Clinical Mentoring of Nurse Practitioners Discussion Paper

Background:

Transitioning from registered nurse to nurse practitioner (NP) can be challenging personally and professionally. Insight into transition experiences may help validate the experiences of new NPs and provide greater understanding of the challenges faced during their professional journey.

Purpose:

The purpose of this article is to report a concept analysis of transition from registered nurse to NP. The article provides new knowledge, understanding, and clarity about the concept of transition. Clinical Mentoring of Nurse Practitioners Discussion Paper

ORDER  HERE A PLAGIARISM-FREE PAPER HERE

Data sources:

Walker and Avants’ framework for concept analysis was used to identify the attributes, antecedents, and consequences of the concept. A literature review of refereed journals was undertaken. Model cases from an ethnographic study conducted in Australia provide real life examples of the attributes of transition.

Conclusions:

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 care.

Implications for practice:

Mentorship along with a nurturing environment may be effective strategies for increasing the NP’s self-confidence and ensuring a smooth and successful transition period.

This article examines the concept of transition in relation to registered nurses’ progression into an advanced practice role as a nurse practitioner (NP) in Australia. The role of NP was introduced into healthcare services in the United States by Loretta Ford at the University of Colorado in the 1960s in response to the need for innovation and healthcare reform (Barton, 2006). Following the integration of the NP role in the United States, Canada, Taiwan, and the United Kingdom introduced a similar advanced practice model (Schober & Affara, 2006, pp. 10–11). However, it was not until 1998 that the role was legislated in Australia with the first NPs endorsed to practice in 2000 (Turner, Keyzer, & Rudge, 2007).The NP role is now well established in Australia with both healthcare professionals and patients recognizing the unique contribution that NPs bring to quality healthcare provision. Acknowledgment of NPs’ expertise is reflected in the increase in numbers with a recent announcement of endorsement of the 1000th NP in Australia (Australian College of Nurse Practitioners, 2014). Australian NPs practice across a wide range of settings including rural and remote contexts to large metropolitan centers and have skill sets ranging from primary health care, chronic disease management, and emergency care (Australian College of Nurse Practitioners, 2014).The following literature review discusses NP transition to practice. Although the studies profiled were different in their origins and methods, the literature shows that transition is a multiphase experience requiring a period of adjustment by the NP and attitudinal change by members of the healthcare team. In relation to the transition of Australian nurses to NPs, different issues were revealed during the ethnographic study because of the historical, social, and political influences.Transitioning to the role of NP is a challenging and demanding time (Duffield, Gardner, Chang, & Catling-Paull, 2009; Newhouse et al., 2011).  Clinical Mentoring of Nurse Practitioners Discussion Paper Nurses struggle with role confusion and defining a distinct place for themselves within the healthcare team (Szanton, Mihaly, Alhusen, & Becker, 2010). There are barriers to the integration of the role with varying levels of support from both nursing and other health colleagues (Flinter, 2012; Harvey, Driscoll, & Keyzer, 2011; Yeager, 2010).Notably, endorsed NPs must embrace a philosophical change in the way they practice. From the time honored role of working holistically within nursing models of care, new NPs must cross traditional boundaries to practice within a disease and treatment-focused model of care (Gardner, Hase, Gardner, Dunn, & Carryer, 2008). NPs move between the traditional models of practice and cultures of nursing and medicine to provide holistic care incorporating defined responsibilities for diagnosis, prescription, and treatment within an advanced practice nursing role. It is for this reason that NPs often encounter initial resistance from both nurses and medical professionals as they transgress and blur traditional boundaries (Yeager, 2009).Although there are many universal features associated with the transition of nurses to NPs, it is also a highly individualized experience. The experience of individuals depends upon the personal characteristics of the NP, interpersonal relationships between healthcare colleagues and the degree of clinical and organizational support offered to NPs during their transition to the role. These transition experiences have been reported variously as “uncomfortable,” “difficult,” and “turbulent” (Cusson & Strange, 2008), “daunting” (Szanton et al., 2010), and “stressful” (Hill & Sawatzky, 2011).While the term transition is commonly used in a range of healthcare contexts, in the absence of clear and contextualized definitions for NPs, understanding the notion of transition from RN to NP is open to conjecture. A concept analysis helps to clarify the meaning of words that are unclear and used in a range of contexts or situations.In summary, these definitions suggest that transition is the journey from a place of comfort and familiarity toward a place of new and unknown territory. Each of the definitions of transition refers to a passage and a process that occurs over time and is accompanied by an adjustment to roles, relationships and patterns of behavior. It is essential therefore that we understand the processes and the antecedents required for successful transitioning from RN to NP. Clinical Mentoring of Nurse Practitioners Discussion Paper

