Since Brown and Olshansky's seminal work in 1997, the difficulties of advanced practice registered nurse (APRN) transition to practice have been well highlighted in the literature.1 One of the greatest challenges is the shift in experience level APRNs encounter when they leave their positions as seasoned RNs to begin practice as new APRNs.1 Through personal communication and published literature, new APRNs resoundingly express a lack of self-confidence as they begin their new practitioner roles. Research indicates that the quality of this career adjustment can impact APRNs' development in their new roles and their decisions to remain in the profession or not.2 A recent literature review, spanning from 2009 through 2019, yielded 155 articles related to APRN transition to practice. An additional 34 articles specifically explored transition programs. Many of these articles discuss various specific transition programs, emphasize the challenges faced by new graduate APRNs entering practice, and share research reporting the challenges of this transition.
Although this topic has been widely discussed, few articles were found that report on formal transition programs. Based on the literature findings, progress in creating formal transition programs has been slow. Despite the 2010 Institute of Medicine report recommending residency programs for nurses following the completion of an advanced practice degree program and the support of the American Association of Nurse Practitioners and other APRN organizations, little progress has been made.2,3 To date, few formal APRN residency or fellowship transition programs exist. It is unclear why formal APRN transition opportunities are not more common; possibilities include the short-term expense or a lack of willing preceptors. Practicing APRNs must consider advocating for themselves and their new graduate peers in order to create successful transition programs in their own organizations.
Industry changes including physician shortages, expanding access to care, and value-based reimbursements mean the NP role is growing, so it is vital that new APRNs receive proper time to hone skills and gain confidence in their decision-making with oversight from an experienced colleague.4,5 These more-efficient models of care delivery particularly rely on APRNs. A 2018 national report by NP NOW, an NP recruitment firm, predicted a shortfall of 29,400 NPs by 2025.3 Both NP NOW and Barnes identified a web publication by Indeed.com reporting in March 2019 that 59.7% of NP jobs were on the top 15 most-difficult-to-fill positions list and that employment turnover rates for NPs are twice that of physicians.3,6,7 The importance of APRNs' successful transitions to practice must not be undervalued or ignored. Now more than ever, APRNs need to play a role in ensuring a purposeful transition for their new graduate colleagues to independent and autonomous practice. This article will examine the current gap in APRN transition to practice education and outline steps organizations can take to create their own formal training program.
Literature review
Although new graduate nurse transition has been studied for some time, few studies have been published regarding the transition from RN to APRN. However, when they are consulted, practicing APRNs consistently admit to the difficulties of making the transition to a higher level of practice. A review of six such published studies provide evidence for the importance of transition programs.
Poronsky conducted a literature review examining the stages and processes of transitioning from an RN to family APRN role. Although her work revealed a lack of consensus on the definitions related to each stage and phase, she determined some consistency related to associated characteristics that included anxiety, role confusion, stress, insecurity, self-doubt, apprehension, emotional turmoil, and isolation.8 These emotional characteristics impact the transition of moving into a new role and both highlight and support what new APRNs have reported.
Barnes studied the relationship between ANP role transition, prior RN experience, and formal orientation.6 Drawing on a convenience sample of 352 NP participants at a national conference, she administered a 16-item Nurse Practitioner Role Transition Scale. The study determined mean years of prior RN experience was 13.8 years, with only 33% of participants reporting they had received some formal orientation. Through exploratory factor analysis, the author found three dimensions that explained this transition: developing comfort, building competence in the role, and understanding the role by others. Overall, her data showed that only a formal orientation was significantly associated with APRN role transition.6 When considering the emotional characteristics identified by Poronsky, transition programs certainly involve much more than just gaining some familiarity with a new job.
Brown and colleagues developed a written questionnaire and conducted focus group discussion based on three major headings.9 These included building a framework for a residency or the characteristics of a successful resident; resources needed or costs impacting sustainability; and program implementation or fiscal benefits of a residency program. The questionnaire was administered to attendees at a regional NP residency forum where 52 questionnaires were completed. The participants were asked to place each theme into high and low areas of impact and feasibility. The conclusions of this study highlighted five “must-haves” that included interprofessional training, a leadership/policy component, quality improvement and scholarship, diagnostic skill honing and special skill readiness, and dedicated mentorship and role development. This article expands on the work of the first two authors to include elements of a framework for transition.
Faraz conducted an extensive integrative review of 41 articles published after 1997 related to transition and the role of the NP.7 Three major themes emerged from the literature related to the novice NP transition into primary care. These themes were categorized as “experiencing role ambiguity,” “quality of professional and interpersonal relationships,” and “facing intrinsic and extrinsic obstacles.” The findings by Faraz align and expand on the work of Brown and colleagues.
