myself making excuses for belonging in this profession.
Strongly agree Agree Neutral Disagree Strongly disagree
5. I try and hide that I am studying to be part of this profession.
Strongly agree Agree Neutral Disagree Strongly disagree
6. I am pleased to belong to this profession.
Strongly agree Agree Neutral Disagree Strongly disagree
7. I can identify positively with members of this profession.
Strongly agree Agree Neutral Disagree Strongly disagree
8. Being a member of this profession is important to me.
Strongly agree Agree Neutral Disagree Strongly disagree
9. I feel I share characteristics with other members of the profession.
Strongly agree Agree Neutral Disagree Strongly disagree
Adams, K., Hean, S., & Macleod-Clark, J. (2009). Investigating the factors influencing professional identity of first-year health and social care students. Learning in Health and Social Care, 5(2), 55–68. https://doi.org/10.1111/j.1473-6861.2006.00119.x
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 96
Appendix C
Cronbach Alpha Analysis
The reliability statistic of the Cronbach alpha analysis of the MCPIS-9 scale questions.
Cronbach's
Alpha
Cronbach's
Alpha Based
on
Standardized
Items N of Items
.843 .856 9
Note. The Cronbach’s alpha shows 0.84 which a good reliability. The standardized items value is
like the alpha score in this case because all nine Likert questions have the same five-point answer
scale.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 97
Appendix D
Cronbach Alpha for the MCPIS-9
Cronbach alpha scores of the MCPIS-9 questions.
Scale Mean
if Item
Deleted
Scale
Variance if
Item Deleted
Corrected
Item-Total
Correlation
Squared
Multiple
Correlation
Cronbach's
Alpha if Item
Deleted
I feel like I am a
member of this
profession
15.09 28.445 .468 .356 .836
I feel I have strong ties
with the members of
this profession
15.11 29.541 .426 .393 .840
I am often ashamed to
admit that I am
studying for this
profession
15.10 26.019 .485 .492 .841
I find myself making
excuses for belonging
in this profession
15.05 24.810 .634 .575 .819
I try and hide that I am
studying to be part of
this profession.
15.26 25.448 .610 .626 .822
I am pleased to belong
to this profession
15.53 27.632 .692 .585 .817
I can identify positively
with members of this
profession.
15.39 27.837 .655 .610 .820
Being a member of this
profession is important
to me
15.51 27.331 .680 .555 .817
I feel I share
characteristics with
other members of the
profession.
15.32 28.709 .513 .421 .832
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 98
Appendix E
Categorical Demographic Data
Categorical data including age, gender, type of NP degree, years of NP experience, years
of RN experience, states of current practice with frequency, and percent in tables E1 through E7.
Table E1
Age
Frequency Percent Valid Percent
Cumulative
Percent
Valid 18-24 13 9.3 9.3 9.3
25-34 50 35.7 35.7 45.0
35-44 35 25.0 25.0 70.0
45-54 26 18.6 18.6 88.6
55-64 13 9.3 9.3 97.9
65+ 3 2.1 2.1 100.0
Total 140 100.0 100.0
Note. Majority of the respondents are between the ages of 25-34 (n=50) with the smallest group
being those aged 65+ (n=3).
Table E2
Gender
Frequency Percent Valid Percent
Cumulative
Percent
Valid Male 42 30.0 30.0 30.0
Female 98 70.0 70.0 100.0
Total 140 100.0 100.0
Note. Mostly female respondents (n=98) with males only representing 30% (n=42).
Table E3
Ethnicity
Frequency Percent Valid Percent
Cumulative
Percent
Valid White or Caucasian 92 65.7 65.7 65.7
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 99
Black or African
American
13 9.3 9.3 75.0
Hispanic or Latino 18 12.9 12.9 87.9
Asian or Asian American 13 9.3 9.3 97.1
American Indian or
Alaska Native
2 1.4 1.4 98.6
Native Hawaiian or other
Pacific Islander
1 .7 .7 99.3
Another race 1 .7 .7 100.0
Total 140 100.0 100.0
Note. Mainly Caucasian at 65.7% (n=92) with a distant second largest group being Hispanic at 12.9% (n=18).c
Table E4
Type of NP degree
Frequenc
y Percent
Valid
Percent
Cumulative
Percent
Valid Family 64 45.7 45.7 45.7
Acute Care Adult/
Gerontology
15 10.7 10.7 56.4
Adult/ Gerontology 18 12.9 12.9 69.3
Pediatric 23 16.4 16.4 85.7
Certified Nurse
Anesthetist
9 6.4 6.4 92.1
Certified Nurse Mid-
wife
9 6.4 6.4 98.6
psychiatry 2 1.4 1.4 100.0
Total 140 100.0 100.0
Note. Most participants are family NPs (n=64) with the least participants in psychiatry (n=2).