Concept analysis

A concept represents a “mental image of a phenomenon, an idea or a construct in the mind about a thing or action” (Walker & Avant, 2005, p. 26). Language allows us to describe concepts or phenomena as we perceive them; however, the accuracy of perceptions depend upon the level of abstractness of the concept (Walker & Avant, 2005). Concept analysis is an analytic process designed to determine the essential features of a concept, how it is used and how it is similar to or different from other related concepts or words (Walker & Avant, 2005). “The purpose of concept analysis is to distinguish between the defining attributes of a concept and its irrelevant attributes” (Walker & Avant, 2011, pp. 162–163). The analysis highlights the unique elements of a concept to provide clarity and meaning of the concept in use. Concept analysis is also used to identify antecedents and consequences of the term in order to increasing understanding (Walker & Avant, 2011).This article examines the literature surrounding the concept of transition and its relevance to the experiences of expert nurses as they transition into the NP role using Walker and Avants’ concept analysis. Walker and Avants’ (2011) concept analysis is built on Wilson’s (1963) 11-step approach. In order to simplify Wilson’s approach, Walker and Avant reduced the approach to eight steps: selecting the concept; determining the aim or purpose of the analysis; identifying all uses of the concept; determining defining attributes; developing model cases; constructing additional cases (e.g., borderline, related, contrary, invented, and illegitimate cases); identifying antecedents and consequences; and defining empirical referents (Walker & Avant, 2011). The first seven of Walker and Avants’ steps were used in this article to explore the transition of nurses to the role of NP. Model cases of successful, unsuccessful and incomplete transition are drawn from the data obtained from an ethnographic study conducted by the lead author as part of her doctoral studies on the topic. There was no requirement for the final step in Walker and Avants’ (2011) process to be included in this report as it was not considered relevant to NP transition. Clinical Mentoring of Nurse Practitioners Discussion Paper

Step 1. Select the concept.

The first step in the analysis is “to select the concept and situate it within the context of existing international nursing knowledge” (Walker & Avant, 2011, p. 160). For the purpose of this article, the concept for analysis was transition to the role of NP.

Step 2. Determine the aims or purposes of analysis.

The purpose of the analysis is to clarify the concept of transition within the context of nurses transitioning to NPs. The aims are to provide a clear and contextualized definition of the concept of transition of nurses to NPs, to identify the attributes of the concept, to enhance understanding, and to reduce ambiguity about the concept.

Step 3. Identifying all uses of the concept.

The third step in the analysis is “to identify all uses of the concept by reviewing and critically analysing current literature” (Walker & Avant, 2011, p. 161)

Literature review and uses of transition

Data sources

The databases used to search the literature included the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Scopus, and Pro-quest from 2000 to 2013 inclusive. The search provided a background to the transition of NPs internationally and the transitional experiences of RNs to NPs in Australia. Searches were limited to journals in the English language. Clinical Mentoring of Nurse Practitioners Discussion Paper

Search words

The key search terms used were transition and nursing, NPs, advanced practice nursing, and nursing roles. Sources were selected based on their relevance and applicability to NP role transition. The papers were selected, read, and reread for differentiation and clarification of the concept of NP transition.In addition to the papers retrieved, hand searching of reference lists was undertaken to identify further studies of interest. Hand-searching journals such as the Journal of the American Academy of Nurse Practitioners and Journal of Advanced Nursing were also undertaken. Papers were examined for

the nature of the context and use of the word transition and

the ideas and words used to explain what happens during transition.

