Postgraduate NP Education: Impact on Job Satisfaction

Tom Bush, DNP, FNP-BC, FAANP

Associate Professor

University of North Carolina at Chapel Hill

Schools of Nursing and Medicine

Orthopedic NP Fellowship Director

1

IOM/RWJ Future of NursingState boards of nursing, accrediting bodies, the federal government, and health care organizations should take actions to support nurses completion of a transition-to-practice program (nurse residency) after they have completed a prelicensure or advanced practice degree program or when they are transitioning into new clinical practice areas

IOM, 2011, p. S 9

Fellowship or Residency?Residency is required for licensure and practice in medicine and some other disciplines

Post-graduate education is optional for licensure and practice in nursing

NP Roundtable Address potential confusion Endorsed use of the term fellowship

Transition-to-practice Does not suggest regulatory control

AANP 2013; Wiltse Nicely & Fairman, 2015

Affordable Care ActPost-graduate NP demonstration project Fund FQHC programs in nurse managed health centers DHHS sought input from nursing educators NONPF & others voted not to support

We thought the money should go to support NP programs to increase the number of NPs

DHHS funded 5 health centers to increase numbers of NP graduates

No funding for post-graduate NP education

Boyar, 2010; M. Price 2014

Cost and CommitmentPost-graduate physician education Federally funded by DHHS through CMS

More than 100k per resident per year Can total more than 500k when state Medicaid payments considered

Indirect Federal support for NP programs Veterans Health Administration Federally Qualified Health Centers

Few employer funded NP programs Most employers expect new NP graduates to perform at an advanced level

with little support

Dower, 2012; Bahouth, Blum, & Simone, 2013

Cost and CommitmentMost post-graduate NP education programs employer funded Recruitment and retention of professionals

Meet immediate and growing workforce needs Costs per trainee can reach 100k annually

NP salary/benefits, lost preceptor revenue, facility overhead and administrative expenses Two thirds support post-graduate NP One third supplements lost preceptor productivity Expenses offset through billable NP activity

Employment commitment may be required

Flinter, 2011; D. Taylor, 2014

ProblemPrograms to facilitate Nurse Practitioner (NP) transition to practice have been developed at public and private institutions across the US and there is no published evidence of their influence on NP job satisfaction

PurposeDetermine the impact of post-graduate education on job satisfaction among NPs

Project Question: Is there a difference in job satisfaction between NPs who have

completed post-graduate fellowship education and NPs who have not participated in formal post-graduate fellowship education?

TheoryFrom Limbo to Legitimacy Anxiety and accomplishments of novice NPs Transition from student to clinician

Feelings of insecurity and illegitimacy Fear of errors and associated anxiety Impacts diagnostic reasoning & clinical decisions

Experience fosters confidence & competence Is anxiety due to transitional identity or inadequate environmental support?

Brown & Olshanksy, 1997

MethodsA non-equivalent group design The Misener Nurse Practitioner Job Satisfaction Scale was administered

to two groups of nurse practitioners Formal post-graduate fellowship n = 80 No formal post-graduate fellowship n = 174

Demographic tool race; gender; age; years of NP experience, highest degree; practice zip code

Misener & Cox 2001

Age Distribution All Participants

Boomer 31.5%

Gen X 43.9%

Gen Y 24.3%

Age Distribution by Group

Mean Years of NP Experience

States Represented

Median Satisfaction Scores

Table 1 Job Satisfaction Scores

Post-graduate education N Median Frequency of

satisfied and very satisfied

Yes 80 5 68.8% No 174 5 50.5%

Table 1

Job Satisfaction Scores

Post-graduate education

N

Median

Frequency of satisfied and very satisfied

Yes

80

5

68.8%

No

174

5

50.5%

Satisfaction DistributionN = 254Mean = 189SD = 36

95 percent of responses are normally distributed

Data AnalysisAnalysis: Independent samples t-test of factor scores to compare job

satisfaction between groups Compare and contrast post-graduate fellowship training effects within

demographic strata Multiple Linear Regression

Calculated to predict participants total job satisfaction based on years of NP experience, state regulatory environment and completion of a post-graduate education program

Independent Samples t TestTable 2 Independent samples t test of factor scores and Cronbach alpha (N = 254) Post-graduate education Yes (n = 80) No (n = 174) Factors M SD M SD t Sig.(2 tailed) Collegiality 0.95 4.33 1.03 3.94 1.05 2.74 .007* Autonomy 0.91 4.93 0.75 4.57 0.87 3.19 .002* Interaction 0.87 4.72 0.76 4.42 0.82 2.79 .006* Growth 0.89 4.38 1.11 3.78 1.16 3.84

Years of Experience

p = .030

Years of Experience/Post-grad. Ed

Statistically significant in No post-graduate education group only (p = .019)

Statistically insignificant

State Regulatory Environment

State Regulation/Post-grad. Ed

Statistically insignificant

Post-graduate Education

p < .001

Regulation/Experience/Post-grad. Education

More than 3 years experience, post-graduate education & full practice authority

VS.

