Keywords

Curriculum Development, Nurse Practitioner, Professional Identity, Role Transition, Rural Nursing

 

Authors

  1. Owens, Rhoda A.

Abstract

AIM: The purpose of this scoping review was to explore the literature regarding the nurse practitioner (NP) role transition and professional identity development at rural health care settings.

 

BACKGROUND: Because of the shortage of primary care providers, NPs are meeting the demand for primary care in rural areas.

 

METHOD: Arksey and O'Malley's six-stage methodological framework for scoping reviews guided this systematic literature review, which resulted in selection of 145 sources.

 

RESULTS: Three major themes emerged: NPs in rural clinical practice, defining NP professional identity, and role transition to an NP identity.

 

CONCLUSION: Further research is needed to guide education program leaders on curriculum development. Rural health care facilities and nursing programs should partner in the orientation and continuing education needs of NPs to prepare and support their role transition and professional identity development. NPs will be instrumental in providing access to quality primary health care in rural communities.

 

Article Content

Most health care systems throughout the Western world are experiencing an increase in the demand for cost-effective quality primary care due to rising patient expectations and the number of chronically ill and aging populations (Graves et al., 2016; Laurant et al., 2005). Recent changes in US health policy, the growth of the total and aging population, and the increased need to manage complex chronic diseases are placing stress on the health care system, leading to the need for additional primary care providers (Graves et al., 2016; Perloff, DesRoches, & Buerhaus, 2016; Schiff, 2012). By 2020, the United States will face a shortage of more than 45,000 primary care physicians (Kirch, Henderson, & Dill, 2012).

 

Nurse practitioners (NPs) make up the most rapidly growing primary care workforce and provide primary care in diverse settings (American Association of Nurse Practitioners [AANP], 2016; Poghosyan, Lucero, Rauch, & Berkowitz, 2012). According to the AANP (2016), 89 percent of NPs are prepared in primary care, and more than 75 percent actively practice primary care in a variety of settings. NPs assess patients, order and interpret diagnostic tests, make diagnoses, and initiate and manage treatment plans, including prescribing medications. Finally, NPs are authorized to work independently under the exclusive licensure authority of the state board of nursing in 22 states plus the District of Columbia (AANP, 2016). New models of primary care delivery that emphasize greater interprofessional collaboration between physicians and other clinicians such as NPs are encouraged (Graves et al., 2016; Perloff et al., 2016; Schiff, 2012).

 

NPs tend to care for rural and underserved populations (Kippenbrock, Lo, Odell, & Buron, 2015). Approximately 66 percent work in communities with populations of less than 250,000, with 35 percent practicing in communities of less than 50,000 (Rutledge, Haney, Bordelon, Renaud, & Fowler, 2014). As a result, NPs are called upon to meet the demand for primary care provider positions in rural areas (Altman, Butler, & Shern, 2015; Rutledge et al., 2014; Schiff, 2012). Thus, leaders of NP education programs must develop curricula that prepare graduates to provide safe, quality primary care to diverse populations, which include rural populations (National League for Nursing, 2017).

 

During role transition from expert RN identity to NP identity, feelings such as inadequacy, role ambiguity, isolation, anxiety, stress, and being overwhelmed have been reported, leading to feelings of incompetence and work dissatisfaction (Barnes, 2015a, 2015b; Poronsky, 2012). Successful professional identity formation during periods of transition happens for individuals when they develop the attitudes, beliefs, behaviors, and learn the knowledge and skills that support the roles and responsibilities of being that professional (Johnson, Cowin, Wilson, & Young, 2012; Trede, Macklin, & Bridges, 2012). Furthermore, successful role transition and professional identity development result in greater work satisfaction for individuals and increased retention (Sabanciogullari & Dogan, 2015; Trede et al., 2012).

 

There is limited research on the transition to NP practice in rural health care settings. This review identifies gaps in the research and recommends future research related to the experiences of RNs as they transition to their inexperienced NP identities at rural health care facilities. Findings from this study can be used to guide curricula in nursing education programs and rural agencies to enhance learning outcomes and quality care delivery by rural NPs.