The papers reviewed here represent a purposive selection of the journal papers that use the concept of transition. While transition is used in a range of healthcare contexts, the most common usage related to transitioning is from health to illness (Kralik & van Loon, 2007; Meleis, Sawyer, Im, Messias, & Schumacher, 2000). In this context, the main characteristics of transition were related to change in states of well-being from health to illness over time but exhibited the common themes displayed in other transitional contexts. Clinical Mentoring of Nurse Practitioners Discussion Paper

Definitions of transition

In addition to the literature search, definitions of transition were also reviewed. The word transition, first used in 1550, was derived from the Latin word transitionem, meaning “a going across or cross over” (Merriam-Webster, 2014). Van Gannep, a leading anthropologist, defined transition as an event in which an individual passes from “one stage of life to another, literally equivalent to giving up the old life and turning over a new leaf” (1960, p. 183). Within the context of rapid change, Bridges (2001, p. 3) defines transition as “that confusing nowhere of in-betweenness… [it] is the way we come to terms with change.” The aforementioned definitions depict time, movement, confusion, stages, and overlapping states as part of transition.

Transition in nursing

Within nursing, Chick and Meleis (1986, p. 239) describe transition as “a passage from one life phase, condition or status to another—a multiple concept embracing the elements of process, time span and perception.” Taking this further by focusing on the context of chronic illness, Kralik, Visentin, and Van Loon (2006, p. 321) define transition as “a process of convoluted passage during which people redefine their sense of self and redevelop self-agency in response to disruptive life events.”The above definitions show that transition is multidirectional and multifaceted, and that it can be confusing, convoluted, protracted and disruptive. Transition constitutes movement from a place of comfortable familiarity to new, previously unknown experiences. It requires the passage of time and adjustment of self to roles, functions, relationships and patterns of behavior. Clinical Mentoring of Nurse Practitioners Discussion Paper

Step 4. Determine the defining attributes.

After critically reviewing the literature the uses, ideas, and words relating to transition were coded by discipline and date, reread, and sorted by definition, phase of transition, attributes, or consequences of transition. The similarities and differences between each discipline were also noted. Data saturation was reached when the researcher found the available literature to be repetitive with no new themes emerging.Characteristics of the concept that are repeated in the literature are the cornerstone of the defining attributes and the most important. The attributes of a concept are the elements that make the concept “what it is and what it is not” so that the concept cannot be confused with anything else (Walker & Avant, 2011, pp. 162–163). The defining attributes demonstrate how the concept is applied to NP practice and the complexities and interactions that affect the process of NP transition.Bridges’ (2003) theoretical framework was used to analyze the literature relating to the concept of transition and to determine the defining attributes. Bridges proposed that all transitions have three phases beginning with an ending, followed by a neutral zone and the new beginning. The first phase, Endings, is associated with changing identities; the self and professional role identity, where the experienced nurse is not yet accepted and identified as an NP. Bridges describes the loss of identity as the “in-betweenness.” The second phase, the neutral zone, is described as a period of being “in limbo” when the NP relinquishes his/her previous identity but feels unsure and vulnerable with the new identity. Self-confidence may be affected by the magnitude of the responsibility as an autonomous NP. This is also a period of growth when lessons are learned and new networks are established. The final phase, Beginnings, involves “new understandings; new values; new attitudes and new identities.” Based on the review of the literature noted previously, the attributes of transition in the context of NPs are identified in Table 1. Clinical Mentoring of Nurse Practitioners Discussion Paper

ORDER  HERE

undefined undefined

Table 1 Defining attributes of transition from RN to NP using Bridges’ theory (2003)

Step 5. Provision of a model case.

A model case is a real life example of the concept of transition including all or some of the critical attributes.The following model case was extracted from the transcripts of an ethnographic study undertaken in Australia (MacLellan, Higgins, & Levett-Jones, 2014). The overall aim of this study was to examine the transition of RNs to NPs using a critical ethnographic approach and a purposive sampling approach consistent with qualitative research (Denzin & Lincoln, 2005). The participants were 10 NPs from diverse clinical backgrounds and regions throughout Australia within their first 12 months of endorsement by the national regulatory authority. Three to four face-to-face interviews over a period of 9–12 months were undertaken using semistructured and open-ended questions. The study was approved by the Human Research Ethics Committee at The University of Newcastle, Australia.In the following section a model case depicting successful transition, a borderline case depicting incomplete transition, and finally a contrary case depicting unsuccessful transition to the NP role are provided. Clinical Mentoring of Nurse Practitioners Discussion Paper

