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Nurse Practitioner Role Transition: A Concept Analysis

Nurse Practitioner Role Transition: A Concept Analysis Hilary Barnes, MSN, CRNP, PhD (candidate)

Hilary Barnes, MSN, CRNP, PhD (candidate), is Family Nurse Practitioner, Widener University, Chester, PA.

Keywords Concept analysis, nurse practitioner, role transition, transition, work role transition

Correspondence Hilary Barnes, MSN, CRNP, PhD (candidate), Widener University, Chester, PA E-mail: hbarnes@mail.widener.edu

Barnes

AIM. A concept analysis of nurse practitioner (NP) role transition. BACKGROUND. The Affordable Care Act is expected to provide 32 million Americans with health insurance, and NPs are gaining attention in addressing this increasing demand for healthcare providers. However, there is limited analysis of the transition from registered nurse to NP. Oftentimes, during this transition, there is a shift from an experienced, expert status to an inexperienced, novice status, with a subsequent loss of confidence in one’s ability and competence. This can hinder successful role development and affect employment continuity within the first year of practice. METHODS AND SOURCES. NP role transition was examined using Walker and Avant’s method of concept analysis. Electronic databases were searched using the terms role transition and nurse practitioner. Thirty articles from nursing, psychology, and business were included. FINDINGS AND CONCLUSIONS. The four defining attributes of NP role transition are absorption of the role, the shift from provider of care to prescriber of care, straddling two identities, and mixed emotions. Personal and environmental antecedents and consequences of the concept are identified. The development of empirical knowledge on NP role transition through further research is important in order for new-to-practice NPs to become high-quality, full-functioning providers.

The transition from registered nurse (RN) to nurse practitioner (NP) can be a significant adjustment in an individual’s career. The transition is rarely easy, and even during the most positive of experiences it can be stressful (Cusson & Viggiano, 2002). During NP role transition, there is the shift from an experienced, often expert status in the RN role to an inexperienced, novice status in the NP role. This change in profes- sional identity can lead to an individual’s loss of confidence, which can hinder successful role develop- ment. Consequently, this impaired role development can affect employment continuity and the decision to remain in the profession within the first year of prac- tice (Cusson & Strange, 2008).

Transitions, as a concept in nursing, have been described as complex and multidimensional (Meleis, Sawyer, Im, Hilfinger Messias, & Schumacher, 2000). They are defined as the period of change between two

relatively stable states that comes with some degree of self-redefinition (Chick & Meleis, 1986). Transitions can occur at any time in an individual’s life; affect one’s environment, health, or relationships; and are shaped by many factors and forces (Heitz, Steiner, & Burman, 2004; Steiner, McLaughlin, Hyde, Brown, & Burman, 2008). Specifically, the changes that occur can be significant for an individual when the transi- tion involves a change in a job or career path (Chick & Meleis, 1986).

With the advent of the 2010 Patient Protection and Affordable Care Act (PPACA) and the pending changes to the U.S. healthcare system, it is anticipated that there will be a need for an increased number of pro- viders to care for the estimated 32 million Americans who will become eligible for health insurance (Mann, 2011; PPACA, 2010). As an integral part to this changing system, NPs are being viewed as part of the

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solution in addressing the nation’s primary care and healthcare needs (American Association of Nurse Practitioners [AANP], 2013a). However, there has been limited examination of the concept of NP role transition and a lack of development of an operational definition of the concept, along with identification of its attributes, antecedents, and consequences.

The purpose of this article is to analyze the concept of NP role transition and develop an operational defi- nition for its use. NP role transition is an important concept for nursing science and nursing practice. As NPs gain greater exposure and professional status in health care, helping new-to-practice NPs move through this transition quickly and smoothly is critical to maintaining continuity of care for patients and opti- mizing efficiency for healthcare systems.

Method

NP role transition was examined using Walker and Avant’s (2005) method of concept analysis. This method examines the basic elements of a concept to determine its defining attributes at the present time. It can be used to clarify a concept that may be unclear or ambiguous and provide a foundation for further development. Within nursing, there are many oppor- tunities to observe and experience phenomena. Concept analysis is important for describing and explaining these phenomena in order to develop the body of literature and advance nursing science (Walker & Avant, 2005).

