Pediatric primary care was the first nurse practitioner (NP) role developed to provide health care to children in areas with inadequate health services in the state of Colorado (Silver, Ford, & Day, 1968). Over the past 50 years, the advanced practice role has expanded to provide care for other population foci and in specialty areas. Today, pediatric nurse practitioners (PNPs) provide care to children running the gamut of complex care in the acute care environment to primary care. As acute care providers, they practice in pediatric intensive care units, emergency departments, and other inpatient settings, as well as coordinating care for children with complex medical needs. As primary care providers, they practice in outpatient clinics, in school-based clinics, and in office practices. They practice in a wide variety of nonacademic and university-affiliated academic institutions (Lausten, 2013; Moote et al., 2011).
There is a dearth of information in the literature on the perception of organizational support by PNPs. A critical unanswered question is the degree to which they feel supported in their practice by their institution. The purpose of this study was to describe whether a difference exists in PNP's perception of organizational support (POS) for their practice in academic and nonacademic affiliated institutions.
Perceived organizational support
Perceptions of organizational support are based on employees in an organization forming global beliefs on the extent to which the organization values their contributions and cares about their well-being (Eisenberger & Huntington, 1986). This in turn affects the development of organizational commitment by employees. Employers believed that if their employees were committed, there would be less absenteeism and turnover. Understanding the determinants of the employee–employer relationship and the development of organizational commitment has been a long-standing interest of employers and organizational researchers. Traditionally, the focus was on the employee's identification with the organization. More recently, the focus has shifted. It is now felt that there is a mutually interdependent relationship between organizational support and psychological contracts (commitment) suggesting the inherent social exchanges underpinning the employee–employer relationship. Perceptions of organizational support develop by the consequences of failures of the employers and by proxy their supervisors to meet those promises (Aselage & Eisenberger, 2003; Maertz et al., 2007).
The past 10 years has seen an increased utilization of NPs practicing across the continuum of services and populations (Brom, Meinky, Szalachz & Graham, 2016). The evolution of the NP role has not only expanded their utilization but also their practice settings; they work on inpatient units and intensive care units, in outpatient clinics, in freestanding clinics, in urban, suburban, and rural areas, and in academic and nonacademic affiliated institutions, providing high-quality cost-effective care, with high levels of competency (Bae, 2016; Choi & De Gagne, 2016; Johnson, Brennnan, Musil & Fitzpatrick, 2016; Collins et al., 2014; Poghosyan, Liu, Shang & D’Aunno, 2017). The acceptance of NPs as integral to the health care team creates a dynamic in which NP's turnover is both costly and disruptive to continuity of patient care. Understanding the reasons for PNPs leaving their practice environment is critical to developing strategies for encouraging them to remain (DeMilt, et al., 2011).
The literature consistently ranks autonomy and positive interprofessional and intracollegial relationships as the top two factors influencing organizational support. Of interest, aside from state legislation, restricting scope of practice, organizational support, and reporting hierarchies are ranked the least favorable, albeit these elements are reported to be important factors in the development of an individual's commitment to their place of employment.
Rowell et al., (2008) describe the development of an ANP promotional program to help inspire commitment; interestingly, only 50% of the eligible practitioners were interested in pursuing the requirements for promotion. Paplanus et al. (2014) describe the development of an NP clinical ladder in a university-affiliated medical center as a means for NP recruitment and retention, however, at the time its implementation was being launched and the outcome of the program was not available.
Job satisfaction and the development of organizational commitment are influenced by perceived organizational support and cultural influences. Hence, Baran, Shanock, and Miller (2011) argue as health care evolves and NPs provide care for increasingly diverse and complex populations, perceived organizational support will be more important for enhancing their well-being (Hain & Fleck, 2014). Lack of perceived organizational support either by nursing or by administration can cause NPs to leave their jobs and/or consider retirement (Falk, Rudner, Chapa, & Greene, 2016).
Multiple studies have focused on factors contributing to NP job satisfaction, using the Misener Nurse Practitioner Job Satisfaction Survey (MNPJSS) (Misener & Cox, 2001). The MNPJSS identified organizational support as NPs having or not having the more tangible aspects, such as space and supplies, as well as the administrative support they felt they needed to do their jobs (Athey, et al., 2015; Bae, 2016; Falk et al, 2016; Faraz, 2017; Lelli, et al., 2015; Motely, et al., 2016; O'Keefee et al., 2015; Pasaro[Combining Acute Accent]n, 2013; Pron, 2013).
Pediatric nurse practitioners' perceptions of organizational support are not well documented and have not been described using an organizational support survey.