Hart and Bowen assessed new NP perceptions of their preparation for transition into practice.10 A national sample of 698 licensed NPs who graduated between 2006 and 2011 completed an 81-item web-based survey. This survey was previously administered but was updated and pilot-tested by the authors and several graduate students from the University of Wyoming. Data in part revealed only 62.6% of respondents either agreed or strongly agreed to having adequate clinical support in their first year of practice. Only 42.2% of respondents described feeling very well or generally prepared following graduation. Most participants, 58%, expressed extreme interest in a postgraduate residency program. Of the 50% who provided written feedback, 90% expressed the need for a postgraduate formal mentor or residency.10 This was the largest study reviewed. It was conducted post transition but captured the consensus of the importance of a postgraduate transition.
Finally, Tracy specifically looked at the role transition of certified registered nurse anesthetists (CRNAs).11 Online recruitment and interviewing were used to explore the perceived experiences of recently graduated CRNAs making their transition into full-time practice. Five factors emerged as being perceived as facilitating the transition to practice. These include mastery of self-efficacy and confidence, expert mentoring and guidance, supportive work environment, peer support, and previous experience as a student nurse anesthetist. Here, Tracy brings forward the student experience prior to moving into a licensed APRN role. This is the only study reviewed that reveals the importance of clinical experiences as a student.
Although these studies can be considered in the development of a transition program, to date there is little to no literature related to how transition programs might be received or how a program would impact the outcomes of length of employment, job satisfaction, confidence to practice, ability to perform, or the impact a new APRN may have on patient care.
Variation in preparation for practice
According to MidlevelU, an online hub for midlevel practitioners, a comparison of education and training shows that physicians must complete 8 years of education and 3 years of residency before practicing independently.12 In contrast, APRNs must complete 5 to 8 years of education, depending on the state in which they receive their education, and have no residency requirements. Another comparison related to clinical hours prior to graduation shows APRNs are required to complete 500 to 1,500 clinical hours while physicians are required to complete 6,000 hours.12 This variation in preparation to practice leaves transitioning APRNs little opportunity to gain confidence and experience prior to becoming independent practitioners.
Developing successful transition programs will require information, interdisciplinary input, and thoughtful design. Turnover is expensive, and although there will be some transition cost involved because of lower preceptor and new-hire productivity, the long-term gains related to engaging, developing, and sustaining employment of a new APRN will undoubtedly outweigh any short-term expense.
Developing a program: First steps
Annual costs per APRN trainee are estimated at as much as $100,000, with two-thirds of this expense supporting the cost of the new APRN and the rest supplementing lost preceptor productivity.2 Justifying a program based on cost will be a key factor for incumbent APRNs interested in developing a transition to practice program at their organization. This is the first step in the process. To understand a particular organization's financials, meet with a nurse recruiter to determine turnover of new first-year APRNs and the costs associated with this turnover. Other sources include the literature from regional or national employment agencies that collect data on these statistics. Tracy has estimated the cost to replace an APRN has been as high as twice that of the APRN's annual salary.11 Additionally, employment turnover rates for NPs, as discussed by both Barnes and Hoff and colleagues, have been reported twice as high as for physicians.2,6 According to Nursing Solutions, Inc., annual turnover levels for acute care NPs were found in one national survey to be between 8% and 11%.13 Smaller organizations may know their turnover rates and be able to calculate the cost. Tracy states that 83% of hospitals do not report these rates or the reasons for turnover.11 Working on a tracking process will be key to understanding the turnover rates before and after program implementation and will help determine successful metrics related to cost.
The next step is to create a structured program that adds value to the transition process and can be measured for success. Holding focus group discussions with new and experienced APRNs, nurse educators, academic faculty, APRN students, and physicians can help determine priorities. Hart and Bowen's study reported that respondents described being the least prepared for billing and coding, simple office procedures, electrocardiogram and radiology interpretation, microscopy, and mental illness management.10 Program standardization inclusive of objectives and milestones must be established by identifying trends described by focus group members in order to address those elements.
Program goals should include, at a minimum, sustained employment beyond 1 to 3 years, individual practitioner productivity, cost related to care, and patient-related metrics such as length of stay and patient satisfaction with their care. Other goals may be driven by individual program expectations.
Time frames for a transition program are widely variable, with the Commission on Collegiate Nursing Education (CCNE) recommending 500 hours and the state of Vermont requiring 12 months or 1,600 hours.14,15 The number of hours may initially be driven by cost or individual progressive development by the new APRN themselves, but ultimately should be determined by program outcomes. Measuring successful transition will be paramount to determining this metric.
