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The lived experience of nurse practitioner graduates' transition to hospital-based practice

Dissertation
Author: Cheryl R. Duke
Abstract:
The purpose of this hermeneutic phenomenology (van Manen, 1990) was to gain insight into the meaning and lived experience of nurse practitioners (NP) with at least one year of work experience regarding their initial transition from new graduate to hospital-based practitioner. This study provided information regarding NP hospital-based transition experience that had not been revealed in the nursing literature. The meaning of transitioning into hospital-based practice was discovered through analysis of nurse practitioner letters and interviews in this phenomenological study. Six themes emerged from this research including: Going from expert RN to novice NP; system integration; "Don't Give Up"; Learning "On the Fly"; They Don't Understand my NP Role; and Succeeding Through Collaboration. Master's prepared, board-certified NPs in North Carolina (NC) with between one and three years of NP practice experience in a hospital setting comprised the population of interest for this study. Twelve participants were purposefully sampled from nine hospitals in NC. Individual, voice-recorded, in-depth, open-ended telephone interviews were conducted with each participant. The majority of the participants indicated a timeframe that ranged from six to 18 months regarding how long it took them to feel more comfortable in their NP role, the lack of comfort was most intense during the first nine months of practice. Participants confronted multiple obstacles and challenges as new NPs. These challenges included navigating and negotiating a new health care provider role; becoming integrated into a hospital system in what was a new role for them and sometimes for the system; learning how to function effectively as a NP while simultaneously working to re-establish themselves as proficient clinicians with a newly expanded practice scope; building key relationships; and educating physicians, hospital leaders, clinical staff, patients, and families about the NP role. This new knowledge demonstrates that although the transition to hospital-based practice for the new NP graduate is individually unique, there are important dimensions of the experience which are universal and should be considered by new NPs, employing hospitals and staff, physicians, and educators. This information can be used to help ensure an ideal transition occurs for the new hospital-based NP.

