EXPLORING THE TRANSITION FROM REGISTERED NURSE TO FAMILY NURSE PRACTITIONER CATHLIN BUCKINGHAM PORONSKY, PHD, RN, FNP-BC⁎ There is limited information available regarding the transition from registered nurse (RN) to family nurse practitioner (FNP). Several authors described this transition as taking place in 4 stages, and others described it as a 2-phase process. However, there is a lack of consensus about the definition of these stages and phases and at what point they occur for nurses who are making the transition from an RN to an FNP. From what is known, this multistage/2-phase transition is accompanied by feelings of anxiety, stress, role confusion, and emotional turmoil. As a nurse faculty member, the author theorized that nurse faculty might be in a position to provide support for graduate students making this transition in role. However, there was little information available about the transition phases, stages, and needs of students during graduate school. The search for a framework to explore transition yielded transition theory, which is described and applied to FNP transition in this article. Transition theory may be useful for examining more fully the phases and stages of RN-to-FNP transition. In this time of increased need for qualified primary care providers, it is essential that graduates of FNP programs transition into practice following graduation. (Index words: FNP transition; Transition theory; Graduate nurse education) J Prof Nurs 29:350–358, 2013. © 2013 Elsevier Inc. All rights reserved.
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HE TRANSITION FROM registered nurse (RN) to family nurse practitioner (FNP) requires a change in role from providing patient care to prescribing patient care (Forbes & Jessup, 2004). This journey requires rigorous graduate level academic preparation, acquisition of new knowledge and skills, and major changes in function and scope of practice. Graduate nursing education can be a time of great inspiration and excitement, yet it is also a time of upheaval and challenge for students while they struggle to meet academic demands and begin to make the transition from RN to FNP.
Background Attainment of the FNP advanced practice nurse (APN) role evolves over time. The paradigm shift in role from RN to an APN has been depicted as “moving from the side of the bed to the head of the bed” (Cusson & Viggiano, 2002, p. 21). Although this change in role is dramatic, there is ∗Assistant Professor and Director of the Family Nurse Practitioner Program, Marcella Niehoff School of Nursing, Loyola University, Chicago, IL. Address correspondence to Dr. Poronsky: Loyola University Chicago, Marcella Niehoff School of Nursing, 2160 S. 1st Avenue, 125-4500, Maywood, IL 60153. E-mail: [email protected] 8755-7223/12/$ - see front matter 350 http://dx.doi.org/10.1016/j.profnurs.2012.10.011
limited information in the literature about the process of transition from RN to FNP (Spoelstra & Robbins, 2010). Information is even more limited with regard to transition during graduate education (Rich, Jorden, & Taylor, 2001; Steiner, McLaughlin, Hyde, Brown, & Burman, 2008). According to Heitz, Steiner, and Burman (2004) and Brykczynski (2009), transition is a two-phase process. Phase 1 begins upon entry to graduate school and continues through program completion and graduation. This period of learning the FNP role is termed acquisition (Brykczynski, 2009). Phase 2, the implementation phase (Brykczynski, 2009), begins after graduation when the new FNP moves into the workplace as an APN. Phase 2 lasts anywhere from 6 months to 2 years postgraduation (Brykczynski, 2009; Heitz et al., 2004). Kelly and Mathews (2001) suggested that new FNPs may lack awareness about the transition process, which in turn may lead to a longer role adjustment period, whereas an enhanced awareness could lead to a shorter adjustment period. New FNPs starting out in practice who have not progressed through Phase 1 of role transition during graduate school may be at risk for greater disconnectedness, isolation, and prolonged disequilibrium during Phase 2 of the transition process than those who began transition during graduate school.
Journal of Professional Nursing, Vol 29, No. 6 (November/December), 2013: pp 350–358 © 2013 Elsevier Inc. All rights reserved.
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Kelly and Matthews recommended that faculty in academic institutions educate FNP students about transition and actively facilitate the transitional process during graduate school. However, for faculty who seek to do this, there is very limited information in the literature about Phase 1 or of successful methods to facilitate RN-to-FNP transition. No recent studies were found that included the transition experience of FNP students during graduate education. Absent from the literature reviewed for this article was information about the steps that FNP students take to navigate acquisition of the APN role. This article aims to provide insight into the transition process and make recommendations for additional research. The findings presented here seek to add to the body of knowledge about RN-to-FNP transition.
