NURSE PRACTITIONER GRADUATE TRANSITION TO PRACTICE Funding: Council of Ontario University Programs in Nursing Ontario Ministry of Heath and Long Term Care
Co Principal Investigators Dr. Betty Cragg (University of Ottawa) Dr. Patricia Bailey (Laurentian University) Co Investigators Dr. Frances Legault (University of Ottawa) Jennie Humbert (University of Ottawa) Suzanne Doucette (University of Ottawa) Masters of Nursing Student Célyne Laflamme (University of Ottawa) Research Associate Maureen Sullivan Bentz (University of Ottawa)
OBJECTIVES To describe the role transition of NP graduates from their perspective and from the perspective of a co participant (employer, physician, NP colleague) working in the same setting, nominated by the NP To explore the support requirements of NP graduates during the first year of practice To make recommendations for NP practice, education, and policy
Theoretical Framework Adapted from Brown and Olshansky (1997) LIMBO TO LEGITIMACY Laying the Foundation 0 1 month Recuperating from school Negotiating the bureaucracy Looking for a job Worrying Launching 1 3 months Feeling like an imposter Confronting anxiety Getting through the day Battling time Meeting the Challenge 6 12 months Increasing competence Gaining confidence Acknowledging system problems Broadening the Perspective 12 months Developing system savvy Affirming oneself Upping the ante
Research Process Descriptive qualitative design (Thorne et al., 1997; Thorne et al., 2004) informed by Focused Ethnography (Morse & Richards, 2002; Muecke, 1994) and Narrative Analysis (Bailey, 2001, 2002, 2004) Sample Purposive sample 15 20 NPs in the first year of NP practice Anglophone and francophone graduates of COUPN PHCNP program in Ontario Nominated colleague for each NP Semi structured interviews At 3, 6, & 12 months of employment with NPs & coparticipants Documents review Job descriptions Organization charts Policies organizational and provincial Reports and reviews of NP programs and practice
Demographics NPs Age Years of Experience Co participants Professional background Previous experience with NPs Anglophones Francophones 17 NPs 15 Co participants 6 NPs 6 Co participants Range: 29 61 Range: 27 46 Mean: 42.8 Mean: 37.7 SD: 9.7 SD: 6.5 Range: 6 37 Range: 3 23 Mean: 19.23 Mean: 14.3 SD: 11.14 SD: 7.03 MD x 5 MD x 3 NP x 4 NP x 3 Administrators x 6 6 5
FULL TIME VS. PART TIME WORK * N.B. Six (6) Francophone Participants were included; Seventeen (17) Anglophone Participants were included
Work Settings Anglophones Clinics Community Health Centres Family Health Teams Primary Care Centers Emergency Departments Francophones Hospital Clinics Emergency Patient populations Community Health Centres
Population Profiles: Diverse All ages (individual, family, groups, community) Geriatrics Aboriginal (urban and on reserve) Homeless Clients with mental illness & addictions Francophone communities Multicultural populations Women s health
Themes 1. Transition to NP Role 2. Contextual Factors Impacting NP Role Transition 3. Interprofessional Relationships 4. Provincial Policy and Politics 5. Educational Preparation
Theme 1 Transition to NP Role Role Adjustment: NPs had high expectations of themselves from the beginning Transition reflected Brown & Olshansky s stages Other factors complicated the transition lack of familiarity with NP role, organizational and professional unfamiliarity with NP needs Co participants frequently not aware of the NP s struggles Those with previous experience more aware of need for support
Theme 1 Transition to NP Role Time management First 3 months much overtime New patient assessments Inappropriate length of bookings Introduction of electronic health records Generally not pressured by co participants to see more patients, but lack of perception of amount of overtime worked By 1 year Little overtime Expectations clearer for NPs and staff
Theme 1 Transition to NP Role Mentoring Key factor Experienced co participants very aware of need for mentoring and support Some NPs had to seek own supports and explain role whiletheywerestilllearningit. There is certainly a responsibility of us when a nurse practitioner comes, to mentor her through. It doesn t matter if they ve been working for a while, you still have a new practice population and they still have to learn the ins and outs of things. (Co part 12 6 months)
Theme 1 Transition to NP Role Previous experience Very experienced nurses, many with ICU and Emergency backgrounds Much life experience Many known in workplaces because of previous employment as RN or as NP student placement Able to draw on experience to deal with start up organizations, lack of appreciation for role and their needs, and conflicts.