TABLE OF CONTENTS

LIST OF TABLES………………………………………………………………………... xi

CHAPTER ONE: INTRODUCTION…………………………………………………… 1

Statement of the Problem…………………………………………………………... 2

Definitions………………………………………………………………………….. 3

Significance of the Study…………………………………………………………... 3

Purpose……………………………………………………………………………... 4

Philosophical and Theoretical Perspectives………………………………………... 5

Summary…………………………………………………………………………… 6

CHAPTER TWO: REVIEW OF THE LITERATURE………………………………….. 7

NP Practice in the Hospital and Other Setting…………………………………….. 7

Advanced Practice Nursing Role Development Models………………………….. 8

NP Role Development……………………………………………………………... 11

Self-Confidence……………………………………………………………... 13

Perceived Competence………………………………………………………. 14

Negotiating Skills……………………………………………………………. 15

Autonomous Decision-Making……………………………………………… 15

NP and Medical Doctor (MD) Collaboration……………………………….. 16

NP Role Socialization……………………………………………………………… 17

Organizational Issues………………………………………………………... 18

Orientation…………………………………………………………………... 18

Mentoring……………………………………………………………………. 21

Support Network…………………………………………………………….. 22

Summary…………………………………………………………………………… 23

CHAPTER THREE: METHOD…………………………………………………………. 24

Research Question and Approach………………………………………………….. 24

Sampling…………………………………………………………………………… 25

Sample Identification………………………………………………………………. 26

Participant Selection……………………………………………………………….. 26

Data Collection Procedure…………………………………………………………. 27

In In-Depth, Open-Ended Interview……………………………………………….. 29

Data Analysis………………………………………………………………………. 30

Focusing on the Phenomenon……………………………………………….. 31

Investigating Lived Experience……………………………………………... 31

Isolating Themes…………………………………………………………….. 32

Writing Descriptions………………………………………………………… 33

Staying Oriented to the Research Question…………………………………. 33

Stepping Back to Look at the Whole………………………………………... 35

Data Validity and Trustworthiness………………………………………………… 36

Credibility………………………………………………………………………….. 36

Audit Trail…………………………………………………………………… 37

Self-Reflection/Reflexivity………………………………………………….. 37

Peer-Debriefing……………………………………………………………… 38

Dependability………………………………………………………………………. 38

Confirmability……………………………………………………………………… 39

Triangulation………………………………………………………………… 39

Bracketing…………………………………………………………………… 39

Transferability……………………………………………………………………… 40

Researcher’s Personal Preparation, Assumptions, and Biases……………………... 40

Summary…………………………………………………………………………… 43

CHAPTER FOUR: FINDINGS………………………………………………………….

44

Participant Description……………………………………………………………... 45

The Lived Experience of New NP Graduates……………………………………… 46

Going From Expert RN to Novice NP………………………………………. 47

It takes time…………………………………………………………… 49

Drawing on the past to inform the present……………………………. 50

Gaining a new self-identity as NP……………………………………..

50

System Integration…………………………………………………………... 52

Pre-employment preparatory phase………….……………………….. 52

Getting credentialed phase…………………….……………………… 53

Getting started phase………………………….………………………. 57

Prior experience in the system…………………………………. 57

Orientation to the system………………………………………. 57

Practicing phase………………………………………………………. 59

Continuity of care……………………………………………… 60

The NP role…………………………………………………….. 60

“Don’t Give Up”….…………………………………………………………. 61

Colleague resistance…………………………………………………... 62

Peer resistance………………………………………………. 62

Medical staff resistance…………………………………..…. 62

Gaining professional respect…………………………………………. 63

Learning “On the Fly”………………………………………………………..

65

Alone and winging it………………………………………………….. 65

Mentoring is key……………………………………………………… 66

Getting oriented………………………………………………………..

66

They Do Not Understand My NP Role……………………………………… 68

Physician understandings and acceptance of NP role………………… 68

Patient and family understandings and acceptance of NP role……….. 68

Hospital based practice constraints…………………………………… 69

Administrative issues…………………………………………………. 70

Regulatory misunderstandings…………………………………. 70

Office space……………………………………………………..

70

NP performance evaluation……………………………………..

71

Succeeding Through Collaboration…………………………………………. 72

Summary…………………………………………………………………………… 74

CHAPTER FIVE: DISCUSSION, RECOMMENDATIONS, AND CONCLUSION…. 76

Discussion………………………………………………………………………….. 76

Meleis’ Transition Theory…………………………………….…………………… 78

Advanced Practice Nursing Models……………………………………………….. 80

Hamric and Taylor Clinical Nurse Specialist Model…………………. 81

Orientation………………….………………………………….. 81

Frustration……………………………………………………… 83

Implementation…….…………………………………………... 83

Integration………………..…………………………………….. 84

Brown and Olshansky’s Novice Primary Care NP Transition Model 85

Laying the foundation……...…………………………………... 85

Launching……………………………………………………….

87

Meeting the challenge……………………….…………………. 88

Broadening the perspective…………………………………….. 89

A Nursing Model to Consider: Benner’s Model of Expert Practice……………... 90

The Hospital-Based NP Transition Experience…………………………..………. 91

Recommendations………………………………………………………………… 96

Implications for New NPs Entering Hospital-Based Practice……….. 96

Implications for Hospital Leadership…………………………………

97

Implications for Physicians…………………………………………... 97

Implications for NP Educators……………………………………….