Method Using the key words family nurse practitioner role transition, nurse practitioner students, graduate nursing education, and transition theories, the following electronic databases were searched: the Cumulative Index to Nursing and Applied Health Literature, Educational Resources Information Center, the medical index (Medline), ProQuest database of theses and dissertations, the Psychological Literature, and World Catalog from 1988 through 2011. The review of the literature included theses, dissertations, reviewed articles, and books in order to encompass a wide variety of theoretical and research literature.
Findings Transition in Adults Adults experience various types of transitions over the course of their lives including developmental, situational, and health-related transitions (Meleis, 2007). Theorists have described transitions in adulthood as turning points or interludes between two periods of stability (Bridges, 1988; Goodman, Schlossberg, & Anderson, 2006; Levinson, 1986). Theoretically, the process of transition requires an individual to let go of former roles, disconnect from previous social links and support, experience a loss of familiar reference points (objects or persons), integrate new knowledge, alter behavior, learn new roles, deal with new needs and/or the inability to meet old needs in familiar ways, make adjustments between former sets of expectations and those that exist in the new situation, and ultimately change his or her definition of self (Bridges, 2004; Meleis, Sawyer, Im, Messias, & Schumacher, 2000; Schlossberg, Waters, & Goodman, 1995). The changes and upheavals inherent with transition can bring about unwelcome feelings. For some individuals, the transition process can be frightening or traumatic (Goodman et al., 2006). The ensuing changes in patterns of behavior brought about by transition can include disorientation, distress, and anxiety, as well as elation and happiness (Chick & Meleis, 1986). This wide array of emotions can leave individuals feeling off balance.
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Transitions in Nursing Chick and Meleis (1986) identified three transitions relevant to nursing: situational, developmental, and health–illness. Situational transitions include professional and educational role transitions. Examples cited by Schumacher and Meleis (1994) include advancing from new graduate to staff nurse, making changes in practice settings or types of patients, and moving from clinician to administrator. Meleis et al. (2000) built on earlier work (Chick & Meleis, 1986; Schumacher & Meleis, 1994) to develop a middle range theory of transition. Using grounded theory methodology, Meleis et al. explored the transitions of pregnancy, motherhood, menopause, migration, and care giving in African American women and Korean and Brazilian immigrant women. They proposed a framework for exploring transition based on four types of transition: developmental, situational, health–illness, or organizational transition. Their framework used patterns and properties to develop nursing therapeutics and included facilitating and inhibiting factors that affect the transition process. Outcome indicators of a successful transition included by Meleis et al. were developing confidence and coping, feeling connected, and mastery. Although this work was carried out with the aim of expanding nursing therapeutics, an overarching goal was to generate a healthy response to transition. Meleis et al. concluded that each transition is a unique, multidimensional and complex experience and that more research is needed “to discover the levels and nature of vulnerability at different points during transitions” (p. 27).
FNP Transition The transition from an RN into an FNP APN role may generate anxiety, conflict, loss of confidence in clinical skills, and feelings of incompetence (Brykczynski, 2009). RN-to-FNP transition has been described as occurring either in stages or in phases; the work of several authors is presented in Table 1. In the literature reviewed, the terms phases and stages were not defined. According to the Encarta English Dictionary, a phase is a clearly distinguishable period in the development of something or in a sequence of events, whereas a stage is a step or level in the development or progress of something. Stages. Brown and Olshansky (1997) carried out a longitudinal grounded theory study of new nurse practitioner's (NP) role transition. They interviewed 35 novice NPs at 1 month, 6 months, and 12 months during their first year of practice. Transition was conceptualized by participants in their study as a four-stage process that begins with laying the foundation for NP practice. This first stage commenced after completing NP education and included preparing and sitting for the certification examination. Next, in the launching stage as new NPs began their APN career, many felt overwhelmed and as imposters in their new NP role. As time went on, these new NPs moved into the phase of meeting the challenge where feelings of anxiety lessened and an increase in
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This study laid the groundwork for research about NP role transition, which was conceptualized as moving from “limbo to legitimacy” during the first year of practice.
RN-to-FNP transition as separate phases occurring during specific time periods was new information.
