Post-Graduate NP Fellowship Training: Analysis of Evidence for Job Satisfaction NCNA Spring Symposium Tom Bush, DNP, FNP-BC, FAANP

Transcription

1 Post-Graduate NP Fellowship Training: Analysis of Evidence for Job Satisfaction 2016 NCNA Spring Symposium Tom Bush, DNP, FNP-BC, FAANP

2 IOM/RWJ Future of Nursing State boards of nursing, accrediting bodies, the federal government, and health care organizations should take actions to support nurses completion of a transition-to-practice program (nurse residency) after they have completed a prelicensure or advanced practice degree program or when they are transitioning into new clinical practice areas IOM, 2011, p. S 9

3 Fellowship or Residency? Residency is required for licensure and practice in medicine and some other disciplines Post-graduate education is optional for licensure and practice in nursing NP Roundtable Address potential confusion Endorsed use of the term fellowship Transition-to-practice Does not suggest regulatory control AANP 2013; Wiltse Nicely & Fairman, 2015

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5 Affordable Care Act Post-graduate NP demonstration project Fund FQHC programs in nurse managed health centers DHHS sought input from nursing educators NONPF & others voted not to support We thought the money should go to support NP programs to increase the number of NPs DHHS funded 5 health centers to support increasing numbers of NP graduates No funding for post-graduate NP education Boyar, 2010; M. Price 2014

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7 NP Practice Patterns AHRQ used NPI numbers to determine the practice partners of each NP Novel method of determination Slightly more than half (52%) of NPs practice primary care while 48% practice in specialty settings Many specialty practices have incorporated NPs into their practice models Nurse practitioners impact inpatient care teams by generating revenue, reducing length of stay and standardizing quality metrics Agency for Healthcare Research & Quality [AHRQ], 2014; Dower & Christian, 2009; Kapu, Kleinpell & Pilon, 2014

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10 Carolinas HealthCare System

11 Carolinas HealthCare System $14.1 million over 5 years $18.4 with expansion Includes: Center for Advanced Practice Fellowship Collaborative program with UNCC SON Expanded in year 2 From 32 fellows to 56 Unanticipated outcome Support network naturally developed to aid communication and camaraderie among fellows Wilcox, Broyhill, Taylor, & Williamson, 2015

12 Carolinas HealthCare ROI Break even projected at 18mo. ROI 27.4 million in 12 months Lower workforce cost ($18.2m) Revenue generated by fellows ($3.5 m) Decreased open position time ($2.1 m) days Decreased turnover rate ($2.9 m) (18 APPs) 12-8% Lower recruitment cost ($0.7 m) (218 APPs) Increased patient access Days to first new patient appointment and days to established patient appointment Wilcox, Broyhill, Taylor, & Williamson, 2015

13 Uncertain Program Permanence University of Miami Pilot Program Intensive clinical experience integrated into ACNP program leading MSN; Currently unavailable University of California at San Francisco Recruiting in 2014; Currently unavailable Ohio State University Cancer Center Recruiting in 2014; Currently unavailable Penobscot Community Health Care Began with HRSA funding; Suspended in 2015 University of North Carolina at Chapel Hill Department of Orthopaedics Graduates in 2006 & 2007; Suspended 2008

14 Cost and Commitment Post-graduate physician education Federally funded by DHHS through CMS More than 100k per resident per year Can total more than 500k when state Medicaid payments considered Indirect Federal support for NP programs Veterans Health Administration Federally Qualified Health Centers Few employer funded NP programs Most employers expect new NP graduates to perform at an advanced level with little support Dower, 2012; Bahouth, Blum, & Simone, 2013

15 Cost and Commitment Most post-graduate NP education programs employer funded Recruitment and retention of professionals Meet immediate and growing workforce needs Costs per trainee can reach 100k annually NP salary/benefits, lost preceptor revenue, facility overhead and administrative expenses Two thirds support post-graduate NP One third supplements lost preceptor productivity Expenses offset through billable NP activity Employment commitment may be required Flinter, 2011; D. Taylor, 2014

16 Problem Programs to facilitate Nurse Practitioner (NP) transition to practice have been developed at public and private institutions across the US and there is no published evidence of their influence on NP job satisfaction

17 Purpose Determine the impact of post-graduate education on job satisfaction among NPs Project Question: Is there a difference in job satisfaction between NPs who have completed postgraduate fellowship education and NPs who have not participated in formal post-graduate fellowship education?

