NURSE PRACTITIONER
GRADUATE TRANSITION TO
PRACTICE
Funding:
Council of Ontario University Programs in Nursing
Ontario Ministry of Heath and Long Term Care
Co-Principal Investigators
Dr. Betty Cragg
(University of Ottawa)
Dr. Patricia Bailey
(Laurentian University)
Co-Investigators
Dr. Frances Legault
(University of Ottawa)
Jennie Humbert
(University of Ottawa)
Suzanne Doucette
(University of Ottawa)
Masters of Nursing Student
Célyne Laflamme
(University of Ottawa)
Research Associate
Maureen Sullivan-Bentz
(University of Ottawa)
OBJECTIVES

To describe the role transition of NP graduates from their
perspective and from the perspective of a co-participant
(employer, physician, NP colleague) working in the same
setting, nominated by the NP

To explore the support requirements of NP graduates during the
first year of practice

To make recommendations for NP practice, education, and
policy
Theoretical Framework
Adapted from Brown and Olshansky (1997)




LIMBO TO LEGITIMACY
Laying the Foundation - 0-1 month
 Recuperating from school
 Negotiating the bureaucracy
 Looking for a job
 Worrying
Launching -1-3 months
 Feeling like an imposter
 Confronting anxiety
 Getting through the day
 Battling time
Meeting the Challenge - 6-12 months
 Increasing competence
 Gaining confidence
 Acknowledging system problems
Broadening the Perspective - 12 months
 Developing system savvy
 Affirming oneself
 Upping the ante
Research Process
 Descriptive qualitative design
(Thorne et al., 1997; Thorne et al., 2004)
informed by Focused Ethnography (Morse & Richards, 2002; Muecke, 1994) and
Narrative Analysis (Bailey, 2001, 2002, 2004)

Sample

Purposive sample 15 - 20 NPs in the first year of NP practice



Nominated colleague for each NP
Semistructured interviews


Anglophone and francophone graduates of COUPN PHCNP program in Ontario
At 3, 6, & 12 months of employment with NPs & coparticipants
Document reviews
 Job descriptions
 Organization charts
 Policies – organizational and provincial
 Reports and reviews of NP programs and practice
Demographics
NPs
Age
Years of
Experience
Anglophones
Francophones
17 NPs
6 NPs
15 Co-participants
6 Co-participants
Range: 29 – 61
Mean: 42.8
SD: 9.7
Range: 27 – 46
Mean: 37.7
SD: 6.5
Range: 6 - 37
Mean: 19.23
SD: 11.14
Range: 3 - 23
Mean: 14.3
SD: 7.03
Co-participants MD x 5
Professional
background
NP x 4
Administrators x 6
Previous
experience with
NPs
6
MD x 3
NP x 3
5
FULL-TIME VS. PART TIME WORK
* N.B. Six (6) Francophone Participants were included; Seventeen (17) Anglophone Participants were included
Work Settings
Anglophones
Francophones
Clinics
 Community Health
Centres
 Family Health Teams
 Primary Care Centers
 Emergency
Departments


Hospital
 Clinics
 Emergency
 Patient populations
 Community Health
Centres
Population Profiles: Diverse
 All
ages (individual, family, groups,
community)
 Geriatrics
 Aboriginal (urban and on-reserve)
 Homeless
 Clients with mental illness & addictions
 Francophone communities
 Multicultural populations
 Women’s health
Themes
1.
2.
3.
4.
5.
Transition to NP Role
Contextual Factors Impacting
NP Role Transition
Interprofessional
Relationships
Provincial Policy and Politics
Educational Preparation
Theme 1 Transition to NP Role

Role Adjustment:
 NPs had high expectations of themselves from the
beginning
 Transition reflected Brown & Olshansky’s stages
 Other factors complicated the transition – lack of
familiarity with NP role, organizational and
professional unfamiliarity with NP needs

Co-participants frequently not aware of the NP’s
struggles

Those with previous experience more aware of need for
support
Theme 1 Transition to NP Role
"It certainly isn’t the lack of support that I have had. It’s a confidence
issue with me and that this is the first week I’ve 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)
"It’s amazing how the baby steps work, you know. You’re 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. It’s been
a long road." (NP10 – 12 months)
Theme 1 Transition to NP Role

Time management
 First 3 months much overtime
New patient assessments
 Inappropriate length of bookings
 Introduction of electronic health records
 Generally not pressured by co-participants to see more
patients, but lack of perception of amount of overtime
worked


By 1 year
Little overtime
 Expectations clearer for NPs and staff

Theme 1 Transition to NP Role

Mentoring
 Key factor
 Experienced co-participants very aware of need for
mentoring and support
 Some NPs had to seek own supports and explain role
while they were still learning it.
“There is certainly a responsibility of us when a nurse practitioner
comes, to mentor her through. It doesn’t matter if they’ve been
working for 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)
Theme 1 Transition to NP Role

Previous experience
 Very experienced nurses, many with ICU and
Emergency backgrounds
 Much life experience
 Many known in workplaces because of previous
employment as RN or as NP student placement

Able to draw on experience to deal with start up
organizations, lack of appreciation for role and
their needs, and conflicts.
Theme 2 Contextual factors impacting role
transition