 

METHOD

A scoping review or study addresses a broad exploratory research question or questions related to a defined area or field by providing a systematic search, selection, and description of the available research and nonresearch literature (Arksey & O'Malley, 2005; Colquhoun et al., 2014; Davis, Drey, & Gould, 2009). Unlike the classic systematic review, a scoping review aims to define themes and/or concepts within a given field as opposed to assessing research literature within a narrowly defined protocol (Arksey & O'Malley, 2005). The purpose of this scoping review is to inform practice, education programs, and policy. It was guided by Arksey and O'Malley's (2005) six-stage methodological framework for scoping reviews. The process is presented with a description of each stage of the methodological framework used for this review.

 

Framework Stage 1: Identifying the Research Question

The starting point for conducting a scoping review is to identify the research question used to guide the process for completing subsequent stages and how search strategies are built. The research question must be broad enough to generate a breadth of coverage but specific enough to guide the scope of inquiry and include aspects such as study population, concepts, interventions, and outcomes (Arksey & O'Malley, 2005). The research question for this scoping review was as follows: What is known from the existing literature on how registered nurses describe their role transition process and professional identity development experiences as nurse practitioners working at rural health care settings?

 

Framework Stage 2: Identifying Relevant Studies

During this stage of the scoping review process, primary research studies (published and unpublished), reviews, and other literature must be searched and identified as suitable for answering the primary research question (Arksey & O'Malley, 2005). To obtain a comprehensive review, multiple sources need to be searched, such as electronic databases, reference lists, and existing networks and relevant organizations; decisions must be made on time span and language to include.

 

Inclusion criteria for this review included peer-reviewed articles and other literature published between 1989 and 2017, written in the English language, that included nurses and/or NPs practicing at rural health care facilities. These dates were chosen since the first theory on rural nursing practice was published in 1989 by Long and Weinert. Because of her extensive research with role transition theory, the decision was made to also include work by Meleis (1975) to define role transition. To ensure completeness of the review, multiple strategies were used to find various types of literature (peer-reviewed research and nonresearch). Electronic data bases searched were PubMed, Cumulative Index to Nursing and Allied Health Literature, Academic Search Premier, and Google Scholar. Key words (alone or in combination) used included role transition, nurse practitioner, professional identity, identity, rural nursing theory, rural nurse practitioner theory, rural nursing practice, and rural health care. Reference lists of articles were examined to supplement the search and locate additional articles. The search also included examination of rural health and professional NP association websites.

 

Articles and other literature outside the inclusion criteria were excluded. It is recognized that, because of the limits set with the inclusion criteria, potentially relevant articles could have been missed. The search continued until saturation and produced a total of 225 relevant sources. (See Figure 1, which outlines the search process, available as Supplemental Digital Content at http://links.lww.com/NEP/A121.)

 

Framework Stage 3: Study Selection

The review's inclusion criteria, purpose, and research question guided selection of literature. Of the 225 relevant sources, 41 duplicated articles were eliminated. Abstracts for the remaining 184 were read to determine relevance to the review's purpose and research question, resulting in the elimination of an additional 48 articles. The remaining 136 sources were read in their full-text versions and retained, along with nine other journal articles obtained from the review of references lists. The final scoping review encompassed 145 articles pertinent to the review's purpose and question.

 

Framework Stage 4: Charting the Data

The next stage of this review involved charting the information obtained by sorting material according to key themes using a narrative review approach (Arksey & O'Malley, 2005). To ensure accuracy and completeness, a data charting form (O'Brien et al., 2016) in Microsoft Excel was developed and used to enter the data. The categories reflected the research question, search terms, type of literature, year of publication, study location, study population, aims of the study, methodology, outcomes measures, results, and themes. Themes and their definitions used to organize the information were developed after reading and reviewing selected literature in relation to this review's purpose and question and formed the basis for the analysis. Three main themes emerged as discussed in the results section.

 

Framework Stage 5: Collating, Summarizing, and Reporting Results

The fifth step of a scoping review involves summarizing, making comparisons, and reporting results to present a narrative and descriptive overview of all materials reviewed and in relation to subsequent developed themes (Arksey & O'Malley, 2005). Gaps in the literature and recommendations for future research, policy, and practice are identified and presented in relation to the review's purpose and research question. The results section contains a narrative descriptive account of the available literature based on the review's question and emerging themes while identifying gaps in the existing literature. Recommendations for practice, education, and future research follow.