Table E5
years of NP experience
Frequenc
y Percent
Valid
Percent
Cumulative
Percent
Valid student 24 17.1 17.1 17.1
5 years or less 58 41.4 41.4 58.6
6-10 years 26 18.6 18.6 77.1
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 100
11-15 years 19 13.6 13.6 90.7
16-20 years 9 6.4 6.4 97.1
21 years or
more
4 2.9 2.9 100.0
Total 140 100.0 100.0
Note. Most participants had five or less years of NP experience. Table E6
State of current practice
Frequenc
y Percent
Valid
Percent
Cumulative
Percent
Valid full authority 45 32.1 32.1 32.1
reduced authority 33 23.6 23.6 55.7
restricted
authority
62 44.3 44.3 100.0
Total 140 100.0 100.0
Note. Majority of participants practices in restricted authority states (n=62).
Table E7
years of RN experience
Frequenc
y Percent
Valid
Percent
Cumulative
Percent
Valid 5 years or
less
67 47.9 47.9 47.9
6-10 years 37 26.4 26.4 74.3
11-15 years 34 24.3 24.3 98.6
over 15 years 2 1.4 1.4 100.0
Total 140 100.0 100.0
Note. Most participants had five or less years of Rn experience before transitioning to the NP
role.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 101
Appendix F
MCPIS-9 Frequencies
The frequencies of the total MCPIS-9 scores.
Frequency Percent Valid Percent
Cumulative
Percent
Valid 9 15 10.7 10.7 10.7
10 10 7.1 7.1 17.9
11 9 6.4 6.4 24.3
12 6 4.3 4.3 28.6
13 7 5.0 5.0 33.6
14 5 3.6 3.6 37.1
15 7 5.0 5.0 42.1
16 9 6.4 6.4 48.6
17 5 3.6 3.6 52.1
18 12 8.6 8.6 60.7
19 8 5.7 5.7 66.4
20 10 7.1 7.1 73.6
21 8 5.7 5.7 79.3
22 3 2.1 2.1 81.4
23 5 3.6 3.6 85.0
24 1 .7 .7 85.7
25 5 3.6 3.6 89.3
26 1 .7 .7 90.0
27 10 7.1 7.1 97.1
28 1 .7 .7 97.9
31 2 1.4 1.4 99.3
33 1 .7 .7 100.0
Total 140 100.0 100.0
Note. The scores show a range of scores between nine and 33. The most frequent score is nine
(n=15) with the next most frequent score of 18 (n=12). Scores of 10, 20 and 27 occur in equal
frequency (n=10). The last frequent scores are 24, 26, 28 and 33 with single entries(n=1)
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 102
Appendix G
Test of Normalcy
Test of normalcy of the independent variable year of NP experience.
Kolmogorov-Smirnova Shapiro-Wilk
Statistic df Sig. Statistic df Sig.
years of NP experience .266 140 <.001 .876 140 <.001
Note. The alpha was set at 0.05. The significant value of the both the Kolmogorov- Smirnov and
the Shapiro Wilk have a p of < 0.001 indicating a lack of normalcy in the independent data.
a. Lilliefors Significance Correction
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 103
Appendix H
Kruskal Wallis Results
The hypothesis test summary from the Kruskal Wallis H-test
Null Hypothesis Test Sig.a,b Decision
1 The distribution of total
MCPIS-9 score is the same
across categories of years of
NP experience.
Independent-Samples
Kruskal-Wallis Test
.034 Reject the null
hypothesis.
Note. The significance level is .050. Asymptotic significance is displayed.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 104
Appendix I
Pairwise Comparison
Pairwise Comparisons of years of NP experience.
