FACILITATING SUCCESSFUL ROLE TRANSITIONS FROM REGISTERED NURSE TO NURSE PRACTITIONERWorldwide, nurse practitioners (NPs) provide a wide range of direct care services to people at every stage of life1. In addition to treating illnesses, they teach individuals and their families about healthy living, preventing and managing illnesses2. In the majority of countries, this essential health care provider has several steps along their educational journey to become an Nurse Practitioner (NP). Most commonly, the individual is a registered nurse (RN) who has practiced extensively and developed considerable clinical expertise before applying for advanced practice graduate courses. However, the transition from RN to NP may prove to be difficult, and those who choose to pursue this new role are faced with many challenges. Moreover, there is a significant cognitive shift from an experienced RN to an inexperienced, new NP. This adjustment in professional identity from an ‘expert’ RN to a ‘novice’ NP has the potential to decrease self-confidence, impede professional role development and may negatively influence decisions of new NPs to remain in the profession during the first year of clinical practice3.
To better understand this issue, we undertook an integrative review of the literature to identify factors that contribute to the successful role transition from RN to NP. The main objective was to synthesize what is known about supportive measures for NP entry into practice, and provide recommendations for future research and support. The search was limited to published English language journal articles and was not restricted by date of publication. Inclusion criteria included articles addressing the role transition from RN to NP and the factors that supported or hindered the transition process. Initially, 674 non-duplicate records were identified, with title and abstract review eliminating 613 records, leaving 61 items for full text screening. Full text review identified 30 articles that met the inclusion criteria. Thirteen articles used qualitative methods (survey, focus groups, telephone, and interview methodologies), 7 studies used quantitative methods (surveys, questionnaires, and pre-posttest studies), and 10 literature reviews from countries including the United States, Australia, Ireland and Sweden.
Successful role transition results in a competent and confident NP who relishes the challenges the new role brings4. In this review, three broad themes were identified including academic and training factors, individual experiences and administrative and professional workplace factors. Within these, eight areas emerged as opportunities to support RN to NP transition. These include (a) awareness of role transition, (b) preceptorship, (c) academic faculty support, (d) social support, (e) fellowship and residency programs, (f) mentorship, (g) role clarity and interdisciplinary collaboration, and (h) orientation.
Academic and training factors
Academic Faculty Support: because the role of the NP continues to evolve and is influenced by many environmental issues, the preparation of the NP by the academic institution needs to be assessed on a frequent basis5. Strategies to assist the novice NP through the transition period are essential to decrease the negative consequences of their experience4,6. Qualitative research through focus groups in which 21 recent NP graduates5 suggest a number of methods in which academic faculty can facilitate the NP graduate's transitional adjustment period. These include: (a) introducing the students to professional organizations and other possible support people; (b) seeking avenues of staying connected to the new graduate such as through innovative technology and continuing education programs; (c) establishing curricula with increased collaboration between medical and NP students during the school years to assist in a mutual understanding of roles; (d) planning seminars with the students emphasizing the adjustment phase of moving from expert, to novice, and back to expert; (e) sharing tips on how to manage limited time when in practice; (f) exploring methods with the students on how to manage and synthesize the volumes of journal readings; (g) discussing with students the loss of privacy that may occur and the need for a protective banner; and (h) emphasizing the gains in personal satisfaction that will offset any negatives5. Educators who conduct seminars to assist students in their adjustment to the practitioner role can structure discussion around expectations of students regarding their perception of the role and how those expectations change as students’ progress through training7-8.
Preceptorship: to close the gap between education and practice, preceptorships have been used to support NPs' clinical learning, both before and after graduation9. Preparedness for practice is a critical issue for new NPs, many who report feeling overwhelmed, frustrated, and inadequate10. Adequate preparation of preceptors for their responsibilities in supervising and mentoring students is critical for a productive learning experience. Preceptors should recognize that NP students have not yet achieved their highest level of proficiency8. A preceptorship model between an experienced expert NP and a student NP that enables frequent contact, evaluations and positive reinforcement, may protect against possible feelings of isolation, enhance professional advancement and build confidence. In order to enhance professional advancement and develop a sense of unity, networking can promote collegial support, develop a sense of unity and enable effective communication channels to boost communication11. Training and adjusting preceptors' schedules to allow learning to take place when in the program may provide NP students with the support necessary for them to increase autonomy in their clinical decision making skills9.