 

An appraisal of the quality of the literature was not completed in accordance with scoping review methodology (Arksey & O'Malley, 2005; Colquhoun et al., 2014; Davis et al., 2009; O'Brien et al., 2016). The purpose of this scoping review is to present only a narrative descriptive overview of all materials reviewed.

 

Framework Stage 6: Consultation Exercise

Arksey and O'Malley (2005) recommend consulting appropriate individuals to provide additional insight on possible issues, organizations, or sources the scoping review alone would not have discovered. As part of this review, the author consulted with family nurse practitioners (FNPs) working in rural and nonrural clinical practice and FNP faculty at a university. The university where the research was conducted is surrounded by rural and frontier regions that are commonly used for student clinical experiences. The FNPs who were consulted provided guidance on organizations and other sources for obtaining additional literature and reports.

 

RESULTS

A descriptive summary of the number of sources and types of evidence found during the selection and charting process is presented in this section, categorized by three major themes: NPs in rural clinical practice, defining NP professional identity, and role transition to NP identity. Selected literature is presented and summarized for each theme, and gaps in the literature are identified.

 

NPs in Rural Clinical Practice

Most previous research has focused on rural nurses working in various clinical practice areas rather than exclusively with rural NPs. Various definitions of rural exist in the literature. The US Census Bureau (2010) broadly defines a rural community as an area not designated as urban (>50,000 inhabitants) and having fewer than 2,500 inhabitants. The Rural Health Information Hub (2017) website is another valuable resource for defining rural areas (http://www.ruralhealthinfo.org).

 

In 42 studies, effective nursing care and provision of care to rural populations are shown to be different from that of urban populations and require the acquisition of unique knowledge and skills. The same nursing theories cannot be applied to both urban and rural populations (Bushy, 2012; Long & Weinert, 1989; Winters, 2013). Rural nursing theory first emerged through research by faculty and graduate students at Montana State University College of Nursing (Long & Weinert, 1989) and continued to grow over the next several years. Researchers agreed that prior existing nursing theories did not fully define rural nursing practice (Bushy, 2012; Winters, 2013). "Rural nursing is defined as the provision of health care by professional nurses living in sparsely populated areas" (Long & Weinert, 1989, p. 114).

 

Several differences exist and must be noted between rural and urban nursing practice. By filling the role of generalist, rural nurses generally experience more autonomy in their positions than urban nurses because they provide and coordinate care for a wide variety of patients with different medical conditions and health care needs (Adams, 2018; Bushy, 2012; Crooks, 2012; Long & Weinert, 1989). In addition, because they practice in sparsely populated areas with fewer health care facilities, rural nurses must cope with a sense of isolation from professional peers and be able to provide access to quality patient care using sparse medical resources and technology (Adams, 2018; Bushy, 2012; Winters, 2013).

 

Rural nurses, in contrast to urban nurses, lack anonymity and experience greater role diffusion than nurses in urban settings (Bushy, 2012; Crooks, 2012; Long & Weinert, 1989). Rural nurses must gain the community's trust; they report knowing people they care for and interacting with them in other social roles, such as friend, neighbor, and family (Bushy, 2012; Crooks, 2012; Long & Weinert, 1989).

 

Rural nurses understand how rural dwellers define health and illness differently than urban individuals (Bushy, 2012; Crooks, 2012; Long & Weinert, 1989). Rural dwellers primarily define health as the ability to work, be productive, and perform usual tasks, secondary to work needs (Long & Weinert, 1989). They are self-reliant, are independent, value close relationships, and prefer to have individuals they personally know care for them (Bushy, 2012; Long & Weinert, 1989). A study by Thomlinson, McDonagh, Crooks, and Lees (2004) found that rural Canadian residents defined health as being able to work productively and having a holistic, balanced relationship between the physical, mental, social, and spiritual aspects of one's life. They valued health-seeking behaviors relating to diet, exercise, sleep, home remedies, and spiritual well-being.

 

Little research exists that defines NP practice at rural health care settings, focusing instead on all RNs working in various rural clinical practice areas. In 42 studies, participants involved only RNs or NPs with other RNs, rather than NPs only. Similar to the work of Long and Weinert (1989), Crooks (2012) reported in an ethnographic study with 10 rural Canadian RNs and no NPs that RNs experienced dual relationships with their patients. Rural health care relationships between RNs and patients are a fusion of complex experiences that connect the working and community environments. Because the NP's scope of practice, roles, and responsibilities differ, further research is needed to determine if their experiences, knowledge, and skills are similar or different from those needed by other RNs to provide effective rural health care.