Model case: Sue’s story—Successful transition

Sue began her nursing career as an enrolled nurse in the 1970s and is very proud of the fact that she has “climbed the ladder” to now reach the pinnacle of clinical nursing as an endorsed NP.I had an opportunity to hear an NP talking about her practice and I was really inspired. I always knew I wanted to be an NP, because I wanted to extend and expand my practice and be able to utilise everything I’d learned; the NP role was clearly where I wanted to be. So that was the beginning of my journey. I actually realised I needed to do my [NP] Masters. This was a bit more of a struggle. The girls who I did my Masters with, they actually became quite close. I would not have got through without their support and that sort of environment of nurture and pushing me in areas that I wasn’t familiar with.When asked about how she had transitioned into the position, she replied:On reflection (and reflections really important I believe) I was as vulnerable as you can be. Now I have got myself out of it—you can do it if you really want to be somewhere, where you want to be.I had fears of starting my NP Masters—like NPs are up there and you’ve either got it or you haven’t but I just did it, and tried not to be alarmed by it. Then I finished my Masters and had my NP endorsement but was not in an NP position. But I thought, I’m in a comfort zone where I am, I have beautiful people around me. So I thought about staying where I was or moving on. Then I thought, ‘this is silly, I’m wasting this [degree].’ And then I thought ‘no. I’m moving on. I’ve come thus far.’ So I started looking for another job, even though I loved where I was. And once I made that decision, everything just came into place.The role was a bit confusing initially but I’ve got enthusiastic organisational support, they were keen. They welcomed me with open arms. Literally the second time I saw them, I felt like I knew them; I could feel the love. And everything started to fall into place, including my confidence level went up and I sort of forged forward. I now act assertively, because basically, no one else does what I do. Everything fell into place—at the end of the day I’ve got new beginnings.Aren’t I blessed to be able to do what I love doing and do what I can do, in a position that allows me to do it. I’ve got balance in my life now – new life, a new job, things are happening. And you know what? It was a very big journey but I wake up in the morning and I go, it’s good to be alive. What can I pack into today? Clinical Mentoring of Nurse Practitioners Discussion Paper

Borderline case: Grace’s story—Incomplete transition

Additional cases are provided to demonstrate the opposite to the model case (Step 6). A borderline case is inconsistent in that it has “some but not all” of the critical attributes of the concept under review, whereas a contrary case describes attributes that are “not examples of the attributes of the concept” (Walker & Avant, 2011, p. 162). This assists the researcher to identify what the concept is not and in so doing provides enhanced clarity around the concept.Grace started her nursing career with hospital training and completed an undergraduate then postgraduate degree. She has enjoyed working in Acute Care since. Grace has spent a year since completion of her NP Master of Nursing degree working in a critical care unit, further developing her skills in acute care. Grace works in a small community hospital and her colleagues are also her friends outside work.I think the whole NP role is about finding yourself and seeing what you’re capable of doing. And because you do have to reassess and step back and evaluate what you do. And I think that’s a good thing. I think it’s that reflective practice. For me, every day that I learn something new that I didn’t know before—that’s a positive for me, because I think, my skills are getting better and everything I pick up new, is good for me.The barriers that I’ve struck have been from the long-term nurses that have been here 30 years, who call themselves senior staff—and they’re senior purely in years of service rather than experience and skills. I’ve actually found them to be quite obstructive, because they’re not open to change, they don’t like somebody who’s worked less than them coming in and telling them there may be a new or a better way to do something. They think that you’re cocky and suddenly treat you differently. “You just think you’re so clever now because you’re an NP.”Obstacles are there to challenge you and if you get over them that’s great, and if you don’t, well you try another way. Sometimes I get a bit frustrated with it, but I don’t ever let it get the better of me, because I haven’t worked this hard to improve myself, to have somebody else put me down.Grace reported on the progress of her NP role one year later sayingThe attitude of the facility hasn’t changed. They want somebody who can get help improve their emergency waiting time figures, but they don’t actually let me function as a fully independent NP. I still have to be part of the nursing numbers and stand at the triage desk all day doing observations and so—they still don’t really get it [the NP role]. No, I still don’t think they get it. Clinical Mentoring of Nurse Practitioners Discussion Paper