98

Implications for Hospital-Based NPs…………………………………

98

Conclusion………………………………………………………………………... 99

REFERENCES…………………………………………………………………………… 104

APPENDIX A: INSTITUTIONAL REVIEW BOARD APPROVAL LETTER……….. 112

APPENDIX B: LETTER OF INVITATION……………………………………………. 113

APPENDIX C: INFORMED CONSENT………………………………………………... 115

APPENDIX D: MESSAGE TO RESPONDENTS……………………………………… 118

APPENDIX E: DEMOGRAPHIC QUESTIONNAIRE………………………………… 119

APPENDIX F: INTERVIEW GUIDE…………………………………………………… 120

APPENDIX G: THEME BOOK………………………………………………………… 121

APPENDIX H: FIELD JOURNAL……………………………………………………… 123

APPENDIX I: PARTICIPANT DESCRIPTION………………………………………... 124

LIST OF TABLES

1. Advanced Practice Nursing Role Development Models……………………………….

9

2. Duke Application of Meleis’ Transitional Conditions and Definitions for Situational Transition for the Nurse Practitioner…………………………......................................

12

3. A Sample of Theme with Corresponding Data from Three Transcripts………………. 34

4. Comparison of Hamric & Taylor and Duke Models…………………………………...

82

5. Comparison of Brown & Olshansky and Duke Models………………………………. 86

CHAPTER ONE: INTRODUCTION Since the inception of the Nurse Practitioner (NP) role in 1965 (Sheer & Wong, 2008), NP practice settings have been primarily community-based with the exception of hospital-based neonatal intensive care units (NICU). More recently, however, the NP role has expanded beyond these traditional settings. Although advanced practice nursing in the acute care setting is not a new patient care approach, the NP role in hospital settings other than NICUs is fairly new and continues to grow (Barnett, 2005; Reveley, Walsh, & Crumbie, 2001; Whitcomb et al., 2002). The increasing utilization of hospital-based NPs in a widening variety of clinical areas can be attributed to several factors, including a continuing shortage of primary care physicians, resident physician work hour limitations, legislation allowing nurse practitioners to bill patients for their professional services, and growing numbers of baby boomers requiring hospitalization (Council of International Hospitals, 2003; Gates, 1993; Hanson & Hamric; 2003; Kleinpell & Hravnak, 2005; Lundberg, Wali, Thomas, & Cope, 2006). As the demand for NPs continues to grow, it is expected that hospitals will employ increasing numbers of newly graduated NPs (Anderson, 1997; Burkholder & Dudjak, 1994; Cusson & Viggiano, 2002; Gates, 1993; Geier, 1999; Genet et al., 1995; Knaus, Davis, Burton, Felten, & Fobes, 1997; Maguire, Carr, & Beal, 1995; Martin, 1999; Schaffner, Ludwig-Beymer, & Wiggins, 1995). As more new NP graduates begin their practice in hospitals, it is anticipated that more transition-to-work programs to support and assist them will be needed (Chang, Mu, & Tsay, 2006; Cusson & Viggiano, 2002). Many factors impact the level and quality of health care offered by new NP graduates who start their careers in hospital settings. Such factors include prior nursing experience and

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skills, patient acuity, the organizational culture of the hospital, and the orientation program and mentoring that focus on new NPs transitioning into hospital settings. New NPs experience what some researcher’s term situational role transition as they begin their new roles (Cusson & Strange, 2008). Situational role transition is defined by Schumacher and Meleis (1994) as a change in role function and scope of practice. The literature suggests that, regardless of practice setting, situational role transition for the new NP graduate can be a stressful and turbulent experience (Brown & Olshansky, 1997; Chang et al., 2006; Heitz, Steiner, & Burman, 2004; Kelly & Mathews, 2001; Maquire et al., 1995; Schumacher & Meleis, 1994). To optimally facilitate the development of new NPs as competent health care providers, the practice environment should provide them support and assistance. According to Bahouth and Esposito-Herr (2009), such support could be facilitated through a robust orientation process during the initial months of employment. New NP graduates, however, are typically expected to “hit the ground running” (Bahouth & Esposito-Herr, 2009; Brown & Olshansky, 1998). Most employing hospitals offer no or limited NP orientation programs, with such programs reportedly varying from nonexistent to a few weeks in duration (Bahouth & Esposito-Herr, 2009; Duke, 2007). Statement of the Problem Little is known about the experience of role transition into hospital-based practice for newly graduated NPs (Reveley et al., 2001). Additionally, neither the meaning associated with such a transition nor the critical elements of a successful transition to practice experience by NPs has been studied. The purpose of this phenomenological study was to gain insight into the meaning and lived experience of NPs with at least one year of work experience regarding their initial transition from new graduate to hospital-based practitioner.