Maintain peer support network, anticipate need for time to adjust to new role, positive self-talk, seek mentor support
Optimistic self-talk, accepting responsibility for self-learning and independence, networking with colleagues outside of work Development of a network of support people, including physicians, family, and patients Anticipatory guidance from faculty, use of case studies in the classroom, and clinical conferences. Roberts, Tabloski, Qualitative and Bova (1997)
Kelly and Matthews Qualitative (2001)
Qualitative Heitz, Steiner, and Burman (2004)
Brown and Qualitative Olshansky (1997)
35 Novice NPs
Four stages: Laying the foundation, launching, meeting the challenge, broadening the perspective
Anxiety, role confusion, stress, insecurity during the first two stages. Stages 3 had ↓ anxiety, ↑ competence and confidence and, 4, a solid feeling of competence and legitimacy Phase 1: Need to let go of the 9 NPs who had Two phases: Phase RN role, sense of loss Phase 2: graduated within 1 = graduate school, self-doubt, apprehension, emotional the past 5 years Phase 2 at start of turmoil re: independent role FNP employment 21 FNPs who had Study focused on Feelings of anxiety, distress, graduated within Phase 2 isolation, and sense of the past 1–7 years disconnection Initial stages: Loss of 100 NP students Four stages: Complete confidence, role confusion dependence, developing competence, independence, and anxiety. Stages 3 and 4: Increasing confidence, and interdependence competency→role acquisition
State of disequilibrium continued years after graduation.
Significance of findings Strategies for coping Associated characteristics Phases/Stages Participants n Type of study Citation
Table 1. RN-to-FNP Transition Stages and Phases
Students were most stressed at the end of their first clinical practicum. Role acquisition includes appreciation of interdependence of nursing and medicine.
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confidence developed. The final stage was broadening the perspective, where many now had a sense of legitimacy in the NP role and competence in their skills. Roberts, Tabloski, and Bova (1997) described an identity crisis of NP students that occurred in four stages. Roberts et al. presented their findings not as the result of a formal research project but as a description of their observations and review of more than 100 NP students' clinical journals. Roberts et al. described the first stage as one of complete dependence, accompanied by a feeling of incompetence when NP students started clinical practicum courses. During the second stage, developing competence, students experienced role confusion with regard to their identity as nurses. As they progressed in clinical courses, they moved onto the third stage of independence. The third stage was accompanied by anxiety due to the growing awareness about the responsibilities and limitations of being a primary care provider. In the fourth and final stage, clinical practice was more independent, and although anxiety was still present, it was to a lesser degree than in Stage 3. The final stage was described as interdependence, a stage of awareness that APN practice was entwined with other professions and patients. Roberts et al.'s (1997) student participants were limited to those in clinical practicum courses. Students in other stages of their educational program were not included in their observations. Phases. Heitz, Steiner, and Burman (2004) explored RN-to-FNP transition from the perspective of recent FNP graduates. They interviewed nine practicing FNPs who had graduated within the past 5 years and asked them to reflect back on their transition. Participants described two distinct phases of transition: Phase 1 occurred during graduate school and Phase 2 began after graduation and at the start of employment as an FNP. Heitz et al. (2004) were the first to describe RN-to-FNP transition as separate phases or periods of development occurring during specific time periods. Participants in Heitz et al.'s study indicated that each phase presented different challenges. During Phase 1 in graduate school, participants recalled that while acquiring new knowledge to become an FNP, there was a simultaneous realization of the need to let go of the RN role. This produced a feeling of loss that was accompanied by a sense of “bouncing back and forth between nursing and FNP [roles]” (Heitz et al., 2004, p. 417). The necessity to switch back and forth between roles was more difficult for those with greater RN experience than for the one study participant who went directly from her undergraduate education into graduate school. Limited information is available regarding the transition experience of graduate students (Rich et al., 2001; Steiner et al., 2008); no additional information regarding Phase 1 was found in the literature reviewed for this article. More information was available about Phase 2. In addition to Heitz et al. (2004), multiple authors revealed that when a new FNP accepted the first job as an APN,
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they experienced a turbulent and stressful period (Barton, 2007; Cusson & Viggiano, 2002; Hayes, 2001; Sloand, Feroli, Bearss, & Beecher, 1998). In addition, Heitz et al.'s participants experienced feelings of self-doubt, apprehension, and emotional turmoil with regard to their new independent role responsibilities. Kelly and Mathews (2001) also explored Phase 2 of RN-to-FNP transition. They used focus groups with 21 practicing FNPs who had graduated in the past 1– 7 years. In addition to anxiety and distress, participants in their study experienced feeling disconnected and isolated while making the transition into APN practice. Unfortunately, some new FNPs continued to perceive themselves in a state of disequilibrium many years after graduation.