Walker and Avant’s (2005) method was modified for nursing from Wilson’s (1963) classic procedure of concept analysis. The steps included in this analysis were the following: identifying the concept of interest, determining the purpose of the analysis, identifying uses of the concept, determining the defining attri- butes, identifying the antecedents and consequences, identifying a model case along with borderline and contrary cases, and discussing the empirical referents (Walker & Avant, 2005).

Data Sources

A search of electronic databases was conducted using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, PsycARTICLES, Business Source Complete, and Regional Business News. The primary search term used was role transition. The term nurse practitioner was

also included in the search of the databases in order to obtain those articles focusing on role transition for the NP; however, no additional articles were obtained on NP role transition outside of the CINAHL. The search was initially limited to articles published between 2000 and 2012, except for the NP-specific articles, upon which no date limitations were placed. Studies obtained from the electronic databases were limited to English-only, peer-reviewed publications.

Nursing

In the CINAHL, a search of the term role transition without any date limits resulted in 148 articles. Sev- enteen articles were retrieved with adding the search term nurse practitioner. The titles and abstracts of these articles were reviewed, and subsequent ancestry searches of selected reference lists were conducted to obtain additional relevant articles. Twenty-four articles from nursing were included in this analysis. Twelve articles examined NP role transition, seven examined transitions in other nursing roles, and five were transitions-focused theoretical publications. These articles represented the original work that has been conducted on NP role transition and the devel- opment of the concept of transitions in nursing.

Psychology and Business

In contrast to nursing, the psychology and business databases resulted in a large number of articles. A search of PsycINFO using the search term role transition and limiting the search to English-only, peer-reviewed articles published between 2000 and 2012 resulted in 3,256 articles. Forty articles were retrieved from a collective search of PsycARTICLES, Business Source Complete, and Regional Business News using the same parameters. There was great overlap of articles between the two searches.

Approximately 250 titles and abstracts were exam- ined until a sample of 33 articles was obtained. The research on role transitions in these disciplines was broad and diverse, and the majority of the articles were not relevant to the present analysis. Articles focusing on work role transitions that were comparable to NP role transition were reviewed until saturation was reached. From this sample, articles that were found to be irrelevant or not fitting were removed. Additional important articles, which were frequently cited and deemed meaningful to the body of research, were

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obtained through ancestry searches of selected refer- ence lists. Six articles from business and psychology were included in this analysis. The articles by Ashforth and Saks (1995), Black and Ashford (1995), Morrison (1993), and Nicholson (1984), although older, were included because they form the basis of research on role transitions in these disciplines.

Additional Data Sources

Additional data sources for this concept analysis included a professional NP organization’s web site and an online dictionary. Expanding data collection to dic- tionaries and other sources was encouraged by Walker and Avant (2005) in order to identify all the possible uses of the concept. As the concept analysis is devel- oped, the authors suggested that researchers consider using only those definitions and uses of the concept that are most pertinent to the analysis (Walker & Avant, 2005).

Findings

Uses of the Concept

In the literature, multiple uses of the concept of transitions were identified. The most prevalent types of transitions were health–illness, life span, develop- mental, and career or work role transitions. Discus- sions of these different transitions were present across the disciplines of nursing, psychology, and business. In nursing, Meleis et al. (2000) described health–illness transitions as the diagnosis of an illness, surgery, reha- bilitation, and recovery. Developmental and life span transitions included pregnancy, childbirth, parent- hood, adolescence, menopause, aging, and death (Meleis et al., 2000). The examination of work role transitions existed primarily in the psychology and business literature. Role transitions within profes- sional institutions and career paths of nurses with a bachelor of science in nursing and beyond were closely examined.

Definitions of Concept Terms

Lacking in the literature is a comprehensive defini- tion of the concept of NP role transition. There is already an informative body of qualitative literature examining this transition but no definition commonly used across the research. Before developing a definition

for the concept of NP role transition, the individual words within the concept are defined. According to the AANP (2013a), NPs are RNs who have received advanced education and clinical training, and are licensed to provide patient care in each state and the District of Columbia. Role can be defined as “a character assigned or assumed; a socially expected behavior pattern usually determined by an individual’s status in a particular society; a part played by an actor or singer; or a function or part performed especially in a particular operation or process” (Role, 2013).