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Definitions For the purpose of this study, the following definitions were used: Nurse Practitioner: A master’s prepared registered nurse who has completed an NP program of study in an accredited master’s program and is nationally certified as a NP. The NP is authorized to practice as a primary care provider with prescriptive authority in 49 states (American College of Nurse Practitioners, 2009), including the state of North Carolina, where study data was collected. Transition: “the process of letting go of the way things used to be and then taking hold of the way things subsequently become” (Bridges, 2001, p. 2); Meleis (1986) defines transitions as “periods in which change takes place in an individual or an environment “(p. 4). Situational transition: Transition to a professional role including functional and scope of practice changes (Schumacher & Meleis, 1994). Role transition: Balancing competing new role demands such as, in the case of NPs, developing competency and developing safe, effective care (Cusson & Viggiano, 2002). Significance of the Study This study is significant for several reasons. The study gives voice to those whose initial adaptations to the practice setting were typically silent and thus unknown. These study findings present a needed holistic, detailed, contextual account of the lived experience of the newly employed hospital-based NP. Although qualitative findings are not generalizable (Munhall, 2007) the voices of NPs who have experienced the transition from graduation to an initial hospital-based practice setting may serve to enlighten those who find themselves in similar circumstances and those who teach and supervise them. Participants’ insights into NP transition experience and its meaning may

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serve as a potential source of awareness about the challenges and positive aspects associated with such an experience. Nurse educators who prepare NPs may incorporate such insights into the nursing curriculum, thus enabling new NPs to anticipate the transitional issues they may face as they seek hospital-based careers. Greater understanding of the NP role in hospital settings may also assist NP students as they consider the potential areas of practice for which they are best suited. As hospitals continue to employ new NPs as patient care providers, the issues that impact role transition for NPs initiating their expanded roles need to be known, understood, and prepared for by administrators. As the hospital-based NP role is developed and clarified, such knowledge can help nursing and other hospital leadership to provide needed support and assistance to these individuals. In summary, understanding the transition experiences of newly graduated NPs to hospital-based practice will ultimately contribute to the development of such individuals as successful, effective members of the health care team. Such knowledge can be used in clinical practice, educational program development, and by hospital administration to promote the successful transition of new NP graduates into hospital-based practice. Purpose The purpose of this phenomenological study was to gain insight into the meaning and lived experience of NPs with at least one year of work experience regarding their initial transition from new graduate to hospital-based practitioner. The research question for this study was, “what is the lived experience and meaning of transitioning into hospital-based practice from the perspective of NPs with at least one year of work experience?”

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Philosophical and Theoretical Perspectives This study was informed by Max van Manen’s (1990) hermeneutic phenomenological approach. Hermeneutic phenomenology is based on Husserl’s descriptive and Heidegger’s interpretive traditions which seek to grasp the meaning of an experience (van Manen, 1990). Hermeneutic phenomenology is a form of phenomenology focused on lived experience and interpretation of “texts” of life (Creswell, 2007). van Manen (1990) states that knowledge is gained through language and understanding, which are intertwined through interpretation (Richards & Morse, 2007, p. 49). The aim for this type of research is to establish a renewed contact with the original experience (van Manen, 1990). The lived experience of transition into practice for NPs in the hospital setting is a phenomenon that will vary among practitioners. The focus of phenomenology is to “describe what all the participants have in common as they experience a phenomenon” (Creswell, 2007, p. 57-58). Through the data collection process, individual experiences can be reflected upon and described. This ultimately provided an opportunity to understand the essence of this experience. van Manen (1990) defines “essence” as the “internal meaning structures of a phenomenon that are grasped intuitively through the study of the ways in which they manifest themselves in the lived experience” (p. 177). He (van Manen, 1990) stated “that lived experience is the starting point and end point of phenomenological research” (p. 36). Through reflective awareness, the nature of what it was like to be a new NP practicing in a hospital was re-lived and expressed through individual verbal descriptions. This “reflective grasp” (van Manen, 1990, p. 77) allowed this lived experience to provide meaning. By transforming these descriptions into textual expressions, the meaning of these experiences were captured and interpreted, thus addressing the aim of phenomenology (van Manen, 1990).