Contrary case: Jessica’s story—Unsuccessful transition

Jessica was an endorsed NP in a rural town working in an NP position with clients requiring chronic and complex care. She had been raised in the town and had never left except for during her nursing training. She was married to a local man who owned a small business and they had four school aged children and elderly parents to care for.At the first interview Jessica was asked about her NP role.I think it’s kind of overwhelming, like where do I start? There are so many people to see, there are 30,000 people within my area. I’m only one person.When I go to visiting sites that don’t know me personally, that’s when I get a lot of angst and lots of derogatory comments. I’ve had a couple of instances of horizontal violence and it has shocked me. It took away my confidence. I felt really uneasy going into that workplace the next time and I thought, my God I need to just pull back a bit as they might see me as a threat.One other thing about the nurse practitioner thing too, I think there’s so many people that say they don’t understand the role and I find I’m always trying to explain the NP role. I feel that in this organisation the role of NP is not really supported.I really was looking forward to the opportunity of using the NP role, because I think it’s the perfect environment for opportunistic intervention. When you’re trying, and you’ve investing a lot of energy and it doesn’t go well, you think, why am I doing this?At the second interview three months later, Jessica said:I have resigned my NP position. I feel completely burnt out and overwhelmed in my job. I think I’m kind of at breaking point with professional boundaries, from living and working in a small community. You don’t realise how tough it is but I had really bad headaches right at the end and after I finished, my headaches all went away. It was kind of a bit of an awakening. Moving away from our home town is massive. I can’t believe that we would be doing this. It actually hurts me and saddens me a lot but that’s probably a sign that I need to do something else. Clinical Mentoring of Nurse Practitioners Discussion Paper

Step 7. Antecedents and consequences.

Antecedents are the precursors to the concept under review. Antecedents to NP transition include appropriate levels of knowledge and skills, educational preparation and the professional recognition of clinical expertise within a defined area of specialist practice. It should be noted that the required level of knowledge and skills for a novice NP varies considerably depending on the country of practice. For example, in Australia, the NP is expected to have expert level of knowledge and skills in his/her area of practice substantiated by the number of hours of clinical experience in the specialist area and a depth of knowledge evidenced through a rigorous examination process (Nursing and Midwifery Board of Australia, 2014). In the United States, each state has different requirements and the NP may be less experienced but he/she is expected to gain expert knowledge and skills through months and years of practice.Consequences are the events that follow the concept or occur as a result of the concept. In the case of NP transition, consequences include loss of identity, loss of confidence, imposter syndrome, marginalization, isolation, role ambiguity. In this seventh step, Walker and Avant suggest that by identifying the antecedents and the consequences (Table 2), the critical attributes of the concept of transition to NP role can be more easily defined (Walker & Avant, 2011). Clinical Mentoring of Nurse Practitioners Discussion Paper