Next, transition is a concept that has been examined and developed in nursing over the past three and a half decades (Chick & Meleis, 1986; Meleis, 1975; Meleis et al., 2000; Schumacher & Meleis, 1994). In theoreti- cal works, transition is defined as a passage from one life phase, condition, or status to another, and as inclu- sive of process, time span, and perception (Chick & Meleis, 1986). Transition can also be defined as “a passage from one state, stage, subject, or place to another, change; a movement, development, or evo- lution from one form, stage, or style to another; a musical modulation; a musical passage leading from one section of a piece to another; and an abrupt change in energy state or level (as of an atomic nucleus or a molecule) usually accompanied by loss or gain of a single quantum of energy” (Transition, 2013).

More specifically, role transition indicates a change in an individual’s identity within a certain context that occurs through the development of new knowledge and skills, as well as a change in behavior (Meleis, 1975). Schumacher and Meleis (1994) identified situ- ational transitions as those surrounding specific social contexts, such as educational and professional roles, which can occur throughout a career. In a theoretical article from organizational psychology, Nicholson (1984) defined work role transitions as any change in employment status and any major change in job content. These definitions will form the basis for the analysis of the concept of NP role transition.

Defining Attributes

In a concept analysis, the defining attributes are those characteristics that provide a strong descrip- tion of what the concept in question is and that allow insight into the concept (Walker & Avant, 2005). From the literature, four defining attributes of NP role transition were identified: absorption of the role, the shift from provider of care to prescriber of care, strad- dling two identities, and mixed emotions.

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Absorption of the role. The first defining attribute of NP role transition is absorption of the role. This is described as a time of high personal development and role learning as the clinician moves from the RN role into the NP role (Nicholson, 1984).

Shift from provider of care to prescriber of care. The second defining attribute is the shift from being a provider of care to a prescriber of care (Cusson & Strange, 2008; Forbes & Jessup, 2004). Within this attribute, there is a dramatic increase in the clinician’s autonomy and responsibility toward the patient’s health care. This is seen as an exciting and positive, yet daunting, change for new-to-practice NPs (Chang, Mu, & Tsay, 2006; Cusson & Viggiano, 2002; Kelly & Mathews, 2001).

Straddling two identities. Straddling two identities is identified as a defining attribute of NP role transi- tion. The new-to-practice NP is no longer performing in the role of the RN, but is also not a physician (Brown & Olshansky, 1997; Kelly & Mathews, 2001). The NP often struggles to form an identity as the role is navigated, and can experience self-doubt, the uneasy feeling of returning to the novice level, and feeling like an impostor (Brown & Olshansky, 1997;

Chang et al., 2006; Cusson & Strange, 2008; Fleming & Carberry, 2011; Forbes & Jessup, 2004; Heitz et al., 2004; Steiner et al., 2008).

Mixed emotions. The final defining attribute of NP role transition is mixed emotions. This attribute is one of the primary characteristics of role transition identi- fied in the nursing literature as well as in the NP- specific research. As seen in Table 1, the emotions cited most frequently in relationship to role transition are exciting, stressful, anxiety, nervous, overwhelmed, frustrated, feelings of inadequacy especially surround- ing knowing and not knowing, ambivalence about the role, uncertainty, not fitting in or not belonging and isolation, and a longing to return to the prior role. It is interesting to note that of these 11 emotions, there are 10 negative emotions and only a single positive emotion. This reflects what was described in the literature, but the excitement expressed by nurses during these various transitions seemed to occur simultaneously with the negative emotions (Cusson & Strange, 2008).

Antecedents

The antecedents in a concept analysis are those events or incidents that must happen prior to the

Table 1. Emotions Associated With Role Transitions in Nursing

Emotion References

Exciting Cusson and Strange (2008), Duchscher (2009), Kelly and Mathews (2001)

Stressful Chang et al. (2006), Chernomas, Care, McKenzie, Guse, and Currie (2010), Cusson and Strange (2008), Dempsey (2007), Duchscher (2009), Kelly and Mathews (2001), Steiner et al. (2008)

Anxious Anderson (2009), Brown and Olshansky (1997), Chernomas et al. (2010), Cusson and Strange (2008), Dempsey (2007), Duchscher (2009), Goodwin-Esola et al. (2009), Kelly and Mathews (2001), Steiner et al. (2008)

Nervous Kelly and Mathews (2001)

Overwhelmed Anderson (2009), Duchscher (2009), Heitz et al. (2004), Kelly and Mathews (2001), Schumacher and Meleis (1994), Steiner et al. (2008)

Frustrated Cusson and Viggiano (2002), Duchscher (2009), Kelly and Mathews (2001)