Exploring Transition The transition process for RN to FNP has been described as a multiphase and a multistage process (Brown & Olshansky, 1997; Heitz et al., 2004; Kelly & Mathews, 2001; Roberts et al., 1997). Several researchers described Phase 2 as a turbulent and stressful period (Cusson & Viggiano, 2002; Hayes, 2001; Sloand et al., 1998). With the exception of Roberts et al. (1997) who observed NP students' stages or steps in skill acquisition in the clinical setting, little is known about the experience of FNP students during graduate school. In order to aid FNP students with Phase 1 of transition, more information is needed. Information about what Meleis et al. (2000) termed as the vulnerable points during transition is not available and warrants additional research. The literature examined for this article included theoretical frameworks for exploring transition, and two are presented here.
Skill Acquisition The process of knowledge and skill acquisition, as described by Dreyfus and Dreyfus (1996), takes place in stages beginning at the novice level and progressing to the expert level of performance. Benner's (1984, 2004) application of this model to nursing practice is well known and often discussed with regard to new nurses' progression in clinical practice. This model is situation based; a function of the nurse's experience with a particular situation and his or her educational preparation. According to Benner (2004), clinical judgment comes from experiential learning based on specific cases “in a complex and undetermined field over time” (p. 189). Progression from novice to expert, although incremental, is not necessarily stepwise or linear. Notably, not all individuals are able progress to an expert level of skill attainment. The transition in role from RN to FNP may encompass more than skill acquisition alone. Recent researchers (Steiner et al., 2008) determined that RN-to-FNP transition is more complex than the novice-to-expert framework. For experienced RNs, this transition requires a “step backward in expertise” (Brown and Olshansky, 1998, p. 55) to a novice level of skill as beginning NPs. Roberts et al. (1997) theorized that some of the anxiety,
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stress, and discomfort of transition stemmed from the requirement for expert RNs to revert backwards. This step backwards can lead to role confusion or a sense of being in between roles, no longer an RN but not yet an NP. In Brown and Olshansky's (1997) study, some new NPs described themselves as imposters or fakes acting as “pretenders in their new role” (p. 49). This in-between period was said to be the most painful period of their first year of practice.
Transition Theory Transition theory (Schlossberg, 1981; 1984; Schlossberg, Waters, & Goodman, 1995) was developed based on research studies of adults in transition and provides a framework to study the transition process of adults. According to transition theory, all transitions in life, whether positive or negative and planned or unplanned, produce stress, and individuals cope with the stress of transition in varying ways (Schlossberg, 1984). There are multiple factors that can influence an individual's balance during transition including the situation itself, the individual's personal attributes, available support, and the individual's strategies for coping (Schlossberg et al., 1995). Transition theory views transition as having no end point. Adults are continuously experiencing transitions, and in the process, they leave behind one set of roles, relationships, routines, and assumptions and establish new ones (Goodman et al., 2006). Transition theory (Schlossberg et al., 1995) integrates the work of several theorists. These include Frederick Hudson (1991, 1999), who conceptualized transitions as a normal and inevitable part of living; Arnold Van Gennep (1960), an anthropologist who identified rites of passage as a process common to all societies; Helen Rose Ebaugh (1988), a sociologist who concentrated on endings or the process of leaving a role; Bloch and Richmond (1998), who focused on energy and hope used in situations of change or transition and, most notably, William Bridges (1980, 1988, 2004), who described a three-stage transition process. Bridges' (1988, 2004) three-stage transition process of endings, neutral zones, and beginnings is a cornerstone of Schlossberg's Transition Theory (Goodman et al., 2006). In Bridges' model, every transition begins with an ending. The individual in transition must recognize the significance of deidentifying with a previous role in order to make the transition toward a new identity. He or she then moves into the second phase or neutral zone, which is a time of confusion and stress. This is a period of leaving old roles, routines, and relationships and entering into new roles, routines, and relationships, which have yet to be established. The in-between period is distressing and challenging for all individuals in transition. It is only when the time of neutrality is finished that the third stage, beginnings, starts. This is a time of breaking up habits, patterns, routines, and roles and establishing new ones. According to Bridges (1980), career changes are the most common type of beginnings.
