NURSE PRACTITIONER GRADUATE TRANSITION TO PRACTICE Funding: Council of Ontario University Programs...
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NURSE PRACTITIONER GRADUATE TRANSITION TO PRACTICE Funding: Council of Ontario University Programs in Nursing Ontario Ministry of Heath and Long Term Care
NURSE PRACTITIONER GRADUATE TRANSITION TO PRACTICE Funding: Council of Ontario University Programs in Nursing Ontario Ministry of Heath and Long Term Care
NURSE PRACTITIONER GRADUATE TRANSITION TO PRACTICE Funding:
Council of Ontario University Programs in Nursing Ontario Ministry
of Heath and Long Term Care
Slide 2
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 Clyne Laflamme (University of
Ottawa) Research Associate Maureen Sullivan-Bentz (University of
Ottawa)
Slide 3
O BJECTIVES 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
Slide 4
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
Slide 5
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
Semistructured interviews At 3, 6, & 12 months of employment
with NPs & co- participants Document reviews Job descriptions
Organization charts Policies organizational and provincial Reports
and reviews of NP programs and practice
Slide 6
Demographics Anglophones 17 NPs 15 Co-participants Francophones
6 NPs 6 Co-participants NPs Age Range: 29 61 Mean: 42.8 SD: 9.7
Range: 27 46 Mean: 37.7 SD: 6.5 Years of Experience Range: 6 - 37
Mean: 19.23 SD: 11.14 Range: 3 - 23 Mean: 14.3 SD: 7.03
Co-participants Professional background MD x 5 NP x 4
Administrators x 6 MD x 3 NP x 3 Previous experience with NPs
65
Slide 7
Slide 8
F ULL - TIME VS. P ART T IME W ORK * N.B. Six (6) Francophone
Participants were included; Seventeen (17) Anglophone Participants
were included
Slide 9
Work Settings Anglophones Clinics Community Health Centres
Family Health Teams Primary Care Centers Emergency Departments
Francophones Hospital Clinics Emergency Patient populations
Community Health Centres
Slide 10
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 Womens health
Slide 11
Themes 1. Transition to NP Role 2. Contextual Factors Impacting
NP Role Transition 3. Interprofessional Relationships 4. Provincial
Policy and Politics 5. Educational Preparation
Slide 12
Theme 1 Transition to NP Role Role Adjustment: NPs had high
expectations of themselves from the beginning Transition reflected
Brown & Olshanskys 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 NPs struggles Those with previous experience more
aware of need for support
Slide 13
Theme 1 Transition to NP Role "It certainly isnt the lack of
support that I have had. Its a confidence issue with me and that
this is the first week Ive actually had where there has been three
days where I can say, You know what? I really did well. A
tremendous blow to my ego and pride is going from expert to not.
That has been tremendously difficult to overcome. I hate being a
novice. I hate it." (NP10 3 months) "Its amazing how the baby steps
work, you know. Youre nervous but you can handle it." (NP10 - 6
months) "Much improved. Very. I get more and more confident. More
continuity with patients, more trust in yourself, more confident in
my decisions, less consulting with physicians. I am doing really,
really well. Its been a long road." (NP10 12 months)
Slide 14
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
Slide 15
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 while they were still
learning it. There is certainly a responsibility of us when a nurse
practitioner comes, to mentor her through. It doesnt matter if
theyve been working for awhile, you still have a new practice
population and they still have to learn the ins and outs of things.
(Co-part 12 6 months)
Slide 16
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.
Slide 17
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
Slide 18
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 dont have an
office. I dont 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,
its going to be another year." (NP 2 -12months)
Slide 19
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
Slide 20
Theme 2 Contextual factors impacting role transition
Opportunities to shape practice and define own roles The nurse
practitioner had been attending some meetings. We just ceased that
now as she has been seeing patients. Because we were taking her
advice and her input on how we should be forming and associations
we should have. So she was very helpful in helping us to formulate
where we are going. (Co-part 1 3 months)
Slide 21
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
Slide 22
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 cant 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 were nurses, so we therefore
dont require nursing support." (NP 9 - 3 months)
Slide 23
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.
Slide 24
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
wont 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)
Slide 25
Theme 4 Provincial Policy and Politics Insecure funding for new
positions "We were funded for 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. Its within my
scope to be able to refer to a dermatologist or whatever, but
because they [physicians] cant get paid the same, I cant do it.
Thats frustrating." (NP 2 - 3 months)
Slide 26
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
Slide 27
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
Slide 28
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
Slide 29
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
Slide 30
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
Slide 31
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.