 

Eight research studies and practice literature articles support the need to integrate rural content into NP education because rural and urban advance practice nursing differ. In 12 other studies, adequate support, relationships, mentoring, and educational preparation to practice in rural health care settings were found to promote NP work satisfaction and retention. For example, Conger and Plager (2008) completed a qualitative study with rural NPs in practice for at least one year using focus groups and individual interviews. One theme emerged: rural connectedness (felt connected) versus disconnectedness (felt disconnected). A sense of rural connectedness that promoted work satisfaction was achieved by NPs when they expressed knowledge on rural nursing theory, rural culture, and values; experienced clinical practice at rural health care facilities; developed support networks and entered relationships with urban medical centers; used electronic communication; and established connections with the rural community. The NPs reported a sense of disconnectedness when they lacked relationships with other health care centers, mentors/support staff, electronic support, and an understanding of rural culture. In another study, Bae (2016) found that other factors promoted an NP's work satisfaction in rural settings, such as feelings of autonomy, respect from colleagues and other providers, and being allowed to practice primary care in their full legal scope of practice.

 

Six studies uncovered the importance of educating advance practice nursing students on use of health care technology such as telemedicine, electronic health records, and clinical decision support systems. The increased use of telehealth to overcome barriers to care and deliver quality, affordable, and timely health care to rural populations makes it vital that NPs become educated on its use. Rutledge et al. (2014) concluded that providing education on various types of health care technology to NPs as students resulted in decreased feelings of isolation, improved connection with other providers, and a commitment to providing health care access to rural and vulnerable populations.

 

Defining NP Professional Identity

Eighteen articles were found to have similar general definitions for professional identity. Professional identity can be defined as the self-perceived attitudes, values, knowledge, beliefs, and skills that are shared with others within a professional group in the workplace obtained through a socialization process (Andrew, 2012; Crossley & Vivekananda-Schmidt, 2009; Sabanciogullari & Dogan, 2015).

 

Adult learning theory postulates that an individual's learning, experiences, and socialization can contribute to developing and/or changing his or her identity. For example, Illeris (2014) defines transformative learning as learning that results in the change of the identity of the learner with the concept "about being a person in the world, who one experiences being, and how one relates to and wants to be experienced by others" (p. 1). Identity in relation to learning is centered on the individual's connection with surroundings (social and material environment) and the socialization process. Change in identity occurs by experiencing the three dimensions of learning: content (what is learned), incentive (motivation to learn), and interaction (with society).

 

The literature includes definitions specific to nurses' professional identity. Twenty-four articles defined how nurses throughout their careers and/or while changing clinical practice areas develop their professional identity. However, these studies explored identities of nurses working at various clinical practice levels; they did not focus exclusively on NPs. Generally, nurses' professional identity development begins before entering nursing education programs, takes place during their education programs and through their learning and socialization experiences, and can change throughout their careers as they change practice areas (Andrew, 2012; Jennings & Rogers, 1988; Johnson et al., 2012; Willetts & Clarke, 2014).

 

Five studies found that successful development of a nurse's professional identity resulted in increased work satisfaction, decreased burnout levels, and low turnover rates. For example, Sabanciogullari and Dogan (2015) discovered in a quasi-experimental study that a professional identity development program promoted professional identity development with increased job satisfaction and decreased burnout levels for 63 RNs at one urban hospital. The program involved a structured orientation, education, and mentoring program for new nurses.

 

Research is lacking on NPs' identity development in rural health care settings. Three studies similarly defined NP professional identity as different from that of an RN but did not include practicing as a provider in a rural health care setting. For example, Piil, Kolbaek, Ottmann, and Rasmussen (2012) found that urban NPs define their identity differently and more specialized than RNs because of having different experiences, responsibilities, roles, and scope of practice.

 

Role Transition to an NP Identity

Meleis (1975) was first to discover that role transition can lead to a change in an individual's identity in society. A role is a character assigned or assumed, socially expected behavior pattern determined by an individual's status in a particular society or a function or part performed especially in a particular operation or process. Role transition can be defined as a change in an individual's self-identity within a certain context that occurs through the development of new knowledge and skills, as well as a change in behavior, role relationships, interactions, expectations, and abilities (Meleis, 1975). In addition, role transitions can occur in a specific social context, such as professional roles throughout a career (Schumacher & Meleis, 1994).