Fellowship and Residency Programs: Residency models are of benefit for new-graduate NPs to ease the transition to practice and promote patient care quality, and nurse retention, and satisfaction12-14. These programs support new NPs or those transitioning to new areas of practice, provide them with the opportunity to gain valuable management skills, help them formalize their identity as NPs, and affirm their confidence as they take on their new roles14. NPs who complete residency training reported feeling that they were more efficient providers15. NP fellowship programs have been implemented in several health care settings, especially in specialty areas, as a way to improve job satisfaction by augmenting skill, competency, and confidence16. Continuation of NP fellowships is recommended for a successful NP role transition to develop clinical growth, retention, leadership skills, and ultimately an expert clinician16-18.
Individual experience factors
Awareness of Role Transition: NPs commonly report feeling underprepared, and find themselves relying on their prior nursing experience, rather than their NP education and advanced clinical care provider15,19. Main personal barriers to a successful transition from an RN to the NP role are loss of confidence, shift of status and identity confusion and poor job satisfaction. In essence, the new NP graduate leaves the comfort zone of the RN scope practice to enter an advanced practice role as a novice which is accompanied by associated stress, anxiety, isolation, inadequacy and role ambiguity, commonly leading to feelings of incompetence19-22. Novice NPs struggle with the challenge of providing safe and competent care to their clients while continuing to fill the gaps in their developing knowledge base. They are expected to have advanced clinical skills and be able to think critically and integrate advanced assessment, pathophysiology, and pharmacology while simultaneously maintaining a biopsychosocial nursing focus23. New graduates are expected to function at an advanced level yet, it has been reported that there is significant uncertainty regarding their role in an increasingly demanding profession7,20-21,24. Consequently, this impaired role development can affect employment continuity and the decision to leave the profession within the first year of practice25-27. Indeed, the initial transitional year is thought to be the critical foundation on which new NP professionals build their practice25,27. An awareness of the stages that the typical novice NPs go through during the initial year of practice and the potential stressors they face may provide insight into the magnitude of the problem7,25-26. Understanding NPs’ role transitions could be used to feed-forward the development of ‘support scaffolding’ such as mentoring and support networks, aiming to enhance smooth passage from RN to NP11. The assumption is that a better awareness of the transitional process will lead to greater understanding and a shorter adjustment period5,7,19. However, awareness precedes engagement. Once an individual is aware, the individual can then become “immersed in the transition process and undertake activities such as seeking information or support, modifying former activities, and making sense of the circumstances”19. Recognizing that feelings of disconnectedness and anxiety are normal and time-limited is the first step in understanding the process7. A greater understanding of NP role transition can help students recognize certain feelings and behaviors as a normal part of the transitional process and use more positive coping mechanism27. It has been suggested that the NP who engages in self-reflection will work through the transitional process more effectively, as opposed to spending time on fears7.
Administrative and professional workplace factors
Orientation: the importance of a thorough orientation period and the support of other professionals, particularly staff nurses and NP coworkers, is especially influential in the transition process4,28. Formal orientation programs provide the foundation for successful practice and are augmented by additional opportunities for professional growth16,25. Novice NPs report a higher job satisfaction when they are offered a formal orientation program, successfully preparing and empowering them while allowing timely transitions and increased role satisfaction26,29.
Social support:the word “support” is used to describe new role experiences and is viewed as one of the most important elements of a successful transition4. Because the role transition of the novice NP is often stressful, social support including support from peers, physicians, family, and patients, is especially vital to the novice NP during the transitional period30. Involvement in professional groups and organizations can prevent feelings of isolation5. Novice NPs should be encouraged to develop support networks among their peers to remind them of the universality of their feelings4 in addition to ongoing networking opportunities30. Several factors that positively affect the RN to NP transition are support/mentorship, autonomy, the opportunity for professional growth and development, flexibility with work-life balance, and a sense of purpose in their work15,30.