Many changes in the Primary Health Care system in
Ontario during this period
 Family Health Teams forming
 Pilot projects in Emergency Departments and other
settings on effect of hiring NPs
 New NP positions in specialized clinics
Theme 2 Contextual factors impacting role
transition

Many employers had funding, but not infrastructure to
support NP practice e.g. job descriptions, organizational
charts, space, support staff
"The biggest challenge is space … I don’t have an office. I don’t have a
space to call my own. So I still have a little cart and when I was hired,
the understanding was that would change. Well naturally, you know
how things are. Moving buildings, it’s going to be another year." (NP
2 -12months)
Theme 2 Contextual factors impacting role
transition

Hiring –
 Word of mouth or student placement
 Few needed to move to find employment
 Fit with agency important to co-participants
 Alternative positions available for those who were dissatisfied with
current NP employment

Orientation – Much variation, often with the NP identifying own needs
and plan own program

Evaluation – Often responsibility unclear, with lack of job description
and expectations.

Continuing education – Many anglophones had to fight for time &
reimbursement
Theme 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)
Theme 3 Interprofessional Relationships

Professional Colleagues
 MDs - family, emergency, specialists
 RNs – family practices/health teams, clinics, emergency
 Support staff – receptionists, lab techs

Relationships dependent on
 Culture and experience of agency with NPs
 Organizational position of NP
 Employee status –
All employees
 NP hired by MD
 Independent practice with consultation

Theme 3 Interprofessional Relationships

NP role confusion
"There had been lots of conversation about what can a nurse practitioner
do? One of the first things I did was download, the brochure [off the
NPAO website] … and had copies left around … in the clinic. So the staff
have learned, the patients have learned, and the physicians have
learned." (NP 4 - 3 months)
"They [physicians] expect that you can manage everything and again, with
medications, prescriptions, they can’t understand, ‘Why do I have to cosign for this?’" (NP 10 - 6 months)
"The physicians had basically been told, they claim that they were told,
that we’re nurses, so we therefore don’t require nursing support." (NP 9 3 months)
Theme 3 Interprofessional Relationships
9
NPs changed jobs during the period of
the study.
 7 anglophones and 2 francophones
7
job changes were because of
interprofessional conflicts.
Theme 4 Provincial Policy and Politics
 Regulations
limit scope of practice, prescription
rights, medical directives required in hospitals
 Some government agencies and
insurance
companies accept NP referrals and forms; some do
not
"Certain insurance companies won’t recognize my notes. The Ministry of
Transportation will not recognize any work done by a nurse
practitioner, yet I can do disability stuff." (NP 10 - 6 months)
Theme 4 Provincial Policy and Politics
 Insecure
funding for new positions
"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. It’s within
my scope to be able to refer to a dermatologist or whatever, but because
they [physicians] can’t get paid the same, I can’t do it. That’s
frustrating." (NP 2 - 3 months)
Theme 5 Educational Preparation
12 month program provided in 2 languages by consortium
of 10 Ontario Universities
 Post baccalaureate, moving to Master's level
 Recommendations from participants
 Role transition preparation
 More clinical
 More preparation for "business aspects"


Budgets, contracts, government forms
"Most of the nurse practitioners I know are struggling with not [having] a clear
understanding of the financial side of things." (NP 2 - 12 months)


Info re particular client groups
Influencing policy – government and agency
Factors Influencing Success
 Age
& personal confidence
 Experience as RN in areas like Emergency,
ICU
 Mentorship and support from NP colleagues
 Availability of MDs and NPs for consultation,
especially in early months
 Adequate resources and support roles
 Organizations that were familiar with role,
scope of practice, and expectations of NPs
 Francophone NPs = precious resources
Factors Hindering Success
 Organizations
with new positions for NPs
 New structures for organizations and
practices
 Team adjustment to the new practitioner
 Few position descriptions, infrastructure
plans
 Contracts temporary with unclear
continuation of position
 Policies and funding limiting scope of
practice
Recommendations
New NPs –
 Look for work in agencies familiar with role
 If impossible, negotiate supports and mentorship
 Mentorship
 All newly graduated NPs need formal mentorship
 New NPs seek and establish links with experienced NPs
 Hiring organizations
 Provide orientation to agency and role
 Job description, role definitions, and organization chart
with clear reporting relationships pre hiring
 New organizations hire experienced NPs or arrange
consultation for NP and agency

Recommendations - continued
Organizations
 Ensure supports of space, clerical and interprofessional
staff and policies and procedures to promote full scope
of practice
 Common repository of resources for NP hiring agencies,
NPs and MDs
 Interprofessional protocols to facilitate NP referrals
 Funding
 Stable, predictable funding for new positions with
timely notification of change
 Support for orientation, mentoring, team building,
continuing education
 Reassess MD funding to avoid competition with NPs

Recommendations - continued
Policy
 Re-examine limitations on prescriptive authority
and referrals to facilitate gate keeper role of NP
 Funding for independent practice
 Role clarification with professional bodies
 Education
 Role transition
 Complex situations e.g. co-morbidity, homelessness
 Business aspects of practice
 Pre-licensure interprofessional education for NPs,
MDs, RNs, etc.

QUESTIONS?
bcragg@uottawa.ca