Feelings of inadequacy

Anderson (2009), Cusson and Viggiano (2002), Dempsey (2007), Duchscher (2009), Heitz et al. (2004), Kelly and Mathews (2001), Steiner et al. (2008)

Ambivalence Cusson and Strange (2008)

Uncertainty Brown and Olshansky (1998), Fleming and Carberry (2011), Kelly and Mathews (2001)

Not fitting in; not belonging; isolation

Anderson (2009), Chang et al. (2006), Duchscher (2009), Fleming and Carberry (2011), Heitz et al. (2004), Kelly and Mathews (2001), Schumacher and Meleis (1994), Steiner et al. (2008), Winfield et al. (2009)

Longing to return to one’s prior role

Fleming and Carberry (2011), Heitz et al. (2004)

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occurrence of the concept (Walker & Avant, 2005). The antecedents for NP role transition are divided into personal and environmental antecedents. In order for NP role transition to occur, individual characteristics, as well as factors external to the NP, need to be in place. The presence and absence of these antecedents can promote or inhibit NP role transition.

Personal antecedents. The personal antecedents of NP role transition are a graduate-level education, experience, active disengagement from the prior role, active engagement in the new role, and an individual’s desire for feedback.

Graduate-level education. The first personal antecedent is a graduate-level education, as this is a requirement for entry-level practice (AANP, 2013b; “Consensus Model for APRN Regulation,” 2008).

Experience. Experience is an antecedent of NP role transition. According to Benner (2001), experience is important for skill acquisition and developing compe- tency, and experience can be valuable during role transition (Cusson & Strange, 2008; Duchscher, 2009; Heitz et al., 2004; Steiner et al., 2008). However, in the available literature, experience as an antecedent to NP role transition is not clearly defined as prior RN experience or overall prior work–life experience. Although much of the NP literature cites experience as important during the NP role transition, there have been no formal studies looking specifically at prior RN experience in relationship to NP role transition. Within some studies, it has been expressed by partici- pants that prior RN experience provided a strong foundation for transition to the NP role (Heitz et al., 2004; Kelly & Mathews, 2001). Cusson and Strange (2008) found that NPs with less staff nurse experience required more time to adapt to the new role. However, these statements were made within larger studies and were not the main focus of the research.

Disengagement. Disengagement is based on the idea that an individual’s continued connection to a prior work role can hinder the adjustment to the new posi- tion (Niessen, Binnewies, & Rank, 2010). If the indi- vidual remains attached and often thinks back to the prior role, this will be a distraction from exploring, solving problems, and coping with stress in the new role. Through active disengagement, attention is removed from the prior work role, thus preventing the individual from dwelling on potential loss and allow-

ing increased openness to the new role. Individuals who are still attached to a prior work role are dis- tracted by thinking about it, and are less motivated to learn and adjust to the new role (Niessen et al., 2010). Disengagement is important to consider during NP role transition, because the longing to return to the prior RN role has been cited in NP-specific research (Fleming & Carberry, 2011; Heitz et al., 2004).

Engagement. Alternatively, Meleis et al. (2000) iden- tify engagement as one of the essential properties of transitions and define it as the degree to which one is involved in the transition experience. The ways in which an individual can be engaged in a transition are through seeking out information, using role models, actively preparing, and proactively modifying activi- ties (Meleis et al., 2000). For example, Cusson and Strange (2008) found that NPs who took an active role in their own learning, sought out new experiences, and asked questions struggled less during the transi- tion into practice.

Desire for feedback. The final personal antecedent of NP role transition is the individual’s desire for feedback. Desire for feedback is how much information an indi- vidual wants from others, such as peers, colleagues, supervisors, or educators, regarding role performance (Nicholson, 1984). Those with a high desire for feed- back will take cues from other staff and colleagues for appropriate behaviors as the new role is learned, and desire for feedback was found to be important to an individual’s development early in a work role transi- tion (Ashforth & Saks, 1995; Black & Ashford, 1995). Desire for feedback has been found to be positively associated with actively seeking feedback, which can lead to increased sense of competence, increased role clarity and mastery, increased job performance and satisfaction, as well as decreased intent to leave a posi- tion (Morrison, 1993, 2002).

Environmental antecedents. The environmental antecedents for NP role transition are job novelty, support, and a formal orientation.