Preceptors matter
Once the justification for the program inclusive of cost, goals, milestones, and time frames have been agreed on, practice partnership will need to be established.16 St-Martin and colleagues showed that preceptorship experience had a strong impact on new APRN development.5 Preceptors who were open to teaching, provided feedback, and were allowed to function independently had a positive impact learning.5 This mentoring is best provided by willing and experienced APRN practitioners. It has been collectively agreed on that NP residency programs cannot be implemented without motivated, trained, and compensated preceptors.17
Traditionally, physician faculty enter into contracts with medical residency programs and receive monetary compensation to provide education and oversight to medical residents. Wiltse-Nicely and Fairman state that these payments are not available for primary care nurse residencies.18 Historically, nurse preceptors have done this for a small stipend or hourly pay increase during the time they are in the role. This has occurred primarily at the undergraduate level in acute care settings. APRN preceptors and mentors have taken on new hires for no direct compensation. However, compensation for preceptors should not be a program barrier. Finding funding can be difficult, with many existing programs remaining self-funded. However, developing a budget or working with a local foundation to secure funding may be two options for overcoming the compensation issue.
Tools for evaluating learning outcomes
Evaluating the learning progress using standard tools is crucial to demonstrating program effectiveness.18 The nursing community still lacks specific data on the direct impact of residency programs, which creates a gap in determining program effectiveness according to Wiltse-Nicely and Fairman.18 Specifically, the impact of transitioning APRNs on patient outcomes is yet to be published. This is open for future research and may provide additional support for these programs. Several questionnaires have been used to measure program effectiveness related to APRNs. Many reflect qualitative descriptive and phenomenographic research approaches that have been developed by the authors and researchers who have published findings. Two widely used survey tools are noted below.
Norcini describes the wide use of Miller's pyramid to evaluate progress toward clinical competence and professional identity using the dimensions of knowledge, competence (knows how), performance (shows how), and action (does) as a framework.19,20 The hierarchical structure of this framework evaluates individual learning progress beginning with the cognitive understanding of concepts and moving to eventual application of those concepts through psychomotor skill and behaviors. This performance-based tool has been used to assess clinical competence transition for several professions, most commonly for medical students and residents in training, since it was developed in 1990.19 No nursing use of this tool has been found in the literature.
The Nurse Practitioner Role Transition Scale (NPRTS) is another potential tool. It is a self-report survey designed to measure NPs' perceptions of the role. It has been tested for content validity and reliability. This 16-item, 5-point Likert scale survey, published in 2015 by Strange, measures self-perceptions of the role transition experience in three dimensions: developing comfort and building competence, understanding the role, and collegial support.21
Whatever tools are used, the importance of finding ways to measure the impact of transition programs on APRN transition experiences during the first year of practice and on patient outcomes will ensure program sustainability.21
National support of transition programs
In the last 3 years, several organizations have begun to assist in creating opportunities to develop, standardize, and accredit transition programs. These include the GraduateNursingEDU.org website repository for fellowship programs, The American Nurses Credential Center (ANCC), the CCNE, and finally, the National Nurse Practitioner Residency and Fellowship Training Consortium, which was founded in 2018.15,22,23
The GraduateNursingEDU.org website (GNEDU) is a resource for NPs interested in learning more about fellowship programs in their area, as well as other important issues related to practice.15 As of 2017, NP fellowship programs by state showed that 51 states reported to the GNEDU database with 32 states reporting having some residency programs, many of these being specialty focused.15 Eighteen states have full-practice privileges in place; however, only seven of those states offer or require some postgraduate residencies. Vermont is the only reporting state with a state board of nursing requirement that mandates a formal agreement between a new APRN and a collaborating provider for no fewer than 12 months or 1,600 hours before they can be licensed and begin practicing as an APRN when they have completed fewer than 24 months and 2,400 hours of active APRN practice in a specialty and population focus.15
The ANCC published the Practice Transition Accreditation Program (PTAP) guidelines in 2016.22 This program has developed criteria and guidelines for organizations to develop residency or fellowship programs. According to the ANCC website, there are 381 sites to date that have one or more programs accredited by the ANCC.22 However, the vast majority of these are for new graduate nurses transitioning into practice. Although PTAP does not prescribe, it does define expected domain criteria to be met as described by the applicant organization. This accreditation must be renewed every 3 years.
The CCNE is one of the most recognized and most influential nursing education accrediting agencies in the US. In January 2019, it posted a press release stating the formation of a Nurse Practitioner Residency/Fellowship Standards Committee. This committee has been charged with creating accreditation standards that can guide academic nursing residency programs nationwide. Currently, the CCNE requires 500 hours of clinical training prior to graduating with an advanced practice degree.14
The National Nurse Practitioner Residency and Fellowship Training Consortium, located in Washington, D.C., is another organization that provides accreditation opportunities.23 This national private nonprofit 501(c)(3) charitable organization was created to advance the model and rigor of postgraduate NP training programs, both residency and fellowship, through accreditation. The Consortium accredits nurse practitioner postgraduate (residency or fellowship) training programs in the US that are based in a variety of settings such as Federally Qualified Health Centers Veterans Affairs, academic practices, or large health systems.