Sample 1-Sample 2 Test Statistic Std. Error Std. Test Statistic Sig. Adj. Sig.a
21 years or more-6-10 years 24.731 21.736 1.138 .255 1.000
21 years or more-student 34.604 21.857 1.583 .113 1.000
21 years or more-16-20 years 39.056 24.320 1.606 .108 1.000
21 years or more-5 years or
less
47.948 20.921 2.292 .022 .329
21 years or more-11-15 years 52.316 22.264 2.350 .019 .282
6-10 years-student 9.873 11.456 .862 .389 1.000
6-10 years-16-20 years -14.325 15.652 -.915 .360 1.000
6-10 years-5 years or less 23.218 9.552 2.431 .015 .226
6-10 years-11-15 years -27.585 12.215 -2.258 .024 .359
student-16-20 years -4.451 15.819 -.281 .778 1.000
student-5 years or less -13.344 9.823 -1.359 .174 1.000
student-11-15 years -17.712 12.428 -1.425 .154 1.000
16-20 years-5 years or less 8.893 14.499 .613 .540 1.000
16-20 years-11-15 years 13.260 16.377 .810 .418 1.000
5 years or less-11-15 years -4.368 10.698 -.408 .683 1.000
Each row tests the null hypothesis that the Sample 1 and Sample 2 distributions are the same.
Asymptotic significances (2-sided tests) are displayed. The significance level is .050.
a. Significance values have been adjusted by the Bonferroni correction for multiple tests.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 105
Appendix J
MCPIS-9 Total and Years of Experience Graph
Graph of the Median Macleod Clark Professional Identity Scores compared with the
years of experience.
Note. The graph shows those in the 21 or more years groups had better MCPIS-9 scores than
those in other groups while those in the 11-to-15-year range had worse MCPIS-9
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 106
Appendix K
Spearman’s Rho for MCPIS-9 and Years of RN Experience
Results of Spearman’s Correlation of the MCPIS-9 and the years of RN experience
Age
years of RN
experience
total MCPIS-
9 score
Spearman's rho Age Correlation
Coefficient
1.000 .395** -.250**
Sig. (2-tailed) . <.001 .003
N 140 140 140
years of RN
experience
Correlation
Coefficient
.395** 1.000 -.064
Sig. (2-tailed) <.001 . .450
N 140 140 140
total MCPIS-9 score Correlation
Coefficient
-.250** -.064 1.000
Sig. (2-tailed) .003 .450 .
N 140 140 140
Note. The variables of MCPIS-9 scores, age and years of RN experience were run with a p value
of 0.05. A statistically significant negative correlation was noted between age and MCPIS- 9
scores (p value = 0.003). Statistically positive correlation between age and years or RN
experience was noted.
a Correlation is significant at the 0.01 level (2-tailed).
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 107
Appendix L
T-test Scores for Gender and MCPIS-9
T-test scores between gender and MCPIS-9 scores.
Note. The significance value of 0.95 is higher than the alpha of 0.05, thus indicates no statistical significance.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 108
Appendix M
Between Subject Data
Between subject data of ethnicity, type of NP degree and state of practice with the
dependent variable of total MCPIS-9 scores broken into tables from G1 through G3.
Table M1
Sum of
Squares df Mean Square F Sig.
Between Groups 56.187 5 11.237 .314 .904
Within Groups 4797.555 134 35.803
Total 4853.743 139
Note. The comparison of ethnicities and totals MCPIS-9 shows no statistically significant results
with p value of 0.90 which is more than the alpha of 0.05.
Table M2
Sum of
Squares df Mean Square F Sig.
Between Groups 152.772 6 25.462 .720 .634
Within Groups 4700.971 133 35.346
Total 4853.743 139
Note. The between groups shows no statistically significant results between total MCPIS-9 scores
and type of NP degree with a significant value of 0.63 which is higher than the p value of 0.05.
Table M3
Sum of
Squares df Mean Square F Sig.
Between Groups 100.055 2 50.027 1.442 .240
Within Groups 4753.688 137 34.698
Total 4853.743 139
Note. The result of the mean comparison shows no statistical significance between MCPIS-9
scores and states of practice with a significance of 0.24 which is higher than the p values of 0.05.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 109
Appendix N
Qualitative Interview Guide
The guiding questions were used during the qualitative interviews.
How did you decide to become a nurse practitioner? How did your NP program incorporate nursing into the program? In what way do you see nursing in the NP prof ession? Skip if a student: Tell me a little bit about your first nurse practitioner experience? Did you have a mentor or orientation period? Yes/no: how do you think that influenced you? Tell me about your current experience. how do you think you have changed between your first experience and your current? IF a student: what do you think has changed from when you were a student to now? How do you think you have changed as a practitioner through your years of practice/study? Tell me a story about a time you had to coordinate care or perform a duty with multiple other healthcare members. How did you feel that your profession as a NP impacted that care coordination? Depending on
tone of answers elucidate Negatives/positive?