Job novelty. The first environmental antecedent is job novelty. Job novelty is defined as how similar a new role is to the previous role, and the degree to which the new role allows the individual to use prior knowl- edge, skills, and habits (Nicholson, 1984). A role with low job novelty will be similar to the prior role, and there will be fewer opportunities for the individual to

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learn or gain new skills. Conversely, a role with high job novelty has fewer opportunities for the individual to reproduce familiar skills and routines. As a result, a position with high job novelty allows for the acquisi- tion of new skills and knowledge, which leads to increased personal development and learning (Black & Ashford, 1995; Nicholson, 1984).

An assumption of this concept analysis is that the new-to-practice NP is in a role of high job novelty, as it is quite different from that of the RN. Although both roles stem from a nursing framework and are consid- ered within the same discipline, the scope of practice of the NP is very different from the RN. Both roles include providing direct patient care, with an empha- sis on health promotion, education, and counseling, as well as physical exam and health history; however, the role of the NP is more independent, and includes diagnosis, prescribing medication, and treatment of acute and chronic illnesses and injuries (American Nurses Association, 2013). Thus, the NP cannot employ the skills and routines previously used as an RN, and will need to develop new knowledge and skills during the transition.

Support. Support is a significant part of the experience in promoting a smooth transition process for new-to- practice NPs (Fleming & Carberry, 2011). Across the nursing literature, support has come from an individu- al’s peers and colleagues (Anderson, 2009; Brown & Olshansky, 1997; Fleming & Carberry, 2011; Kelly & Mathews, 2001), as well as mentors or preceptors (Cusson & Strange, 2008; Heitz et al., 2004; Schumacher & Meleis, 1994). The sources of support for new-to-practice NPs are other NPs, collaborating physicians, RNs, and staff (Cusson & Strange, 2008; Fleming & Carberry, 2011; Heitz et al., 2004; Kelly & Mathews, 2001; Steiner et al., 2008). NPs have also cited appreciation from patients and their families as sources of support (Heitz et al., 2004; Kelly & Mathews, 2001; Steiner et al., 2008). Finally, support- ive friends and family outside of work can be benefi- cial (Brown & Olshansky, 1997; Kelly & Mathews, 2001).

Formal orientation. Formal orientations have been found to promote role transition for new-to-practice RNs (Goodwin-Esola, Deely, & Powell, 2009; Winfield, Melo, & Myrick, 2009), clinical nurse specialists (Miga, Rauen, & Srsic-Stoehr, 2009), and NPs (Bahouth & Esposito-Herr, 2009; Cusson & Strange, 2008; Yeager, 2010). Extensive training and orientation programs

have not been widely implemented for NPs, but the available literature argues that NPs who receive struc- tured orientations transition more easily, quickly, and are personally more satisfied with the role than those NPs who do not (Bahouth & Esposito-Herr, 2009; Cusson & Strange, 2008). Although an orientation may not fully eliminate a new clinician’s anxiety or stress surrounding the transition, a successful orienta- tion can help promote a sense of confidence, compe- tence, and satisfaction (Goodwin-Esola et al., 2009). Finally, orientations can help encourage role socializa- tion, which may allow new graduates to feel like part of the team (Winfield et al., 2009).

Consequences

The consequences in a concept analysis are those events that come about as a result of the occurrence of the concept (Walker & Avant, 2005). There are two consequences of NP role transition: a successful role transition or an unsuccessful role transition. Ulti- mately, the desired outcome of the NP role transition is a successful role transition outcome, but an individual may experience an unsuccessful transition outcome. When an individual’s experience culminates in a suc- cessful role transition, there is a subjective sense of well-being, increased confidence and competence, good connections with others, mastery of skills, and autonomous practice (Meleis et al., 2000). Conversely, an unsuccessful role transition can result in resig- nation, turnover, and lack of cohesiveness among staff and colleagues (Brown & Olshansky, 1998; Schumacher & Meleis, 1994). These consequences, along with the aforementioned defining attributes and antecedents, are presented in a concept map (Figure 1), which provides a visual description of NP role transition (Walker & Avant, 2005).

NP Role Transition Definition

Based on the concept analysis, the following defi- nition of NP role transition was developed:

NP role transition is a process consisting of multiple mixed emotions that occurs over time, and is a period of great personal development and learning as the NP takes on new autonomy and responsibility for patients. This process occurs as the new NP moves out of the RN role and absorbs the NP role, and is affected by personal and environmental antecedents, which can lead to a successful or unsuccessful role transition.