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Summary NPs are increasingly practicing in hospital-based settings and thus more frequently experiencing a transition from training to new professional roles in hospital settings. The NP is responsible for providing safe and competent patient care through their knowledge of best practices (McKinley, 2004). Given the increasing demand for the NP in hospital settings, NPs are and will continue to be important providers of healthcare in hospitals. Despite a growing trend of employment of NPs in hospitals, a limited understanding existed about the NPs’ lived experience of transition into hospital-based practice and the meaning that such a transition held for these nursing professionals. Gaining insight into the meaning and lived experience of this transition by means of this phenomenological study afforded opportunities for NPs and others to understand their experiences from their perspective and potentially improve the assistance, support, and oversight that NPs receive during this stage of their careers.

CHAPTER TWO: REVIEW OF THE LITERATURE The nursing literature review was organized to include advanced nursing practice theoretical frameworks and models, research studies on NP practice in hospital and other settings, role development, and role socialization. The purpose of this literature review was to produce a thorough understanding of the literature related to role transition for the new NP. The literature review covered a 32- year time period, ranging from 1978 to 2010. The literature covered this particular time frame because this was the period in which relevant literature on these topics related to NP practice could be located. Each of these areas will be discussed. NP Practice in the Hospital and Other Settings

D r.’s Loretta Ford and Henry Silver developed the nurse practitioner role in 1965 in response to a shortage of primary care physicians (Sheer & Wong, 2008). The traditional practice setting for NPs has been community based primary care, in mostly rural and medically underserved areas (Jones, 1985; Molitor-Kirsch, Thompson & Milonovich, 2005). Approximately 90% of NPs work in outpatient settings (Cooper, Laud, & Dietrich, 1998). However, due to several recent trends in healthcare including changes in the physician workforce, medical resident duty hour restrictions, and healthcare finance reform, more NPs are practicing in the hospital setting and this growth is expected to continue (Burkholder & Dudjak, 1994; Cummings, Fraser, & Tarlier, 2003; Genet et al., 1995; Knaus et al., 1997; Lundberg et al., 2006; Maguire et al., 1995; Rosenfeld, McEvoy, & Glassman, 2003; Schaffner et al., 1995). Expansion of the NP role in this setting has been diverse. At the time of this study, NPs were being employed in a variety of inpatient areas including the emergency departments, neonatal intensive care units, obstetrics, medicine, surgery, and a variety of other specialty services (Cowan et al., 2006; Molitor-Kirsch et al., 2005).