Theme 2 Contextual factors impacting role transition Many changes in the Primary Health Care system in Ontario during this period Family Health Teams forming Pilot projects in Emergency Departments and other settings on effect of hiring NPs New NP positions in specialized clinics
Theme 2 Contextual factors impacting role transition Many employers had funding, but not infrastructure to support NP practice e.g. job descriptions, organizational charts, space, support staff "The biggest challenge is space I don t have an office. I don t have a space to call my own. So I still have a little cart and when I was hired, the understanding was that would change. Well naturally, you know how things are. Moving buildings, it s going to be another year." (NP 2 12months)
Theme 2 Contextual factors impacting role transition Hiring Word of mouth or student placement Few needed to move to find employment Fit with agency important to co participants Alternative positions available for those who were dissatisfied with current NP employment Orientation Much variation, often with the NP identifying own needs and plan own program Evaluation Often responsibility unclear, with lack of job description and expectations. Continuing education Many anglophones had to fight for time & reimbursement
Theme 3 Interprofessional Relationships Professional Colleagues MDs family, emergency, specialists RNs family practices/health teams, clinics, emergency Support staff receptionists, lab techs Relationships dependent on Culture and experience of agency with NPs Organizational position of NP Employee status All employees NP hired by MD Independent practice with consultation
Theme 3 Interprofessional Relationships NP role confusion "There had been lots of conversation about what can a nurse practitioner do? One of the first things I did was download, the brochure [off the NPAO website] and had copies left around in the clinic. So the staff have learned, the patients have learned, and the physicians have learned." (NP 4 3 months) "They [physicians] expect that you can manage everything and again, with medications, prescriptions, they can t understand, Why do I have to co sign for this? " (NP 10 6 months) "The physicians had basically been told, they claim that they were told, that we re nurses, sowethereforedon trequirenursing support." (NP 9 3 months)
Theme 3 Interprofessional Relationships 9 NPs changed jobs during the period of the study. 7 anglophones and 2 francophones 7 job changes were because of interprofessional conflicts.
Theme 4 Provincial Policy and Politics Regulations limit scope of practice, prescription rights, medical directives required in hospitals Some government agencies and insurance companies accept NP referrals and forms; some do not "Certain insurance companies won t recognize my notes. The Ministry of Transportation will not recognize any work done by a nurse practitioner, yet I can do disability stuff." (NP 10 6 months)
Theme 4 Provincial Policy and Politics Insecure funding for new positions "Wewerefundedfor a full year but we were worried about funding for the year and we were afraid we were going to lose her so we actually put her on staff. The posting went up before we heard from the ministry. But we do have full funding for a full year." (Co part 15 12 months) MD funding mechanisms led to competition with NPs and restrictions on practice "Not being able to refer to specialists because of billing issues. It s within my scope to be able to refer to a dermatologist or whatever, but because they [physicians] can t get paid the same, I can t do it. That s frustrating." (NP 2 3 months)
Theme 5 Educational Preparation 12 month program provided in 2 languages by consortium of 10 Ontario Universities Post baccalaureate, moving to Master's level Recommendations from participants Role transition preparation More clinical More preparation for "business aspects" Budgets, contracts, government forms "Most of the nurse practitioners I know are struggling with not [having] a clear understanding of the financial side of things." (NP 2 12 months) Info re particular client groups Influencing policy government and agency
Factors Influencing Success Age & personal confidence Experience as RN in areas like Emergency, ICU Mentorship and support from NP colleagues Availability of MDs and NPs for consultation, especially in early months Adequate resources and support roles Organizations that were familiar with role, scope of practice, and expectations of NPs Francophone NPs = precious resources
Factors Hindering Success Organizations with new positions for NPs New structures for organizations and practices Team adjustment to the new practitioner Few position descriptions, infrastructure plans Contracts temporary with unclear continuation of position Policies and funding limiting scope of practice
Recommendations New NPs Look for work in agencies familiar with role If impossible, negotiate supports and mentorship Mentorship All newly graduated NPs need formal mentorship New NPs seek and establish links with experienced NPs Hiring organizations Provide orientation to agency and role Job description, role definitions, and organization chart with clear reporting relationships pre hiring New organizations hire experienced NPs or arrange consultation for NP and agency
Recommendations continued Organizations Ensure supports of space, clerical and interprofessional staff and policies and procedures to promote full scope of practice Common repository of resources for NP hiring agencies, NPs and MDs Interprofessional protocols to facilitate NP referrals Funding Stable, predictable funding for new positions with timely notification of change Support for orientation, mentoring, team building, continuing education Reassess MD funding to avoid competition with NPs
Recommendations continued Policy Re examine limitations on prescriptive authority and referrals to facilitate gate keeper role of NP Funding for independent practice Role clarification with professional bodies Education Role transition Complex situations e.g. co morbidity, homelessness Business aspects of practice Pre licensure interprofessional education for NPs, MDs, RNs, etc.
QUESTIONS? We invite your questions about the research and findings. bcragg@uottawa.ca