How do you think the NP profession is viewed in society, by patients, administrators, and other medical professionals? How do you think the NP profession fits into the current healthcare system? In what way does your practice authority impact your profession and decisions? What do you think is unique about the nurse practitioner role?
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 110
Appendix O
Qualitative Value Themes
The summary of the recurring concepts dividing into sections of value, attitude, and belief.
Value
Relationships with patients, nurses, physicians and administrators
must be rebuilt.
Attitude
Attitude of caring influences the NP
attitude- mentorship and life
experience.
Trust between NP and Physicians is
essential to patient care.
Belief
Nursing concept of holistic care remains
the core of NP PI.
NPs are not hindered by existing
medical hierarchy
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 111
Appendix P
MCPIS-9 Question Correlation Qualitative Question
Visual of the MCPIS-9 questions and the qualitative questions to see how they influenced
the development of the questions.
MCPIS-9 (Quantitative) Interview guide (Qualitative)
I feel like I am a member of this profession How did you decide to become a nurse practitioner?
I feel I have strong ties with members of this profession
Did you have a mentor or orientation program?
I am often ashamed to admit that I am studying for this profession
How did your NP program incorporate nursing into the program?
I find myself making excuses for belonging to this profession
How do you think you have changed between your first experience and your current?
I try and hide that I am studying to be part of this profession
Tell me a time you had to coordinate care or perform a duty with multiple other healthcare members
I am pleased to belong to this profession Tell me about your current experience How do you think the NP profession is viewed in society, by patients, administrators and other medical professionals?
I can identify positively with members of this profession
In what way do you see nursing in your NP profession
Being a member of this profession is important to me
What so you think is unique about the nurse practitioner role? In what way does your practice authority impact your profession and decisions?
I feel I share characteristics with other member of this profession
How did you feel that your profession as a NP impacted that care coordination? How do you think the NP role fits into the current healthcare system?
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 112
Appendix Q
MCPIS-9 Frequencies
Breakdown of the MCPIS-9 into the frequencies for qualitative participants
MCPIS-9 Frequency
I feel like I am a member of this
profession
Strongly agree (n=5)
Agree (n=1)
I feel I have strong ties with
members of this profession
Strongly agree (n=2)
Agree (n=4)
I am often ashamed to admit that I
am studying for this profession
Strongly disagree (n=5)
Agree (n=1)
I find myself making excuses for
belonging to this profession
Strongly disagree (n=5)
Agree (n=1)
I try and hide that I am studying to
be part of this profession
Strongly disagree (n=5)
Disagree (n=1)
I am pleased to belong to this
profession
Strongly agree (n=6)
I can identify positively with
members of this profession
Strongly agree (n=6)
Being a member of this profession is
important to me
Strongly agree (n=6)
I feel I share characteristics with
other member of this profession
Strongly agree (n=5)
Agree (n=1)
Note. The majority had positive sentiments to the nine MCPIS-9 questions. Most answered they
feel like a member of the NP profession with strongly agree (n=5) and agree (n=6). Participants felt
ties with other NP professionals with most agreeing (n=4) and other strongly agreeing (n=2).
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 113
Appendix R
MCPIS-9 Qualitative Interview Guide and In Vivo Excerpts
Integration of the quantitative MCPIS-9 and the qualitative interview guide questions
with some in vivo excerpts from participants. The goal is to show how the interviews show a
correlation to the high MCPIS-9 scores and what the participants may have been reflecting on
while taking the survey. The side-by-side MCPIS and qualitative questions are labeled into nine
tables labeled R1 through R9
Table R1
I feel like I am a member of this profession (MCPIS-9) -->How did you decide to become a nurse practitioner?
“I had good role models who were
nurses who encouraged me to pursue a career in
nursing”.
“My father was a surgeon, and my mom
was a nurse, and so they were
missionaries in South America. And so, I’ve just seen that modeled
for pretty much my whole life… My dad
wanted me to go down to this medical school, so I didn’t do that. So, I just felt like this was a great way
that I could, you know, do both”.
“I want to do a little bit more than be the typical eyes and ears
of the doctor and following orders. But
being able to make decision on my own
and diagnose and treat”.
“I was so interested that I could practice independently and
take care of patients”.
“One was autonomy” .
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 114
Table R2
Table R3
I feel I have strong ties with members of this profession (MCPIS-9)--> Did you have a mentor or orientation program?