Mentorship: mentorship is defined as an intense relationship between a novice and an expert to promote role socialization and, ultimately, role success of the novice32. Mentoring creates a supportive environment to advance the beginner's learning and fill the gap between didactic information and real-world experience. Working with a mentor is an effective strategy to ease stress and anxiety experienced during that first year of NP practice. A mentoring relationship augments the development of the novice NP's knowledge and clinical skills within the context of individualized guidance and support. Time spent with a mentor facilitates socialization into the NP role, promotes self-efficacy, and enables novice NPs to meet the demands of the organization and health care system25,28,31. The careful selection of a mentor to facilitate role development and job satisfaction is important. Professional colleagues need to be patient, give verbal support, and consistent guidelines during this transitional period because their encouragement is important in the professional growth and acceptance of the NP5. Feedback about their work is important and helps the NPs to develop confidence in their assessment and diagnostic skills29.
In addition to guiding novice NPs in developing their clinical competence and skill, mentors offer a realistic view of the NP role and provide support to the novice NP during times of stress and uncertainty. Mentors also facilitate integration and socialization within this health care setting. The time spent with a mentor provides the novice NP with the opportunity to realize that learning is a lifelong process and although some days are better than others, the NP role can be very gratifying19,25,32.
Expert NPs play a valuable part in easing the transition into the NP role, but they should not be solely responsible for this task. Health care organizations need to embrace a culture of mentoring to promote a healthy work environment, facilitate learning, and encourage staff retention. Most importantly, organizations must allot funding for mentorship and mentorship programs. This involves providing orientation and educational training programs for mentors and mentees and supplying opportunities for personal and professional growth22.
Role Clarity and Interdisciplinary Collaboration: professional collaboration between experienced health care providers is essential for orientation and transition into practice4,17. A literature review study18 discovered that when NPs were able to collaborate with their interdisciplinary team, physicians, or other advanced practice providers, they felt more supported, had more self-confidence, and reported a more successful transition8,15,30. Transitioning to the role of NP is complex and dependent on the individual and the attitudes of healthcare colleagues. Change and adaptation are required of both the NP and members of the healthcare team. Failure to adapt by either party undermines the potential for NPs to deliver improved health care28. Some practitioners recalled early frustration and anxiety stemming from unclear job descriptions and little administrative support in their clinical setting33. Clarity of expectations and a gradual increase in responsibilities are likely to optimize adjustment to the NP role34.
The most frequently cited extrinsic obstacles reported by novice NPs were colleagues' negativity or lack of understanding of the NP role34-35. Struggling to identify as an advanced nurse in the new role while trying to merge the roles of nursing and medicine results in unclear boundaries and identity confusion9. Greater understanding by colleagues and employers regarding the continued role transition of new NPs may facilitate more positive relationships and less criticism as NPs continue to grow and assume their new responsibilities5,30,35-36.
Summary
The results and recommendations arising from this review have broad and international relevance. The NP role responds to the need for increased healthcare resources, with a well-qualified practitioner offering timely access to efficient and affordable health services internationally37. Accordingly, it is essential that novice NPs be supported as they transition into their new roles. Aiming to develop a competent, confident, expert NP is a wise and efficient investment4. As described above, educational institutions, employers, novice NPs and NP professional organizations all have key roles in the successful transition from student to primary care practitioner30. Increased awareness amongst educators may facilitate optimal preceptorship experiences and anticipatory discussions of role transitions. One important aspect is to connect novice NPs with mentors and professional association supports as early as possible to develop supportive professional and social networks. Employers too share in the responsibility of ensuring requirements are met to promote the continuing education and retention of novice NPs. Investing in NP specific orientation and mentorship is a highly effective training, support and retention strategy. Moreover, investment in organizational multidisciplinary teams at the practice level not only supports the novice NP but the system as a whole. In this manuscript we have summarized specific, actionable and cost-effective approaches to facilitate RN to NP transitions. Future work could focus on individual or combined interventions across organizations facilitating a smooth transition into advanced practice27,30.