Conclusion
Because APRNs are expected to be leading members of healthcare teams, formal training is essential to the transition process.20 Clinical readiness, leadership skills, communication, and professional identity are key components to the development of new APRNs. Creating a well-designed transition program that offers a structured path to independent practice will undoubtedly have an overall positive impact on the bottom line, productivity, and patient outcomes. Understanding current internal data, reviewing resources provided by organizations that are developing standards for these programs, and connecting with colleagues from around the country are all great assets available toward developing a successful program.
REFERENCES
1. Brown MA, Olshansky EF. From limbo to legitimacy: a theoretical model of the transition to the primary care nurse practitioner role.
Nurs Res. 1997;46(1):46–51.
2. Hoff T, Carabetta S, Collinson GE. Satisfaction, burnout, and
turnover among nurse practitioners and physician assistants: a review of the empirical literature.
Med Care Res Rev. 2019;76(1):3–31.
3. Nurse practitioner agency nurse among hardest healthcare roles to fill. NPNow.com. 2019.
www.npnow.com/nurse-practitioner-agency-nurse-among-hardest-healthcare-roles-to-fill.
5. St-Martin L, Harripaul A, Antonacci R, Laframboise D, Purden M. Advanced beginner to competent practitioner: new graduate nurses' perceptions of strategies that facilitate or hinder development.
J Contin Educ Nurs. 2015;46(9):392–400.
6. Barnes H. Exploring the factors that influence nurse practitioner role transition.
J Nurse Pract. 2015;11(2):178–183.
7. Faraz A. Novice nurse practitioner workforce transition into primary care: a literature review.
West J Nurs Res. 2016;38(11):1531–1545.
8. Poronsky CB. Exploring the transition from registered nurse to family nurse practitioner.
J Prof Nurs. 2013;29(6):350–358.
9. Brown K, Poppe A, Kaminetzky C, Wipf J, Woods NF. Recommendations for nurse practitioner residency programs.
Nurse Educ. 2015;40(3):148–151.
10. Hart AM, Bowen A. New nurse practitioners' perceptions of preparedness for and transition into practice.
J Nurse Pract. 2016;12(8):545–552.
11. Tracy A. Perceptions of certified registered nurse anesthetists on factors affecting their transition from student.
AANA J. 2017;85(6):438–443.
12. MidlevelU.com. MD vs. NP vs. PA: here's how the number of clinical hours compare. 2017.
www.midlevelu.com/blog/md-vs-np-vs-pa-heres-how-number-clinical-hours-compare.
14. Commission on Collegiate Nursing Education. CCNE NP Residency/Fellowship Standards Committee [Press Release]. January 17, 2019.
www.aacnnursing.org/Portals/42/CCNE/PDF/CCNE-NP-Residency-Fellowship-Prog.pdf.
15. GraduateNursingEDU.org. Nurse Practitioner Fellowship Programs by State—2017. 2017.
www.graduatenursingedu.org/nurse-practitioner-residency-programs.
16. Jones-Bell LJ, Halford-Cook C, Parker NW. Transition to practice-part 3: implementing an ambulatory care registered nurse residency program: RN residency and transition to professional practice programs in ambulatory care-challenges, successes, and recommendations.
Nurs Econ. 2018;36:35–45.
17. Bush CT. Postgraduate nurse practitioner training: what nurse executives need to know.
J Nurs Adm. 2014;44(12):625–627.
18. Wiltse Nicely KL, Fairman J. Postgraduate nurse practitioner residency programs: supporting transition to practice.
Acad Med. 2015;90(6):707–709.
19. Norcini JJ. Work based assessment.
BMJ. 2003;326(7392):753–755.
20. Miller GE. The assessment of clinical skills/competence/performance.
Acad Med. 1990;65(9 suppl):S63–S67.
21. Guido-Sanz F, Diaz DA, Anderson M, Gonzalez L. Role transition and communication in graduate education: the process.
Clin Simul Nurs. 2019;26(C):11–17.
22. American Nurses Credentialing Center.
Practice Transition Accreditation Program. Silver Springs, MD: ANCC; 2016.
www.nursingworld.org/organizational-programs/accreditation/ptap.
23. National Nurse Practitioner Residency & Fellowship Training Consortium. About Us. 2019.
www.nppostgradtraining.com/About-Us.