undefined undefined

Table 2 Antecedents and consequences have been identified and charted as follows

Discussion

In their seminal paper, Brown and Olshansky (1997) described the experiences of novice NPs during their first year of practice. Using a grounded theory methodology, they interviewed 35 graduates of an NP program at 1, 6, and 12 months following graduation. The authors developed a theoretical model to describe the journeys of nurses from Limbo to Legitimacy by identifying the following four subcategories: Laying the foundation—the first stage between completion of NP studies and the commencement of their first NP position. The second stage, Launching, was described as the first few months of turmoil and included strong feelings of insecurity as the NPs battled management’s expectations of them as NPs. By 6 months into the position, the NPs were beginning to feel more confident and so were considered to be Meeting the challenge of the NP role and, in the final stage of transition, they were Broadening the perspective as the NPs grew in confidence and even introduced new tasks to extend their role. These subcategories were incremental in nature and emphasized the complex issues involved during transition (Brown & Olshansky, 1997).Brown and Draye (2003) and Heitz, Steiner, and Burman (2004) reported that some NPs experienced initial resistance to their roles by physicians and other nurses. These NPs felt betrayed and isolated as they had left traditional nursing for their new role. Few would disagree that most nurses enter the profession with the sole purpose of caring for others, yet it appears that there is too often a lack of compassion toward each other (Hutchinson, Vickers, Wilkes, & Jackson, 2010).Benner (1986) demonstrated that nurses progress through five stages of clinical development on a continuum from novice to expert. Benner reported that time was a necessary element in gaining experience and confidence in their clinical skills. Benner also stated that nurses were “seen to be at their most competent when they had been in the same job or similar situations for a period of time” (1986, p. 25). These studies support the findings of the current study in terms of the feelings of chaos, turmoil, and confusion experienced by NPs during transition. As transition is a multifaceted and complex process, the NP requires time to adjust and make changes to self-identity and other relationships. How the NP changes as an individual and professionally, and how others view the NP, often depends on recognition or lack of recognition of clinical competence (Lee, Jennings, & Bailey, 2007). Clinical Mentoring of Nurse Practitioners Discussion Paper Characteristically, the early stages of transition are met with feelings of “enthusiasm, optimism and a focus on mastering necessary clinical skills” (Chang, Mu, & Tsay, 2006, p. 85). However, the early confidence of NPs is gradually replaced by the realization that they are “out of their comfort zone” and in a completely new and unfamiliar environment (Kelly & Mathews, 2001). The period of transition has been described as “difficult,” “stressful,” “turbulent,” and “uncomfortable,” a time where NPs experience raised levels of anxiety and lack of confidence (Maville, Kranz, & Tucker, 2004; Yeager, 2010). This conflict and confusion appears to be entwined with NP feelings of self-doubt in their clinical competence (Yeager, 2009).Literature on NP transition reports that many nurses, all of whom are experts in their area, often, and not surprisingly, revert to novices when they begin their career as a NP. As novices, they lack confidence to make the crucial clinical decisions required in their new role (Nicolson, Burr, & Powell, 2005). Benner (2001) describes how these negative experiences can lead to an initial decline in the NP’s clinical competency and to a loss of confidence in their knowledge and clinical abilities until they settle into their new role in the healthcare team. The changed working conditions, relationships, and the associated stress has also been reported by Chang et al. (2006, p. 89) as having a “devastating effect on the development and confidence of NPs during their first year of practice.” These feelings of self-doubt can lead the newly promoted expert nurse to feeling what has been observed as Imposter Syndrome (Redfern Jones, 2009).This is reportedly because of the increased scrutiny by management and senior clinicians along with a decrease in clinical confidence, in some cases back to novice level (Yeager, 2010). Another major contributing factor is that some NPs feel undeserving; as a result and they live in fear of being uncovered as a fraud, believing they achieved their role by luck or charm or by being in the right place at the right time (Mattie, Gietzen, Davis, & Prata, 2008). This was identified as a common phenomenon almost 20 years ago when Henning, Ey, and Shaw (1998) reported that one third of all health professionals transitioning into new roles are affected by feelings of self-doubt, regardless of their discipline and status.NPs report a loss of identity, feeling as if they are “in limbo,” insecure, uncertain, and vulnerable. Bridges (1980) is well known for using Alice in Wonderland as a way of describing the confused identity of someone in transition: “who are you?” said the caterpillar… “I hardly know, Sir, just at present,” Alice replied. “at least, I knew who I was when I got up this morning, but I think I might have changed several times since then” (Carroll, 1967, p. 47). This statement highlights the “confusing nowhere of in-betweenness” that NPs experience during transition.Crafter and Maunder (2012, p. 11) propose that transition is “not a moment of change but the experience of changing.” Thus, the transition journey is equally as important to the NP as the final outcome (Crafter & Maunder, 2012). Role transition is best understood by examining the individual NP as they bring their previous sociocultural experiences to shape the way they respond to transition within their new social context. There needs to be a period of adjustment where NPs become familiar with their new social and cultural experiences.Adaptation takes place through personal reflection and knowledge construction and in doing so NPs negotiate their new position within the workplace. Similar to new graduate nurses, transition to the NP role seems to be about finding a way in a new world (Duchscher, 2009; Yeager, 2010).Despite feelings of insecurity and lack of confidence, the transition process is recognized as a dynamic period of individual adjustment and adaptation and an important element in shaping the new identity (Crafter & Maunder, 2012). This adjustment is required, not just by the NP, but by the entire clinical team. It is vitally important to understand how other health professionals perceive the potential role of the NP and how the NP fits into the dynamic healthcare team. Conflicting ideas about the acceptance of NPs have been reported in the literature. Brown and Draye (2003) and Heitz et al. (2004) reported that some NPs experienced only initial resistance to their roles by other nurses. Cusson and Strange (2008) and Yeager (2010) described some NPs experiencing a lack of support, resentment, or even passive resistance by nursing colleagues. This lack of support by fellow nurses has also been described by Lloyd Jones (2005), with Cusson and Strange (2008) reporting that in some cases it was responsible for the NP’s decision to resign or change jobs. This concurs with Yeager’s (2009) findings where an attrition rate of 6% of NPs within the first year of NP practice was identified.Friendships and positive peer support are vital in facilitating successful transition as they can provide an insight into other people’s behavior and reinforce a sense of belonging. Encouragement should be given to providing flexible networking opportunities and nurturing relationships between experienced and novice NPs (Crafter & Maunder, 2012; Szanton et al., 2010). Ongoing development of clinical knowledge and skills through a collegial mentoring relationship, is “arguably the most important feature in ensuring competence and capability” (Barton, 2006, p. 824).  Clinical Mentoring of Nurse Practitioners Discussion Paper This is also recommended by Maville et al. (2004), who considered time management skills, stress reduction skills, and involvement of caring academic support to be the most important elements in successful transition. The mentoring that occurs during NP education should ideally be continued through transition and beyond.