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The utilization of NPs in the hospital setting offers promise for increased efficiency and high quality care. Published studies have demonstrated positive outcomes for hospitalized patients when care was provided by a NP (Cowan et al., 2006; Dahl & Penque, 2000; Geier, 1999; Knaus et al., 1997; Lundberg et al., 2006; Nyberg, Waswick, Wynn, & Keuter, 2007; Schaffner et al., 1995). Hoffman, Tasota, Scharfenberg, Zullo, and Donahoe (2003) reported that medical teams with advanced practice nurses had decreased patient stays in ICU admissions, decreased length of hospitalization, and better discharge documentation. Current and future trends support the continued utilization of the NP in the hospital setting (Anderson, 1997; Gates, 1993; Geier, 1999; Genet et al., 1995; Martin, 1999). In summary, the utilization of NPs to practice exclusively in the hospital has grown over recent years. Organizations that hire nurse practitioners need to be aware of the role transition issues that are typically experienced. Advanced Practice Nursing Role Development Models Theoretical models and conceptual frameworks that have been applied to advanced practice nursing roles were compared in Table 1. These included Brown and Olshansky’s (1997) theoretical model called “from Limbo to Legitimacy,” and Hamric and Taylor’s CNS role development model (Hamric & Spross, 1989; Hamric, Spross, & Hanson, 2009). Brown and Olshansky (1997) developed a theoretical model in their grounded theory study, which described the first year of primary care practice for the new NP. Because of a limited understanding regarding the phenomenon of role transition for the new NP, Brown and Olshansky (1997) utilized grounded theory, which allowed a qualitative exploration of this phenomenon and development of their “from Limbo to Legitimacy” model in 1998. The categories in this model included: laying the foundation, which included pre- employment and recovering from school, seeking employment and working through licensure

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Table 1 Advanced Practice Nursing Role Development Models

Limbo to Legitimacy NP Model (Brown & Olshansky, 1998) CNS Role Development Model (Hamric & Taylor, 1989, 2009)

Laying the Foundation Orientation

Launching Frustration

Meeting the Challenge Implementation

Broadening the Perspective Integration

10

bureaucracy; launching, which included gaining employment, feeling anxious, and experiencing the impostor phenomenon, getting through the day, and working on management challenges; meeting the challenge, which included gaining competence and confidence, and developing a clearer sense of their NP role; and broadening the perspective, which included navigating the health care system with improved ability and effectiveness, developing active political involvement, self acknowledgement of capabilities and accepting more challenges. The NPs in Brown and Olshansky (1997) study were described as developing a “clear sense of themselves” (p. 48) at the end of the first year of practice. It was not clear if this has the same implications for the new NP graduate who began practice in a hospital setting. Hamric and Taylor’s Clinical Nurse Specialist model (Hamric & Spross, 1989; Hamric, Spross, & Hanson, 2009) were also discussed as a model of role development. The four major categories in this model included: orientation, which included skills mastery and having intense mentoring; frustration, which included feeling overwhelmed, unsure of role choice, and tended to digress into previous RN role; implementation, which included acclimating to the advanced practice role (APN), adapting to change, and completing the transition into the advanced practice role, if needed; integration, which included continued evolution of the NP role and development of skill and competencies. Hamric and Taylor’s Clinical Nurse Specialist model (Hamric & Spross, 1989; Hamric, Spross, & Hanson, 2009) provided an additional perspective regarding the APNs development of skills for the new CNS. The concept of transition, as globally defined by Meleis (1986), refers to “periods in which change takes place in an individual or an environment.” This definition and framework provided an appropriate conceptual model for this area of nursing research. Universal properties of transitions are that they occur over time. The nature of the transition can include change in

11

identity, roles, relationships, abilities, and patterns of behavior. Schumacher and Meleis (1994) described three types of transitions as developmental, situational, and health-illness. Meleis (1997) defined three global indicators of a successful transition, for all transition types, which were indicated by (1) subjective well-being, (2) role mastery, and (3) well -being of relationships. The newly practicing NP experiences a situational transition, which is demonstrated by a change in role function and scope of practice. Situational transition, which is experienced by the newly graduated NP, is supported using Meleis’ (1975) Transition Theory. Meleis’ conditions and definitions as they would relate to the NP are shown in Table 2. Meleis’ (1975) Transition Theory was used by Kelly and Mathews (2001) and Chang et al. (2006) in their research on role transition for the NP. A qualitative approach was utilized by these researchers due to a lack of fundamental understanding of this phenomenon. The type of practice setting in the research conducted by Kelly and Mathews (2001) was not revealed other than indicating the study was conducted somewhere in central Illinois. The research conducted by Chang et al. (2006) was located at Taiwan in an acute care setting. This location of the research studies is pointed out because the NP roles and scope of practice in these situations were not equivalent. Despite these differences, Meleis’ Transition Theory was appropriately utilized in both studies. As the foundation of this theory, Meleis defined transition as an adaptation or change in role, behavior patterns, abilities, and relationships. This application provided a framework to consider for defining the phenomenon of transition to practice for the new NP. NP Role Development Role development and successful transition depends on mastering five important elements that have been described in the literature. These include the development of self-