There are limited studies investigating PNPs' perceptions of organizational support related to their reporting structures and organizational policies for their practice. The purpose of this study was to describe the difference in PNP's perception of organizational support (POS) for their practice in academic and nonacademic institutions.
A descriptive cross-sectional study design was used to examine the POS in PNPs practicing in academic and nonacademic institutions and to describe the differences between PNP reporting structures and POS. After obtaining written approval from the Pediatric Nurse Credentials Board (PNCB) for access to their membership list, institutional review board approval was obtained from Case Western Reserve University. Participants were recruited online from the membership list of the PNCB.
Participants were a random convenience sample of PNPs from the membership list of the PNCB. Participants received an online cover letter with links to the two surveys to be completed.
The first survey had 19 items and was designed to obtain demographic and institution characteristic data. The second survey was Eisenberger Perceived Organizational Support Survey. The Perceived Organizational Support Survey has 16 items using a 7-point Likert-type response format (1 = strongly disagree to 7 = strongly agree). The scale assesses employee perceptions on how the organization values their contribution and its' concern for their well-being. The survey is reliable with a Cronbach alpha of 0.74–0.95 (Table 2).
Inclusion criteria were: 1) being a PNP and 2) actively working in clinical practice in a university-affiliated or non–university-affiliated institution.
The only exclusion criterion was working in other practice settings, for example, school based, office practices, or in education. Ninety-nine PNPs participated. All of them met the inclusion criteria; however, only 86 PNPs had completed the two surveys providing evaluable data.
A power analysis for a population size of 10,040 determined that to achieve a 20% response rate with a 5% margin of error, 272 PNPs needed to participate. To meet this expectation, 1,325 names were randomly selected from the PNCB membership list using the Microsoft Excel Random Number Generator Formula.
All surveys were completed online with responses directly uploaded into a secure platform. The surveys did not contain any identifying information, so neither the respondents nor their institutions could be identified.
Demographic data results
Data entry was analyzed using the Statistical Package for the Social Sciences (SPSS) Version 23 (SPSS Inc., Chicago, IL). Descriptive statistics (i.e., mean and SD) were used to describe the demographic/institution characteristic and the POS questions.
Evaluating if there was any difference in PNPs' perception of organizational support (POS) for their practice in academic and nonacademic institutions, a Fisher exact t-score was used (Table 4).
Of the 1,325 randomly contacted PNPs, 99 responded for a response rate of 7.4%; however, only 86 of the respondents completed both surveys and had evaluable data. Those who responded were self-selected and met the inclusion criteria. The demographic/institutional characteristics are shown in Table 1.
Forty-two (48.8%) were acute care PNPs and 44 (51.2%) practiced in a primary care setting. The mean age was 43.3 ± 11.2 years; 82 (95.3%) PNPs were female and 4 (4.7%) were male. Sixty-three (73.3%) PNPs worked in an urban area, 13 (15.1%) in the suburbs, and 10 (11.6%) in a rural area. Nineteen (22.1%) of the institutions had >500 beds, 23 (26.7%) had 250–500 beds, 24 (27.9%) had 100–250 beds, and 11 (12.8%) had 100 beds. Forty-eight (55.8%) PNPs practiced in outpatient settings, whereas 37 (43%) were inpatient PNPs. Fifty-six (65.1%) PNPs practiced in academic affiliated institutions, of whom 48 (55.8%) were employees of the hospital, whereas 23 (26.7%) were university employees. Seventy-one (82.6%) PNPs practice full time, whereas 15 (17.4%) practice part time. Thirty-five (40.7%) participants reported to a physician, 18 (20.9) to nursing, 22 (25.6%) to administration, and 10 (11.6%) to “other.” Seventy-six (88.4%) PNPs received annual evaluations. Twenty-five (29.1%) PNPs were evaluated by nurse managers, 20 (23.3%) by their collaborating physician, 14 (16.1%) by their division chief, 7 (8.1%) by their department chair, and 14 (16.3%) by administration. The average length of time PNPs were in their current positions was 7.24 ± 8.0 years. Forty-eight (55.5%) of the institutions had Magnet designation. Nurse practitioner clinical ladders were used in 21 (24.4%) of the institutions, which was important for 47 (54.7%) of the respondents. The primary reasons for the respondents working in their current positions were ranked in the following order: job opportunity 34 (39.5%), area of interest 39 (45.3%), the institution's reputation for advanced practice 10 (11.1%), and finally, the institution's overall reputation 3 (03.5%) (Table 1).