For the most part, I was kind of hitting the ground running”.
“I think that people that have been a nurse practitioner for, you know, anywhere from one year t, you
know, pretty, much a lifetime, took me under their wing and showed me what, you know, what that particular
role that they did as far as bring a nurse practitioner”.
“What was more helpful in making me feel part of the team was just the support from my direct colleagues at
the site”.
I am often ashamed to admit that I am studying for this profession (MCPIS-9)-->How did your NP program incorporate nursing into the
program?
“I said, I’m fortunate enough to work with two great doctors who
communicate well, and I do feel like we have a good team in regard to
primary care. Which is important”.
“I think that there is a good camaraderie and rapport as far as
nurse practitioner and doctors. An, I feel like that they are confident, and
more comfortable with nurse practitioner to take care of patients”.
“They did trust us, but a lot of times it’s scary because at night you’re on
your own. You have residents to rely on. So that’s what we
constantly call… If we communicate, we didn’t
communicate with them constantly then and we just will do what we wanted, I’m sure the physicians
would have had trouble with use. So, that’s why just letting them
know and updating was a big thing for me. And that’s what I did, and
they truly appreciated that”.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 115
Table R4
Table R5
I find myself making excuses for belonging to this profession (MCPIS-9)-->
How do you think you have changed between your first experience and your current?
“You basically… made me more mature and in this area being more proactive and not having to lean back on others. I’m constantly doing things independently on
my own and figuring things out on my own".
"Definitely be patient and ask questions and don't be afarid to be confident. Becuase I felt like I needed to ask every little thing. And I knew what to do. I knew
the right answer. So, just kind of reassure yourself you do know more than what you actually feel like".
I try and hide that I am studying to be part of this profession (MCPIS-9)-->
Tell me a time you had to coordinate care or perform a duty with multiple other healthcare members
“I think a lot of physicians that I currently work for are very open to nurse practitioners. I’ve had several say
that they prefer a nurse practitioner over a P.A. because of our nursing background. I see some that are hesitant because they don’t know how to utilize us. They think
they’re just to help them stay independent. An then I see that, you know, other given you a full range of practice
and let you do what you want”.
"I think that at least my organization, becuase they've utilized nurse practitioners a lot in their teaming. I think they do respecttheir advance care providers or clinicans,
as they call us. While other facilities like, let's say, a teaching hospital, I still hear from my fellow NP colleagues there who feel that becuase they have
residents and interns that ttying to figure out the role of the NP can be a little difficult".
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 116
Table R6
Table R7
Table R8
I am pleased to belong to this profession (MCPIS-9) -->Tell me about your current experience.
How do you think the NP profession is viewed in society, by patients, administrators and other medical professionals?
“Some of the patients who are educated, they understand nurse
practitioner. But some of them, you really need to let them know that I’m not a
nurse. I went back to school and I’m a nurse
practitioner, so it’s mixed”.
“They have no clue, and it irritates me when you have to say we’re like a PA. We
are, but we aren’t, but sometimes people can’t get it unless you um, put it in
terms that they know”.
“I ask them, always, do you want to follow up with an MD? And they always say no, I’ll continue with you. So, I think once you maintain the relationship and explain, I think they
really like nurse practitioners” .
“I mean we have a good relationship and
sometimes, the nurses have had to have a clash with
them because they forget. They keep thinking, I’m a nurse”. “Why can’t you do it? Because you still have
your RN license”.
I can identify positively with members of this profession (MCPIS-9) -->
In what way do you see nursing in your NP profession
“I have an extra degree where I can actually manage medication,
prescribe, and diagnose. But you know the core root of what I do is nursing”.
“I’m in this profession, so I think that’s really laid a foundation, and I still think when I talk to my patients
and all, that TLC is there… So, I think I pretty much maintain my nursing
core”.
“Being able to utilize medical knowledge, but never letting go of that
nursing ability to say, how does this affect you"?
Being a member of this profession is important to me (MCPIS-9)-->
What so you think is unique about the nurse practitioner role?
In what way does your practice authority impact your profession and decisions?
“Letting people talk and hearing their story about whatever is going on is more valuable than anything I might
have to say”.
“We build relationships and then we know, we give overall care, not only
focused. And we spend a lot of time to understand the patient’s need. And I think that all comes back to the basic
of nursing”.