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Table 2 Duke Adaptation of Meleis’ Transitional Conditions and Definitions for Situational Transition

for the Nurse Practitioner

Condition: Based on Meleis (1975) Adaptation of Meleis’ Definition as it Relates to an NP Transition Context

Meaning Personal awareness and understanding of the anticipated or experienced transition from RN to NP.

Expectation What the new NP expects of the transition. This includes cultural beliefs and attitudes.

Level of knowledge and skills The event of RN to NP role transition that requires new knowledge and skill.

Environment External facilitative resources. This includes people and the workplace.

Level of planning Effective planning that will facilitate a positive transition with key people.

Emotional & physical well being Includes a wide range of emotions encountered by the new NP such as low self-esteem, role confusion, apprehension, and stress.

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confidence (Brown & Olshansky, 1997; Hayes, 1998; Jones, 1985; Kelly & Mathews, 2001; Rosoff, 1978; Shea & Selfridge-Thomas, 1997), perceived competence (Brown & Olshansky, 1997; Chang et al., 2006; Hamric & Hanson, 2003; Heitz et al., 2004; Lukacs, 1982), negotiating skills (Jones, 1985; Rosoff, 1978), professional autonomy (Heitz et al., 2004), and effective physician collaboration (Almost & Laschinger, 2002; Kelly & Mathews, 2001; Maguire et al., 1995). Each of these five elements will be discussed. Self-Confidence The first element that may influence NP role development was self-confidence. Brown and Olshansky (1998) defined self-confidence as a feeling of security regarding ability. Self- confidence increased naturally as the NP gained more independence through the creation of a diverse knowledge base and gaining of independence. Brown and Olshansky (1997) found that 35 new NPs experienced stress associated with their new responsibility of making decisions. During their first year of practice, however, these NPs were able to develop their skills and gained confidence. A positive influence on self-confidence was the support and feedback provided by mentors and other significant role models, including the collaborating physician (Kelly & Mathews, 2001; Maguire et al., 1995). In fact, Jones (1985) suggested that self- confidence was the most important characteristic that facilitated NPs’ effectiveness. Conversely, self-confidence could be eroded by negative influences that impacted self- confidence such as defending professional credibility with co-workers and lack of necessary time to adapt (Brown & Olshansky, 1998). Inadequate time for adaptation resulted in difficulty making independent decisions, which could lead to prolonged feelings of self-doubt and apprehension. Thus, role transition would be negatively impacted if the NPs self-confidence was poor or stunted. Similar findings were reported by Heitz et al. (2004) who also focused on the

14

new NP graduate. According to these researchers, nurse practitioner interactions with others in the workplace significantly influenced role development in the first six months of practice. These interactions included negativity such as when the NP asked a nurse for help or experienced challenging encounters from colleagues and patients that required them to defend their role. They proposed that self-doubt resulted from fear, apprehension, and disillusion, which resulted in emotional turmoil when faced with independent role responsibilities (Heitz et al., 2004). One participant described the work setting in this study as a family planning clinic. These findings cannot be generalized to the hospital setting. Perceived Competence Perceived competence was found to influence role development for the NP (Brown & Olshansky, 1997). This element was found to be closely related to self-confidence and increased over time, resulting in diminished anxiety. New NPs experienced improved feelings of competence through repetition of performing clinical skills and decision making (Brown & Olshansky, 1998). These positive feelings of competence were experienced by NPs in the primary care practice setting, but it remains unclear if their findings can be generalized to new hospital-based NPs. Although the hospital setting may be one of the practice sites where the NP received clinical experience as a student, it may still be difficult to feel comfortable there as a new NP. Researchers in Taiwan described 10 acute care NPs experiences in the hospital and noted that the NPs felt unfamiliar in their initial practice period. These NPs experienced stress and felt pressure to adapt to their new role (Chang et al., 2006). These findings could not be applied to the hospital in the United States due to differences in NP roles, culture, and scope of practice from one country to another, but raise important NP issues in the hospital setting.

