The passage of the Patient Protection and Affordable Care Act (PPACA) precipitated many changes in healthcare that have important implications for nursing practice.1 The PPACA created an influx of new patients seeking care, introduced new models of care, and called for the optimization of nursing practice including greater involvement in care coordination and population health management.2,3
With the influx of newly insured patients, changes in care models, expanded responsibilities, and increased patient acuity, it is important to ensure nurses are equipped to address these new challenges. Pursuance of baccalaureate or higher levels of nursing education, which includes specific training in care coordination or other professional development opportunities, such as continuing education, may help prepare nurses for the transformed healthcare environment.4,5 Job preparedness extends beyond one's educational attainment, however. It is important to also ensure nurses perceive they are equipped not only for a nursing career but also for their day-to-day responsibilities within their current positions. Our research sought to examine perceived job preparedness among practicing RNs across different demographic and professional characteristics.
We developed and conducted a web-based survey of nurses. Contact information for nurses believed to be in ambulatory care practices was obtained from a commercial mailing list provider that provided a national database of names, job titles, email addresses, company names, and the phone numbers of 10 533 US RNs and advanced practice RNs.6 A web-based survey tool (Qualtrics) was used to email all nurses in the database. The 1st round of surveys was emailed in August 2018, with follow-up rounds sent in September, October, and November 2018. Of the 10 533 emails sent, 6319 emails were not deliverable, leaving 4214 valid addresses. There were 435 completed surveys, resulting in a 10.3% completion rate.
Survey questions assessed barriers to nursing practice, satisfaction with daily work responsibilities, and work setting environment. For the purposes of this study, we focused on a single question that assessed whether a participant thought their educational training prepared them for their job: “Do you believe your nursing education has equipped you for your work?” (yes/no). Additional questions addressed nurses' demographic (eg, age, gender, race/ethnicity, educational attainment) and work setting (eg, practice setting) characteristics. Specifically, participants were asked to self-report their practice location and their residence as rural, suburban, or urban based upon their own perception, not a specified definition.
Descriptive statistics examined frequencies and percentages for responses to questions with categorical responses and means and standard deviations for questions with continuous responses. χ2 Tests were used to assess the relationships between categorical demographic and work factor variables and feeling that one's education had prepared them for their job. Independent t test analyses were performed to examine differences in continuous variables (eg, age, years of nursing experience). Unadjusted and adjusted logistic regression analyses were performed to determine the odds of reporting that one's education equipped them for their job by practice location, job characteristics, and demographic characteristics. Only factors that were statistically significant at P < .25 in bivariate analyses were included for the adjusted logistic regression analysis. Analyses were conducted with statistical software (SAS, version 9.4; SAS Institute Inc, Cary, North Carolina). This study was approved by the University of South Carolina Institutional Review Board as exempt.
Respondents averaged 20.8 years of nursing experience, and 72.4% had a bachelor's, master's, or doctorate in nursing (Supplemental Digital Content 1, available at http://links.lww.com/JONA/A751). Nearly half of survey respondents (47.8%) worked in an ambulatory setting. Most (83.0%) were in a full-time position and had been in their current position for a mean of 7.9 years. The mean age of survey respondents was 47.4 years. The study sample was overwhelmingly female (89.4%) and non-Hispanic white (89.0%). Nearly three-fourths (72.4%) were married, and most did not have children living at home (52.5%). Only more than 1 in 4 (25.9%) reported living in rural areas.
Thirty participants (6.9%) indicated that their nursing education did not prepare them for their work (Supplemental Digital Content 2, available at http://links.lww.com/JONA/A752). Those who reported feeling ill-prepared reported fewer mean years of experience compared with those who felt equipped (15.3 vs 21.2 years, respectively; P = .02). A higher percentage of nurses living in rural areas reported feeling ill-prepared (15.3%) compared with suburban (5.1%) and urban (5.4%) nurses (P = .009). Male nurses and those who preferred not to report their gender (19.6%) were more likely to report feeling ill-prepared compared with female nurses (5.4%) (P = .003).
Unadjusted logistic regression analysis showed that nurses practicing in rural areas had more than 3 times the odds of reporting feeling ill-prepared for one's job (odds ratio [OR], 3.17; 95% confidence interval [CI], 1.29-7.84) compared with those who practiced in urban settings (Table 1). Compared with female nurses, male nurses had greater odds of reporting feeling ill-prepared for their job (OR, 4.26; 95% CI, 1.82-9.99). Years of experience was also associated with lower odds of reporting that one's education equipped them for their job. Race/ethnicity, age, full-time position, and practice setting were not found to be associated with feeling ill-equipped for one's job. Adjusted analysis showed similar findings for practice location (rural OR, 4.29; 95% CI, 1.64-11.19), gender (male OR, 4.30; 95% CI, 1.74-10.66), and nursing experience (OR, 0.83; 95% CI, 0.70-0.98; for every 5-year increase in experience).
We conducted a national survey of RNs to examine perceptions regarding how well their education prepared them for their work. We found that those who worked in rural settings and male nurses were more likely to perceive that their education did not prepare them for their work. Additional years of nursing experience were associated with a lower odds of indicating a lack of preparedness for one's work.
We found that rural practicing nurses were less likely to indicate that their education prepared them for their jobs, even after accounting for years of nursing experience. Rural patients are more likely to have multiple chronic conditions and a higher prevalence of poor health-related behaviors.7 Thus, their healthcare needs may be more complex than that of suburban or urban patients.
We also found that male nurses were more likely to indicate that they felt their education did not prepare them for their job. Previous studies have shown that male nursing students often feel isolated in both the classroom and clinical education settings and feel that nursing education is highly feminized.8 Such experiences may contribute to the perception that their education did not equip them for their day-to-day work experiences. As the proportion of male nurses in practice has increased in recent years, it is especially important to ensure they feel they are well equipped for their practice.9
Of note, we found that educational attainment was not significantly associated with a feeling of being ill-prepared for one's job. This runs counter to previous studies that have shown that bachelor's-prepared nurses self-report greater preparedness compared with their peers with an associate's degree.10 However, our study examined perceived preparedness among currently practicing nurses with varying levels of experience but a high average level of experience. This may suggest that experience in nursing practice mitigates the relationship between educational attainment and perceived preparedness.
The results of this study must be interpreted within its limitations. The response rate was low, survey respondents were racially and ethnically homogenous, and the actual number of nurses who felt unprepared was small (n = 30), limiting the statistical power of the survey. Additional research with larger samples of nurses will be needed to confirm our results.
We found that rural practice setting and male gender were associated with greater odds of indicating that one's education did not prepare them for their job. Among rural nurses, this may be because they are more likely to be caring for more complex patients than their urban counterparts. To address gender differences in perceived preparedness, nursing faculty should receive additional training to address the increasing proportion of both male nursing students and male nurses to ensure these individuals are adequately prepared for their clinical practice.
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