Pediatric nurse practitioners' perceived organizational support
Eisenberger Perceived Organizational Support Survey had a Cronbach alpha coefficient of 0.927 and 0.936 on standardized items (Table 2), demonstrating its reliability to assess whether PNPs feel supported by their institutions. The mean score for the 16 items was 4.26 (SD ± 1.62) (Table 3). The perceived support scores ranged from a low of 3.14 to a high of 5.36. To increase the statistical power, the “agree” scores, which ranged from “slightly agree” to “strongly agree,” were combined and the “disagree” scores, which ranged from “slightly disagree” to “strongly disagree,” were combined, to determine if there was a difference in the type of institution PNPs practice in and if they feel valued by the institution. What is worth noting is that “feeling valued by their institution” had the highest mean score of 5.36 followed by “help is available when I have a problem.” A Fisher exact T-test was run, which showed that there was no difference, p = .7418 (Table 4). These results are similar to those of Eisenberger & Huntington (1986) when they studied nine different organizations and their employees' perception of organizational support, the mean scores for those organizations ranged from a low of 2.88 for postal clerks to a high of 5.67 for manufacturing, white-collar workers, and secretaries.
What was unexpected is the number of responses that were in the neutral or “4” range. One could conclude that as a whole these items were not significant to influence the PNPs' perceptions of organizational support.
The majority of PNPs reported to a collaborating physician, n = 35 (40.7%), followed by administration, n = 22 (25.6%); it is worth noting that nurse managers did annual evaluations for 25 (29.1%) of the PNPs, thus evaluating PNPs that had no reporting line to them. However, this does not seem to influence the perception of organizational support.
The reasons PNPs were in their current job in ranked order were area of interest, n = 39 (45.3%), followed by job opportunity, n = 34 (39.5%). Of little importance was the institution's reputation for advanced practice or prestige of the institution. Seventy-four (74.4%) of the respondents did not feel an NP clinical ladder was important.
The type of institution they practiced in did not influence the perceived organizational support of the PNPs represented in this study. It can be concluded that neither location (be it urban, suburban, or rural) nor the size of the institution (with less than 100 to over 500 beds) appear to influence their perceptions.
This is relevant because there are variations in PNP practice; in some institutions the PNPs delivered only primary care, in others acute care and they practiced in a variety of inpatient and outpatient settings. Organizational commitment is formed in large part by positive perceptions of organizational support, which in turn affects employees' performance and should be regarded as a high priority in management/employee relationships (Pasaro[Combining Acute Accent]n, 2013).
Practicing in the specialty area of interest, closely followed by job opportunity ranked as the leading reasons why the PNPs who responded practiced where they did. A better understanding of PNP practice opportunities may help understand how they perceive organizational support. Studies have shown that NPs permitted to function to the full scope of their practice have an increase in job satisfaction, organizational commitment, and retention (Athey, et al, 2016; Choi & De Gagne, 2016; Faris, Douglas, Maples, Berg, & Thrailkill, 2010).
The limitations to this study included a study sample contacted via e-mail from one PNP association. The study was limited to acute and primary care PNPs who practiced in a hospital or academic affiliated hospital. Therefore, the participants were self-selected and did not include the broader range of practicing PNPs. In addition, the response rate was lower than anticipated. As the focus of this study was limited to determine if the type of institution a PNP practiced in influenced their perception of organizational support, future studies should look at all the practice areas for PNPs to determine their perceptions of organizational support.
Pediatric nurse practitioners practicing in academic and nonacademic affiliated hospitals have positive perceptions of organizational support. Although most of the PNPs in this study report to a physician and are evaluated by their physician counterparts, to whom they report and by whom their annual evaluation is completed for their perceptions of support. From the POS results, one can conclude that organizational commitment is strengthened, which should decrease the negative impact of staff turnover and the costs associated, as well as positively affecting the quality and continuity of patient care.
Nurse practitioner clinical ladders were important for most of these respondents, which is noteworthy. This is in agreement with Rowel et al. (2008) who observed that 50% of eligible NPs were interested in pursuing the requirements for promotion. Perhaps, that would change if reporting structures had an advanced practice direct report line. Although PNPs have a nursing background and bring the elements of caring and empathy to their practice, they do not practice as professional nurses; their practice aligns with the medical model for diagnosing and treating diseases. Because PNPs are integral to the provision of care to children, providing opportunities for them to continue to enhance their clinical skills and expand their scope of practice will only enhance their perception of organizational support. Institutional recognition of PNPs' skill and experience will be evidenced by having opportunities and positions for which PNPs can work and continue providing quality care to their pediatric patients. Such recognition creates a win-win dynamic for the PNP, the institution, the patients they care for, and the US health care system.
Acknowledgment:The lead author would like to thank Dr. Donna Hallas, Clinical Professor at Rory Meyers College of Nursing at NYU, pediatric mentor, for her encouragement and support in the development of this project.
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