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Negotiating Skills The NP is also influenced by the development of negotiating skills. This includes being able to negotiate contracts, salary, benefits, continuing education, and professional fees (Marquis & Huston, 1996). Rosoff (1978) proposed many years ago that NP training needed to include contract negotiations and goal setting which could assist with successful entry into practice and role transition for the new NP. Interestingly, Brown and Olshansky (1998) suggested that negotiating skills were not necessary; instead new NPs needed to be able to decide what expectations they were willing to give up with their first NP position. They suggested that NPs may not have an accurate perception of this role at graduation when seeking employment. These conflicting reports raised a need to better understand the NP experience in the hospital setting. Autonomous Decision-Making Autonomous decision making skills were another critical element of successful NP role development (Cajulis & Fitzpatrick, 2007). Autonomous decision-making is particularly difficult for the new NP because it requires adaptation to an expanded scope of practice (Cusson & Viggiano, 2002; Heitz et al., 2004). These authors suggested that the development of autonomous decision-making was a confusing process for the new NP, thus hindering the attitude necessary for autonomous decision making. This confusion may be attributed to previous RN training in a traditional helper role versus the assertive and decisive role characteristics required by the NP who has moved from primarily practicing dependently in acute care to having independent decision making and care determination (Luckas, 1982). The development of autonomy occurred on a continuum and in stages as the NP gained comfort and was able to be accountable with the responsibility of decision-making (Lukacs, 1982). The

Full document contains 139 pages
Abstract: The purpose of this hermeneutic phenomenology (van Manen, 1990) was to gain insight into the meaning and lived experience of nurse practitioners (NP) with at least one year of work experience regarding their initial transition from new graduate to hospital-based practitioner. This study provided information regarding NP hospital-based transition experience that had not been revealed in the nursing literature. The meaning of transitioning into hospital-based practice was discovered through analysis of nurse practitioner letters and interviews in this phenomenological study. Six themes emerged from this research including: Going from expert RN to novice NP; system integration; "Don't Give Up"; Learning "On the Fly"; They Don't Understand my NP Role; and Succeeding Through Collaboration. Master's prepared, board-certified NPs in North Carolina (NC) with between one and three years of NP practice experience in a hospital setting comprised the population of interest for this study. Twelve participants were purposefully sampled from nine hospitals in NC. Individual, voice-recorded, in-depth, open-ended telephone interviews were conducted with each participant. The majority of the participants indicated a timeframe that ranged from six to 18 months regarding how long it took them to feel more comfortable in their NP role, the lack of comfort was most intense during the first nine months of practice. Participants confronted multiple obstacles and challenges as new NPs. These challenges included navigating and negotiating a new health care provider role; becoming integrated into a hospital system in what was a new role for them and sometimes for the system; learning how to function effectively as a NP while simultaneously working to re-establish themselves as proficient clinicians with a newly expanded practice scope; building key relationships; and educating physicians, hospital leaders, clinical staff, patients, and families about the NP role. This new knowledge demonstrates that although the transition to hospital-based practice for the new NP graduate is individually unique, there are important dimensions of the experience which are universal and should be considered by new NPs, employing hospitals and staff, physicians, and educators. This information can be used to help ensure an ideal transition occurs for the new hospital-based NP.