REFERENCES
-
1. International Council of Nurses. Guidelines on Advanced Practice Nursing 2020 [Internet]. Geneva: International Council of Nurses; 2020 [cited 2022 Jan 15]. 44 p. Available from: https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf
» https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf -
2. Canadian Nurses Association. Nurse Practitioners [Internet]. [cited 2022 Jan 15]. Available from: https://www.cna-aiic.ca/en/nursing/advanced-nursing-practice/nurse-practitioners
» https://www.cna-aiic.ca/en/nursing/advanced-nursing-practice/nurse-practitioners -
3. Barnes H. Exploring the factors that influence nurse practitioner role transition. J Nurse Pract [Internet]. 2015 Feb [cited 2022 Jan 15];11(2):178-83. Available from: https://doi.org/10.1016/j.nurpra.2014.11.004
» https://doi.org/10.1016/j.nurpra.2014.11.004 -
4. Cusson RM, Strange SN. Neonatal nurse practitioner role transition. the process of reattaining expert status. J Perinat Neonatal Nurs [Internet]. 2008 Oct-Dec [cited 2022 Jan 15];22(4):329-37. Available from: https://doi.org/10.1097/01.JPN.0000341365.60693.39
» https://doi.org/10.1097/01.JPN.0000341365.60693.39 -
5. Kelly NR, Mathews M. The transition to first position as nurse practitioner. J Nurs Educ [Internet]. 2001 Apr [cited 2022 Jan 15];40(4):156-62. Available from: https://doi.org/10.3928/0148-4834-20010401-05
» https://doi.org/10.3928/0148-4834-20010401-05 -
6. Jangland E, Yngman Uhlin P, Arakelian E. Between two roles - experiences of newly trained nurse practitioners in surgical care in Sweden: a qualitative study using repeated interviews. Nurse Educ Pract [Internet]. 2016 Nov [cited 2022 Jan 15];21:93-9. Available from: https://doi.org/10.1016/j.nepr.2016.10.005
» https://doi.org/10.1016/j.nepr.2016.10.005 -
7. Huffstutler SY, Varnell G. The impostor phenomenon in new nurse practitioner graduates. Top Advanc Pract Nurs [Internet]. 2016 [cited 2022 Jan 15];6(2). https://www.medscape.com/viewarticle/533648
» https://www.medscape.com/viewarticle/533648 -
8. Lukács JL. Factors in nurse practitioner role adjustment. Nurse Pract [Internet]. 1982 Mar [cited 2022 Jan 15];7(3):21-3. Available from: https://doi.org/10.1097/00006205-198203000-00005
» https://doi.org/10.1097/00006205-198203000-00005 -
9. Pleshkan V, Hussey L. Nurse practitioners’ experiences with role transition: supporting the learning curve through preceptorship. Nurse Educ Pract [Internet]. 2020 Jan [cited 2022 Jan 15];42:102655. Available from: https://doi.org/10.1016/j.nepr.2019.102655
» https://doi.org/10.1016/j.nepr.2019.102655 - 10. Hart AM, Bowen A. New nurse practitioners’ perceptions of preparedness for and transition into practice. J Nurse Pract [Internet]. 2016 Sep [cited 2022 Jan 15];12(8):545-52. Available from: https://doi.org/10.1016/j.nurpra.2016.04.018
-
11. Kerr L, MacAskill A. The journey from nurse to advanced nurse practitioner: applying concepts of role transitioning. Br J Nurs [Internet]. 2020 May 28 [cited 2022 Jan 15];29(10):561-5. Available from: https://doi.org/10.12968/bjon.2020.29.10.561
» https://doi.org/10.12968/bjon.2020.29.10.561 -
12. Painter J, Sebach AM, Maxwell L. Nurse practitioner transition to practice: development of a residency program. J Nurse Pract [Internet]. 2019 Oct 1 [cited 2022 Jan 15];15(9):688-91. Available from: https://doi.org/10.1016/j.nurpra.2019.05.003
» https://doi.org/10.1016/j.nurpra.2019.05.003 -
13. Sargent L, Olmedo M. Meeting the needs of new-graduate nurse practitioners: a model to support transition. J Nurs Adm [Internet]. 2013 Nov [cited 2022 Jan 15];43(11):603-10. Available from: https://doi.org/10.1097/01.NNA.0000434506.77052.d2