Implications for practice and research

The fact that NPs are safe and effective providers of specialty specific health care, particularly to underserved populations around the world, is not in dispute (Newhouse et al., 2011). Nor is the fact that they will continue to be a vital resource in the delivery of health care in the future. However, new NPs in Australia continue to be challenged by defining a distinct role for themselves in practice.Although transition may be accompanied by considerable personal upheaval, research suggests that personal attributes and strong collegial relationships can support the NPs through the transitional phase and mitigate the feelings of self-doubt. Confidence and a positive self-image along with effective mentoring are fundamental factors in achieving success as an NP, with the final outcome of successful transition being confidence and competence in their new role.In order to more fully understand the experience of transition for NPs, and how that experience affects the individual as well as the profession, at micro- and macrolevels, further research is required in these two main areas. Clinical Mentoring of Nurse Practitioners Discussion Paper

Research that examines the attitudes of other members of the healthcare team toward NPs as relationships with co-workers appears to be a vital element in successful transition to NP practice.

Research into NP preparedness for practice including knowledge and skill development as well as factors that enhance and detract from their confidence and resilience.

Further investigation of the transition experience of NPs in these aspects will be illuminative and go some way toward filling the gap that exists in the literature.

Strengths and limitations

Identifying the issues that ensure a successful transition for NPs has been difficult because of the scarcity of available literature and the diverse contexts of advanced practice. The authors acknowledge these factors as limitations of this study. However, the strength of this concept analysis is that it based on an ethnographic study of the transition of nurses to the role of NP in Australia. The first author in this article was principal investigator as part of her doctoral studies. Model, borderline, and contrary cases of the concept were derived from the data from the ethnographic study. Clinical Mentoring of Nurse Practitioners Discussion Paper

Conclusion

Each NP has unique and valuable abilities that will only be realized if they are nurtured and guided throughout the transition journey. A successful transition will only occur if there is a genuine commitment from a supportive professional and organizational structure. Lack of confidence and self-doubt appear to be common responses to the new role so it is essential for the organization to offer encouragement and reassurance to the novice NP that these feelings will gradually disappear as their clinical confidence increases.The literature surrounding NP transition was mainly from publications from the United States, Taiwan, and the United Kingdom. Although there are a range of themes in the literature about the transition experience, for example, insecurity and loss of confidence, there are subtle differences in Australia because of our historical, social, and political influences. In the literature review, the focus was on NPs’ transition to practice and although the studies profiled were different in their origins and their methods, the authors agree that transition is a multiphase experience that requires a period of adjustment by the NP and often an attitudinal change by the other members of the healthcare team.Now that the problems being experienced by NPs in transition have been identified and understood, there is an opportunity to put strategies in place to resolve them. As the implications for practice are multifaceted, the findings from this study have the potential to improve the transition and retention of RNs to NPs within the Australian healthcare system. Attrition and sustainability remain key issues for the nursing workforce as well as optimizing clinical performance for NPs to provide quality care to all Australians. Clinical Mentoring of Nurse Practitioners Discussion Paper

References

Barton, T. D. (2006). Clinical mentoring of nurse practitioners: The doctors’ experience. British Journal of Nursing, 15(15), 820–824.[Context Link]

Benner, P. (1986). [Context Link]

Benner, P. (2001). [Context Link]

Bridges, W. (1980). [Context Link]

Bridges, W. (2001). [Context Link]