More than 3 years experience, post-graduate education & restricted practice

p = .018

Multiple Linear Regression Table 3 Multiple linear regression predicting Total Job Satisfaction from regulatory environment, years of experience (Block 1) and post-graduate education (Block 2) t p value State regulatory environment -3.27 -.545 .587 Years of experience as a nurse practitioner .16 .531 .596 Post-graduate education -16.68 -2.972 .003* Note. R2 = .04. * p < .05.

Table 3

Multiple linear regression predicting Total Job Satisfaction from regulatory environment, years of experience (Block 1) and post-graduate education (Block 2)

t

p value

State regulatory environment

-3.27

-.545

.587

Years of experience as a nurse practitioner

.16

.531

.596

Post-graduate education

-16.68

-2.972

.003*

Note. R2 = .04.

* p < .05.

LimitationsParticipants recruited by email invitation Indirectly through program directors

Comparison group recruited through an online community of professionals

Parametric tests on ordinal data may be considered a study limitation Distribution nearly normal with few outliers

Supports the use of parametric tests in this study

Post-graduate NP Education Significance: Post-graduate fellowship training significantly impacts NP satisfaction with

professional growth, autonomy, collegiality and interaction Satisfaction with work time and job benefits is less apparent in this study

Knowledge of factors that influence job satisfaction is advantageous: NPs considering fellowship education Employers considering program development Policy makers

ReferencesBoyar, K. L. (2010). Nurse practitioner residency programs and healthcare reform on ADVANCE for NPs & PAs. Retrieved from http://nurse-practitioners-and-physician-assistants.advanceweb.com/Features/Articles/Nurse-Practitioner-Residency-Programs-and-Healthcare-Reform.aspx

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.

Dower, C., & Christian, S. (2009). Physician assistants and nurse practitioners in specialty care: Six practices make it work. San Francisco: University of California.

Flinter, M. (2011). From new nurse practitioner to primary care provider: Bridging the transition through FQHC-based residency training. Online Journal of Issues in Nursing, 17(1), 6.

ReferencesKapu, A. N., Kleinpell, R., & Pilon, B. (2014). Quality and financial impact of adding nurse practitioners to inpatient care teams. The Journal of Nursing Administration, 44(2), 87-96. doi:10.1097/NNA.0000000000000031; 10.1097/NNA.0000000000000031

IOM (Institute of Medicine). (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.

Landivar, L. (2013). Men in nursing occupations. Washington, DC: U.S. Census Bureau.

Misener, T. R., & Cox, D. L. (2001). Development of the misener nurse practitioner job satisfaction scale.Journal of Nursing Measurement, 9(1), 91-108.

Wilcox, M. A., Broyhill, B. H., Taylor, D. A., & Williamson, S. B. (2015). The lifecycle of the advanced clinical practitioner. Nurse Leader, 13(2), 27-30. doi:http://dx.doi.org/10.1016/j.mnl.2015.01.015

Wiltse Nicely, K. L., & Fairman, J. (2015). Postgraduate nurse practitioner residency programs: Supporting transition to practice. Academic Medicine : Journal of the Association of American Medical Colleges, 90(6), 707-709. doi:10.1097/ACM.0000000000000567 [doi]

Postgraduate NP Education: Impact on Job SatisfactionIOM/RWJ Future of NursingFellowship or Residency?Affordable Care ActCost and CommitmentCost and CommitmentProblemPurposeTheoryMethodsAge Distribution All ParticipantsAge Distribution by GroupMean Years of NP ExperienceStates Represented Median Satisfaction ScoresSatisfaction DistributionData AnalysisIndependent Samples t TestYears of Experience Years of Experience/Post-grad. EdState Regulatory EnvironmentState Regulation/Post-grad. EdPost-graduate EducationRegulation/Experience/Post-grad. EducationMultiple Linear Regression LimitationsPost-graduate NP Education ReferencesReferences