» https://doi.org/10.1097/01.NNA.0000434506.77052.d2 -
14. Wiltse Nicely KL, Fairman J. Postgraduate nurse practitioner residency programs: supporting transition to practice. Acad Med [Internet]. 2015 Jun [cited 2022 Jan 15];90(6):707-9. Available from: https://doi.org/10.1097/ACM.0000000000000567
» https://doi.org/10.1097/ACM.0000000000000567 -
15. Mounayar J, Cox M. Nurse practitioner post-graduate residency program: best practice. J Nurse Pract [Internet]. 2021 Apr 1 [cited 2022 Jan 15];17(4):453-7. Available from: https://doi.org/10.1016/j.nurpra.2020.10.023
» https://doi.org/10.1016/j.nurpra.2020.10.023 -
16. Auffermann K, O'Keefe R, Smith T, Cohn T. Exploring novice nurse practitioner job satisfaction. J Am Assoc Nurse Pract [Internet]. 2021 Oct [cited 2022 Jan 15];33(10):802-10. Available from: https://doi.org/10.1097/JXX.0000000000000454
» https://doi.org/10.1097/JXX.0000000000000454 -
17. Bryant S, Parker K. Participation in a nurse practitioner fellowship to instill greater confidence, job satisfaction, and increased job retention. J Am Assoc Nurse Pract [Internet]. 2020 Oct [cited 2022 Jan 15];32(10):645-651. Available from: https://doi.org/10.1097/JXX.0000000000000313
» https://doi.org/10.1097/JXX.0000000000000313 -
18. Goodwin M, Fingerhood M, Slade E, Davidson P. Development of an innovative curriculum-to-career transition program for nurse practitioners in primary care. Nurs Outlook [Internet]. 2021 May-Jun [cited 2022 Jan 15];69(3):425-34 Available from: https://doi.org/10.1016/j.outlook.2020.11.012
» https://doi.org/10.1016/j.outlook.2020.11.012 -
19. Faraz A. Facilitators and barriers to the novice nurse practitioner workforce transition in primary care. J Am Assoc Nurse Pract [Internet]. 2019 Jun 5 [cited 2022 Jan 15];31(6):364-70. Available from: https://doi.org/10.1097/JXX.0000000000000158
» https://doi.org/10.1097/JXX.0000000000000158 -
20. Poronsky CB. Exploring the transition from registered nurse to family nurse practitioner. J Prof Nurs [Internet]. 2013 Nov-Dec [cited 2022 Jan 15];29(6):350-8. Available from: https://doi.org/10.1016/j.profnurs.2012.10.011
» https://doi.org/10.1016/j.profnurs.2012.10.011 -
21. Cusson RM, Viggiano NM. Transition to the neonatal nurse practitioner role: making the change from the side to the head of the bed. Neonatal Netw [Internet]. 2002 Mar [cited 2022 Jan 15];21(2):21-8 Available from: https://doi.org/10.1891/0730-0832.21.2.21
» https://doi.org/10.1891/0730-0832.21.2.21 -
22. Owens RA. Transition experiences of new rural nurse practitioners. Jr Nurse Pract [Internet]. 2018 Jun [cited 2022 Jan 15];14(8):605-12. Available from: https://doi.org/10.1016/j.nurpra.2018.05.009
» https://doi.org/10.1016/j.nurpra.2018.05.009 -
23. Szanton SL, Mihaly LK, Alhusen J, Becker KL. Taking charge of the challenge: factors to consider in taking your first nurse practitioner job. J Am Acad Nurse Pract [Internet]. 2010 Jul [cited 2022 Jan 15];22(7):356-60. Available from: https://doi.org/10.1111/j.1745-7599.2010.00522.x
» https://doi.org/10.1111/j.1745-7599.2010.00522.x -
24. Thompson A . An educational intervention to enhance nurse practitioner role transition in the first year of practice. J Am Assoc Nurse Pract [Internet]. 2019 Jan [cited 2022 Jan 15];31(1):24-32. Available from: https://doi.org/10.1097/JXX.0000000000000095
» https://doi.org/10.1097/JXX.0000000000000095 -
25. Hill LA, Sawatzky JAV. Transitioning into the nurse practitioner role through mentorship. J Prof Nurs [Internet]. 2011 May-Jun [cited 2022 Jan 15];27(3):161-7. Available from: https://doi.org/10.1016/j.profnurs.2011.02.004