18 Theory From Limbo to Legitimacy Anxiety and accomplishments of novice NPs Transition from student to clinician Feelings of insecurity and illegitimacy Fear of errors and associated anxiety Impacts diagnostic reasoning & clinical decisions Experience fosters confidence & competence Is anxiety due to transitional identity or inadequate environmental support? Brown & Olshanksy, 1997

19 Methods A non-equivalent group design The Misener Nurse Practitioner Job Satisfaction Scale was administered to two groups of nurse practitioners Formal post-graduate fellowship n = 80 No formal post-graduate fellowship n = 174 Demographic tool race; gender; age; years of NP experience, highest degree; practice zip code Misener & Cox (2001)

20 Gender Distribution N = 254 Study sample Study Participants American Community Survey APRN Distribution 9% 91% U.S. Census Bureau (2013)

21 Gender Distribution by Group Post-graduate education No post-graduate education

22 Race Distribution

23 Race Distribution by Group Post-graduate education No post-graduate education

24 Age Distribution All Participants Boomer 31.5% Gen X 43.9% Gen Y 24.3%

25 Age Distribution by Group Post-graduate education No post-graduate education

26 Mean Years of NP Experience

27 Highest Degree

28 Highest Degree by Group Post-graduate education No post-graduate education

29 States Represented

30 Median Satisfaction Scores Table 1 Job Satisfaction Scores Post-graduate education N Median Frequency of satisfied and very satisfied Yes % No %

31 Satisfaction Distribution N = 254 Mean = 189 SD = percent of responses are normally distributed

32 Data Analysis Analysis: Independent samples t-test of factor scores to compare job satisfaction between groups Compare and contrast post-graduate fellowship training effects within demographic strata Multiple Linear Regression Calculated to predict participants total job satisfaction based on years of NP experience, state regulatory environment and completion of a post-graduate education program

33 Independent Samples t Test Table 2 Independent samples t test of factor scores and Cronbach alpha (N = 254) Post-graduate education Yes (n = 80) No (n = 174) Factors α M SD M SD t Sig.(2 tailed) Collegiality * Autonomy * Interaction * Growth <.001** Time Benefits Note. * p <.05. ** p <.001.

34 MSN or Doctoral Degree Statistically insignificant

35 Highest Degree/Postgraduate Ed. Statistically insignificant

36 Years of Experience p =.030

37 Years of Experience/Post-grad. Ed Statistically insignificant in No post-graduate education group only (p =.019)

38 State Regulatory Environment Statistically insignificant

39 State Regulation/Post-grad. Ed Statistically insignificant

40 Post-graduate Education p <.001

41 Regulation/Experience/Post-grad. > 3yrs experience, post-graduate education & full practice authority state VS. (p =.018) > 3yrs experience, post-graduate education & restricted practice state

42 Multiple Linear Regression Table 3 Multiple linear regression predicting Total Job Satisfaction from regulatory environment, years of experience (Block 1) and post-graduate education (Block 2) β t p value State regulatory environment Years of experience as a nurse practitioner Post-graduate education * Note. R 2 =.04. * p <.05.

43 Limitations Participants recruited by invitation Indirectly through program directors Comparison group recruited through an online community of professionals Parametric tests on ordinal data may be considered a study limitation Distribution nearly normal with few outliers Supports the use of parametric tests in this study

44 Post-graduate NP Education Significance: Post-graduate fellowship training significantly impacts NP satisfaction with professional growth, autonomy, collegiality and interaction Satisfaction with work time and job benefits is less apparent in this study Knowledge of factors that influence job satisfaction is advantageous: Policy makers NPs considering fellowship education Employers considering program development

45 References Agency for Healthcare Research & Quality. (2014). The number of nurse practitioners and physician assistants practicing primary care in the United States. Retrieved from ndex.html American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. Washington DC: American Association of Nurse Practitioners - the NP roundtable's discussion paper on NP education and post-graduate training, Retrieved from legislation-regulation/policy-toolbox/np-policy-essentials/445-aanpand-the-np-roundtable-joint-statements Bahouth, M. N., Blum, K., & Simone, S. (Eds.). (2013). Transitioning into hospital-based practice : A guide for nurse practitioners and administrators. New York, NY: Springer Pub. Co. Retrieved from

46 References Boyar, K. L. (2010). Nurse practitioner residency programs and healthcare reform on ADVANCE for NPs & PAs. Retrieved from assistants.advanceweb.com/features/articles/nurse-practitioner- Residency-Programs-and-Healthcare-Reform.aspx Brown, M., & Olshansky, E. F. (1997). From limbo to legitimacy: A theoretical model of the transition to the primary care nurse practitioner role. Nursing Research, 46(1), Dower, C., & Christian, S. (2009). Physician assistants and nurse practitioners in specialty care: Six practices make it work. San Francisco: University of California. Flinter, M. (2011). From new nurse practitioner to primary care provider: Bridging the transition through FQHC-based residency training. Online Journal of Issues in Nursing, 17(1), 6.

47 References Kapu, A. N., Kleinpell, R., & Pilon, B. (2014). Quality and financial impact of adding nurse practitioners to inpatient care teams. The Journal of Nursing Administration, 44(2), doi: /nna ; /NNA IOM (Institute of Medicine). (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. Landivar, L. (2013). Men in nursing occupations. Washington, DC: U.S. Census Bureau. Misener, T. R., & Cox, D. L. (2001). Development of the misener nurse practitioner job satisfaction scale. Journal of Nursing Measurement, 9(1), Wilcox, M. A., Broyhill, B. H., Taylor, D. A., & Williamson, S. B. (2015). The lifecycle of the advanced clinical practitioner. Nurse Leader, 13(2), doi: Wiltse Nicely, K. L., & Fairman, J. (2015). Postgraduate nurse practitioner residency programs: Supporting transition to practice. Academic Medicine : Journal of the Association of American Medical Colleges, 90(6), doi: /acm [doi]