Bridges, W. (2003). [Context Link]

Brown, M., & Draye, M. (2003). Experiences of pioneer nurse practitioners in establishing advanced practice roles. Journal of Nursing Scholarship, 35(4), 391–397.[Context Link]

Brown, M., & Olshansky, E. F. (1997). From limbo to legitimacy: A theoretical model of the transition to the primary care nurse practitioner role. Nursing Research, 46(1), 46–51.[Context Link]

Carroll, L. (1967). [Context Link]

Chang, W., Mu, P., & Tsay, S. (2006). The experience of role transition in acute care nurse practitioners in Taiwan under the collaborative practice model. Journal of Nursing Research, 14(2), 83–92.[Context Link]

Chick, N., & Meleis, A. I.(Eds.). (1986). [Context Link]

Crafter, S., & Maunder, R. (2012). Understanding transitions using a sociocultural framework. Educational & Child Psychology, 29(1), 10–18.[Context Link]

Cusson, R. M., & Strange, S. N. (2008). Neonatal nurse practitioner role transition: The process of reattaining expert status. Journal of Perinatal & Neonatal Nursing, 22(4), 329–337.[Context Link]

Denzin, N., & Lincoln, Y.(Eds.). (2005). [Context Link]

Duchscher, J. E. B. (2009). Transition shock: The initial stage of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing, 65(5), 1103–1113.[Context Link]

Duffield, C., Gardner, G., Chang, A. M., & Catling-Paull, C. (2009). Advanced nursing practice: A global perspective. Collegian, 16(2), 55–62.[Context Link]

Flinter, M. (2012). From new nurse practitioner to primary care provider: Bridging the transition through FQHC-based residency training. [Context Link]

Gardner, A., Hase, S., Gardner, G., Dunn, S., & Carryer, J. (2008). From competence to capability: A study of nurse practitioners in clinical practice. Journal of Clinical Nursing, 17(2), 250–258.[Context Link]

Harvey, C., Driscoll, A., & Keyzer, D. (2011). The discursive practices of nurse practitioner legislation in Australia. [Context Link]

ORDER  NOW

Activity/Assignment:

A discussion forum post in response to the article on APN Role Transition – (MacLellan et al, 2014). https://pubmed.ncbi.nlm.nih.gov/25186979/Links to an external site. Clinical Mentoring of Nurse Practitioners Discussion Paper
Review other articles provided for well-rounded information on APN role transition:
Latham CL, Fahey LJ. Novice to expert advanced practice nurse role transition: guided student self-reflection. J Nurs Educ. 2006 Jan;45(1):46-8. doi: 10.3928/01484834-20060101-09. PMID: 16496741.
Barnes H. (2015). Exploring the Factors that Influence Nurse Practitioner Role Transition. The journal for nurse practitioners: JNP, 11(2), 178–183. https://doi.org/10.1016/j.nurpra.2014.11.004
200219-Nurses-experiences-of-transitioning-into-advanced-practice-roles.pdf (emap.com)Links to an external site.
Facilitators and barriers to the novice nurse practitioner w…: Journal of the American Association of Nurse Practitioners (lww.com)Links to an external site.
How does role transition affect the experience of trainee Advanced Clinical Practitioners: Qualitative evidence synthesis – Moran – 2018 – Journal of Advanced Nursing – Wiley Online LibraryLinks to an external site.
Scenario: Clinical Mentoring of Nurse Practitioners Discussion Paper

Using the MacLellan, Levett-Jones & Higgins (2014) article as a guide, prepare a thorough response to share with peers. https://pubmed.ncbi.nlm.nih.gov/25186979/Links to an external site.
You have been asked to address “APN Role Transition” in the discussion forum. Begin by addressing the following:

Provide critical analysis of the three real-life case examples that speak to a successful transition, incomplete transition, and successful transition from the RN to NP role.
What are the key elements & concepts of role transition from RN to NP discussed in the aforementioned article and other assigned readings? Explain why these elements promote successful transition.
Reflecting on your personal RN-NP role experience and skills, what stage of transition in the APN role do you identify for yourself and why?
What educational experiences and practice skills will you need to successfully advance in your transition process.
What barriers do you anticipate in the transition process from RN to APN role and how would you work to resolve the barriers? Clinical Mentoring of Nurse Practitioners Discussion Paper