» https://doi.org/10.1016/j.profnurs.2011.02.004 -
26. Barnes H. Nurse practitioner role transition: a concept analysis. Nurs Forum [Internet]. 2015 Jul-Sep [cited 2022 Jan 15];50(3):137-46. Available from: https://doi.org/10.1111/nuf.12078
» https://doi.org/10.1111/nuf.12078 -
27. Brown MA, Olshansky EF. From limbo to legitimacy: a theoretical model of the transition to the primary care nurse practitioner role. Nurs Res [Internet]. 1997 Jan-Feb [cited 2022 Jan 15];46(1):46-51. Available from: https://doi.org/10.1097/00006199-199701000-00008
» https://doi.org/10.1097/00006199-199701000-00008 -
28. MacLellan L, Levett-Jones T, Higgins I. Nurse practitioner role transition: a concept analysis. J Am Assoc Nurse Pract. 2015 Jul [cited 2022 Jan 15];27(7):389-97. Available from: https://doi.org/10.1002/2327-6924.12165
» https://doi.org/10.1002/2327-6924.12165 -
29. Dillon DL, Dolansky MA, Casey K, Kelley C. Factors related to successful transition to practice for acute care nurse practitioners. AACN Adv Crit Care [Internet]. 2016 Apr-Jun [cited 2022 Jan 15];27(2):173-82. Available from: https://doi.org/10.4037/aacnacc2016619
» https://doi.org/10.4037/aacnacc2016619 -
30. Pop RS. Mentoring nurse practitioners in a hospital setting. J Nurs Res [Internet]. 2017 Aug [cited 2022 Jan 15];25(4):304-9. Available from: https://doi.org/10.1097/JNR.0000000000000161
» https://doi.org/10.1097/JNR.0000000000000161 -
31. Gerhart LA. Mentorship: a new strategy to invest in the capital of novice nurse practitioners. Nurse Lead [Internet]. 2012 Jun 1 [cited 2022 Jan 15];10(3):51-3. Available from: https://doi.org/10.1016/j.mnl.2011.09.011
» https://doi.org/10.1016/j.mnl.2011.09.011 -
32. Twine N. The first year as a nurse practitioner: an integrative literature review of the transition experience. J Nurs Educ Pract [Internet]. 2017 [cited 2022 Jan 15];8(5):54-62. Available from: https://doi.org/10.5430/jnep.v8n5p54
» https://doi.org/10.5430/jnep.v8n5p54 -
33. MacLellan L, Higgins I, Levett-Jones T. An exploration of the factors that influence nurse practitioner transition in Australia: a story of turmoil, tenacity, and triumph. J Am Assoc Nurse Pract [Internet]. 2017 Mar [cited 2022 Jan 15];29(3):149-56. Available from: https://doi.org/10.1002/2327-6924.12423
» https://doi.org/10.1002/2327-6924.12423 -
34. Faraz A. Novice nurse practitioner workforce transition into primary care: a literature review. West J Nurs Res [Internet]. 2016 Nov [cited 2022 Jan 15];38(11):1531-45. Available from: https://doi.org/10.1177/0193945916649587
» https://doi.org/10.1177/0193945916649587 -
35. Soco C, Simonovich SD, Dillon D, Bishop-Royse J, Lattner C. Communication, leadership and organizational support facilitate successful transition into practice for nurse practitioners in the emergency department. J Am Assoc Nurse Pract [Internet]. 2020 Sep 1 [cited 2022 Jan 15];33(12):1156-65. Available from: https://doi.org/10.1097/JXX.0000000000000500
» https://doi.org/10.1097/JXX.0000000000000500 -
36. Heitz LJ, Steiner SH, Burman ME. RN to FNP: a qualitative study of role transition. J Nurs Educ [Internet]. 2004 Sep 1 [cited 2022 Jan 15];43(9):416-20. Available from: https://doi.org/10.3928/01484834-20040901-08
» https://doi.org/10.3928/01484834-20040901-08 -
37. International Council of Nurses Policy Brief. Advanced Practice Nursing: an essential component of country level human resources for health [Internet]. 2016 [cited 2022 Jan 15] Available from: https://www.who.int/workforcealliance/knowledge/resources/ICN_PolicyBrief6AdvancedPracticeNursing.pdf
» https://www.who.int/workforcealliance/knowledge/resources/ICN_PolicyBrief6AdvancedPracticeNursing.pdf