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Stages in Transition Theory Transition theory was developed as a framework for counselors, social workers, and psychologists to aid adults in coping with life's transition. Like Bridges' (1980) model, transition theory is a three-stage model for adults in transition (Goodman et al., 2006; Schlossberg et al., 1995). Transition theory uses the terms moving in, moving through, or moving out of the transition to identify the three distinct stages of the transition process. The significance and impact of the transition, as well as the ability to maintain balance varies over time depending on an individual's stage of transition. Applying the theoretical model of transition theory to the transition process begins with an individual making a determination about which stage (moving in, moving through, or moving out) he or she is in (Goodman et al., 2006). If at the moving in stage, then balance requires becoming familiar with new rules, regulations, expectations, and norms of behavior. Examples cited by the authors include transition into a new marriage, job, or educational environment. When adults in the new situation begin to learn the ropes, they are moving through transition and dealing with issues such as how to better balance the new situation with other parts of their lives (Goodman et al., 2006). Moving out is an ending of one series of transitions and an exploration of what comes next; this stage may be accompanied by grief. Schlossberg et al. (1995) cited changing jobs and returning to school as examples of “transitions in which adults mourn the loss of former goals, friends and structure” (p. 45). The letting go required to make the transition can cause unexpected feelings and unanticipated struggles with the new role.
Coping With Transition After an individual is guided to identify his or her stage of transition (moving in, moving through, or moving out), the next step is to identify resources for coping with the transition, termed taking stock, by using the four Ss (4 Ss) of situation, self, support, and strategies (Schlossberg et al., 1995). Through an assessment of the 4 Ss, (a) the situation itself, (b) one's own self characteristics, (c) available sources of support, and (d) strategies for coping, the individual in transition determines his or her assets and deficits for managing the current transition. According to transition theory, “No matter where one is in the transition process, no matter what the transition is, one deals with it differently depending on these 4 Ss ” (Schlossberg et al., 1995, p. 27). The 4 Ss are designed to assess assets and deficits for coping with situational transitions, relationship transitions, and personal transitions. The 4 Ss. The 4 Ss are described by Schlossberg et al. (1995) as follows: The first S, the situation, refers to what is happening and considers a number of following factors to be important: Trigger: Was there a trigger for this transition, or what set it off?
Timing: Is the transition happening at a good or bad time in the individual's life, and is it on time or off time in terms of that individual's social clock? Control: What aspects of the transition does the individual perceive as being controllable? Role change: Does this transition involve role change? Duration of the transition: Is this transition seen as temporary or permanent, or is the duration uncertain? Previous experiences with similar transitions: How did the individual cope with similar transitions? Was that effective, and what are the implications for this transition? Concurrent stress: Are there other stresses this individual is facing now, and if so, what is the extent of those stressors? Assessment of the transition: Does the individual view the current transition as positive, negative, or neutral? The second S, the self, refers to the individual to whom the transition is happening. Each individual's personal, cultural, and psychological factors are unique characteristics that comprise what that individual brings to the transition. The authors of transition theory identified two categories of factors in their model to describe the self. The first is personal and demographic characteristics and included gender, age, ethnicity, socioeconomic status, stage of life, and state of health. The second category is psychological resources and aids to coping that included ego development, outlook, commitment, optimism, and self-efficacy (Evans, Forney, & Guido-DiBrito, 1998; Schlossberg et al., 1995). Support, the third S, refers to what help is available and is composed of three factors: types, functions, and measurement. Support in this model refers to the types of social support available from the relationships of family, networks of friends, and institutions (Evans et al., 1998; Schlossberg et al., 1995). The functions of support are affection, affirmation, assistance, and honest feedback. Measurement of support takes place by identifying which sources of support are available. Strategies are the fourth S and refer to the ways in which a person copes. Strategies include tactics that modify the situation, control the meaning of the transition, and aid in managing stress. Strategies employ four modes of coping: seeking information, taking direct action, inhibiting or not taking action, and intrapsychic behavior (Schlossberg et al., 1995). According to Goodman et al. (2006), the first three modes in the model are self-explanatory, and the fourth, intrapsychic, refers to mechanisms that enable people to carry on such as denial, wishful thinking, and distortion. After taking stock utilizing the 4 Ss, the individual in transition is then prepared to take charge and strengthen his or her resources for coping with transition. Each individual's transition, even if it is the same kind of transition, will differ, and individuals will move through transitions differently. Thus, RNs in graduate school may each be in transition toward the FNP APN role, but their ability to successfully manage the transition will vary
EXPLORING RN-TO-FNP TRANSITION
depending on where they are in terms of progression in school, their 4 S factors, and their resources for taking charge of the transition process.