 

Nine studies focused on the process of role transition and professional identity development for NPs, but none focused exclusively on NPs practicing in rural health care settings. The role transition and change in identity from expert RN to inexperienced NP can be stressful and lead to a loss of self-confidence and feelings of incompetence. An impaired role transition and identity development for NPs in the first year has been shown to decrease work retention and satisfaction, causing NPs to leave the profession within the first year of practice (Barnes, 2015a, 2015b; Cusson & Strange, 2008).

 

Eight studies discovered that role transition and change in professional identity begin for NPs while they are enrolled in their NP education programs and in the postgraduate period of practice; however, NPs in these studies did not practice in rural areas (Heitz, Steiner, & Burman, 2004; Steiner, McLaughlin, Hyde, Brown, & Burman, 2008). For example, Heitz et al. (2004) learned in a descriptive qualitative study with eight FNP graduates of one university that role transition and change in identity from RN nurse to FNP happens in two phases: first during the education phase and then after graduation during the first six months to two years while working as an independent FNP. Positive influences include faculty nurturing, preceptor guidance and role modeling, networking and support, NP role experiences, clinical and lab experiences, and personal support systems. In a later quantitative study with 155 participants, Steiner et al. (2008) found that prior life and professional experiences also facilitated the beginnings of the transition to an FNP identity.

 

Research in six studies supports prior experience as an RN, formal NP orientation, and mentoring as positive influences on NP role transition and identity development. Barnes (2015b) reported in a quantitative study with 365 urban NPs currently practicing in primary care or specialty areas that having a structured NP orientation and mentoring program promoted successful transitions to their identities. However, NPs in this study did not practice in rural areas.

 

IMPLICATIONS AND FUTURE RESEARCH

The findings of this scoping review have important implications for both NP education and rural health care practice. Specifically, this review discovered a lack of research and evidence on how RNs describe their role transition and professional identity development experiences as NPs who are initiating work in rural health care settings. A few studies state that role transition and identity development begin for NPs while they are enrolled in their NP education programs and continue into their postgraduate period of practice.

 

Certain factors have been shown to facilitate successful transition and new identity development for NPs, such as faculty nurturing, education and clinical experiences, prior nursing experiences, preceptor guidance, supportive relationships with colleagues, and formal mentoring and orientation programs. However, these studies sampled NPs working in urban areas; little is known about the phenomenon in rural health care.

 

It is important to note that rural nursing theory literature concludes that the provision of nursing care to rural populations is different from that of urban populations and requires the acquisition of unique knowledge and skills. Abundant research exists exploring RNs' experiences practicing in rural health care, but there is little that focuses exclusively on NPs. Because the experiences, knowledge, skills, and scope of practice required for NPs are different from that of RNs, more research with rural NPs is needed.

 

Successful role transition and professional identity development have been shown to support work satisfaction and retention, competence, and confidence in one's new professional identity. Therefore, more research is vital to investigate factors and experiences that promote successful transition and change in professional identity for NPs while working in rural areas. Findings could be used to guide NP program curriculum development and rural health care facility leaders on how to better support and facilitate this process so that new rural NPs can provide safe, competent primary care to rural and vulnerable populations. Advancement in curriculum development and implementation holds promise to impact the recruitment and retention of NPs in rural areas. This strategy is greatly needed to respond to the nursing workforce shortages in rural areas.

 

CONCLUSION

This scoping review methodology was guided by Arksey and O'Malley (2005). Findings from this review provide nurse educators and rural health care leaders with some possible factors to consider in promoting the successful role transition and identity development of new rural NPs. NPs actively practice primary care in a variety of settings. Because of the shortage of primary care providers, more NPs are being utilized to provide primary care to vulnerable and rural populations.

 

More research must be done to further explore rural NP transitioning and identity development experiences and factors that promote success with this process. This author is currently conducting a qualitative study to explore the experiences of new FNPs who are beginning practice at several Midwest rural health care facilities. Findings will be presented to NP nursing programs and rural health care facilities in the region to guide curriculum and orientation and professional development programs that better prepare and support NPs to administer safe, quality primary care that improves health care access in rural communities.

 

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