“Nursing 100% is being able to establish a relationship person to
person…. Medicine, it’s a lot of telling people what to do. We don’t tell
people what to so. We ask them what they’re ready to do first”.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 117
Table R9
I feel I share characteristics with other member of this profession
How did you feel that your profession as a NP impacted that care coordination?
How do you think the NP role fits into the current healthcare system?
“So, I mean, we, don’t really I think we fit fine where we are. We are
independent”.
“I think in the hierarchy here, it’s basically we have the MDs and then the nurse practitioners, as we used to be called years before mid-level
providers and we have nurses. So, I think we fit right in there.
“I think it (NPs) fit. I mean, I think a lot of times we can be equals. But they do have more training and knowledge, especially when it
comes to a specialty”.
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 118
Appendix S
The Informed Consent Document Template - Adults
The Professional Identity of the Nurse Practitioner: A Mixed Methods Study
INTRODUCTION You are invited to join a research study to look at the professional identity of the nurse practitioner. Please take whatever time you need to discuss the study with your family and friends, or anyone else you wish to. The decision to join, or not to join, is up to you. In this research study, we are investigating the nurse practitioners’ perception of professional identity. WHAT IS INVOLVED IN THE STUDY? If you decide to participate you will be asked to fill out a survey with demographic information like age, gender, years of nursing experience, ethnicity, year of nurse practitioner experience, state of practice and type of degree and professional identity questionnaire using Macleod Clark professional identity scale. We think this will take you about 15 minutes. If you agree to an additional interview portion of the study, you may provide your email at the end. If you are chosen, you will be contacts for a 30-45 minute Zoom interview. The investigators may stop the study or take you out of the study at any time they judge it is in your best interest. They may also remove you from the study for various other reasons. They can do this without your consent. You can stop participating at any time. If you stop, you will not lose any benefits. RISKS There are no foreseeable to risks to participation in this study BENEFITS TO TAKING PART IN THE STUDY? It is reasonable to expect the following benefits from this research: personal chance to win one of two $100.00 Amazon gift cards if you complete the questionnaire AND the interview portion. There are other benefits to your fellow nurse practitioners through better understanding of the nurse practitioner profession and how our unique profession contribute to improving patient outcomes. However, we can’t guarantee that you will personally experience benefits from participating in this study. Others may benefit in the future from the information we find in this study. CONFIDENTIALITY We will take the following steps to keep information about you confidential, and to protect it from unauthorized disclosure, tampering, or damage: Include such items as anonymity of response, storage of surveys in locked cabinet, destruction of surveys after study completion. Dr. Frutchey and Dr. Diener will have access to your information as a part of the study committee and IRB committee. There will be direct quotes used in the data, but no personal information will be associated with the quote which may link it to any individual. Data will be protected using a computer with a password required for getting onto the system. INCENTIVES You will have a chance to win one of two $100.00 Amazon gift cards if you complete the questionnaire and the interview portion. YOUR RIGHTS AS A RESEARCH PARTICIPANT? Participation in this study is voluntary. You have the right not to participate at all or to leave the study at any time. Deciding not to participate or choosing to leave the study will not result in any penalty or loss of benefits to which you are entitled, and it will not harm your relationship with the University of Oklahoma City. To withdraw, simply do not complete the questionnaire. CONTACTS FOR QUESTIONS OR PROBLEMS? Call Soohee Karamichos at 617-834-9915 or email [email protected] if you have questions about the study, any problems, unexpected physical or psychological discomforts, any injuries, or think that something unusual or unexpected is happening. Contact Elizabeth Diener, Chair of the Institutional
THE PROFESSIONAL IDENTITY OF THE NURSE PRACTITIONER 119
Appendix S
The Informed Consent Document Template - Adults
Continuation of Appendix S. Review Board, at (405) 208-5944 or [email protected] (link sends e-mail) if you have any questions or concerns about your rights as a research participant. Dr. Cheryl Frutchey committee chair can be reached at Kramer School of Nursing Oklahoma City University 2501 N. Blackwelder, Oklahoma City, OK 73106
Office 108/ 🕿405.208.5921
Consent of Subject (or Legally Authorized Representative) _________________________________________________ Signature of Subject or Representative Date I have explained the study and the Informed Consent to the research participant. __________________________________________________ Signature of Researcher Date Upon signing, the subject or the legally authorized representative will receive a copy of this form, and the original will be held in the subject’s research record.
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- Chapter 3 Methodology
- Instrument
- Setting
- Data Collection Plan
- Chapter 4 Results
- Summary of the Mixed Methods Findings
- References