Application to FNP Transition Application of transition theory is illustrated by a presenting a hypothetical transition experience of two FNP students, Ms. A. and Mr. B. Although both students are in Phase 1 of RN-to-FNP transition graduate school, they are in different stages. Ms. A is in her first year of the program; she is in the moving in stage. Mr. B. is halfway through his clinical practicum courses; he is in the moving through stage. Each student utilized the 4 Ss to take stock of their graduate school transition. An application of taking stock of the first S, the situation, is portrayed in Table 2; each situation differs, which in turn may affect these FNP students' ability to maintain balance during transition. The other three Ss, self, support, and strategies are discussed below. Taking stock of the second S, the self, shows differences in personal and demographic characteristics. Ms. A. is female, age 25 years, of Asian ethnicity, single, upper middle-class socioeconomic status, young adult stage of life, and excellent state of health. In contrast, Mr. B is male, age 36 years, of Caucasian ethnicity, married, middle-class socioeconomic status, middle adult stage of life, and good state of health. Taking stock of support, the third S, reveals that Ms. A. has limited available social support. She relocated to a new city to attend graduate school, and her family is living in another city. Her network of friends is limited to a small group of coworkers; she has recently sought institutional support from the university by joining the graduate student nurses association. Mr. B. has lived in the same community all of his adult life. He has a strong social support network of family, friends, and colleagues. He is active in his church and finds this a source of institutional support. The fourth S, strategies, encompasses coping mechanisms of seeking information, taking direct action, inhibiting or not taking action, and intrapsychic behavior (Schlossberg et al., 1995). By taking stock, Ms. A. sees that she copes by not taking action and tends to engage in intrapsychic mechanisms of denial and wishful thinking. Mr. B. sees his coping mechanisms as seeking information and taking direct action. By completing this selfassessment of their assets and deficits for balancing transition, both hypothetical students are now better prepared to take charge and strengthen their resources for balancing transition.
Discussion NPs play a key role in providing care and have demonstrated their ability to increase access to costeffective, comprehensive, and high-quality care (American College of Nurse Practitioners, 2009). The shortage of providers and recent changes in the health care delivery system indicate a need for more NPs to provide
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primary care (Pohl, 2010). The increased demand requires that FNP students be able to function effectively in the APN role after graduation. FNPs have become important players in the health care system of the 21st century (Cronenwett & Dzau, 2010; Rich et al., 2001). While there are more new potential FNP primary care providers being educated, entry into practice must include navigating the gap between educational preparation and the primary care setting (Harrington, 2011). Neal (2008) also recognized that RN-to-FNP transition begins during graduate education. Her unpublished doctoral dissertation confirmed the work of other researchers’ findings (Heitz et al., 2004; Roberts et al., 1997) and brought to light the significance for practice. According to Neal (2008), if transition to the FNP role does not begin during graduate school then “the likelihood of pursuing the transition to practitioner following graduation is minimal” (p. 6). However, awareness precedes engagement. In order for FNP students to become actively engaged in making this transition, they must have awareness about the process. According to Kralik, Visentin, and van Loon (2006), once an individual is aware, the individual can then become “immersed in the transition process and undertake activities such as seeking information or support, modifying former activities, and making sense of the circumstances” (p. 323). FNP students may be unaware of the transition process and, thus, unable to engage or seek out productive ways to incorporate the changes and disruptions that RN-to-FNP transition may entail in their personal and professional lives during graduate school. Faculty could aid FNP students by raising awareness about the transition process and guiding them on how to better navigate and balance the transition (Kelly & Mathews, 2001). If FNP graduates fail to begin the role transition process during graduate education and do not transition into practice, the societal need for increased primary care providers will continue to go unmet
Conclusion In the literature reviewed for this article, transition is depicted as a part of life, and the capacity to balance transitions are dependent on multiple factors including the nature of the transition itself and the surrounding environment, an individual's personality, and available resources and supports (Goodman et al., 2006; Schlossberg et al., 1995). Regardless of the type of the transition, it is a process that takes place in phases and/or stages, occurs over time, and involves movement from one state to another (Bridges, 2004; Chick & Meleis, 1986; Schlossberg et al.). The concept of FNP role transition is not well researched. Development of a model based on additional research could aid in identifying key ideas about the transition from RN-toFNP APN practice. Transition theory (Schlossberg et al., 1995) may offer a framework for better understanding the stages and vulnerable points of each phase of the transition to FNP nursing practice in a more complete way. Applying Schlossberg et al.'s (1995) model of transition stages (moving in, moving through, and
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Table 2. Hypothetical Example of Transition Theory to RN-to-FNP Transition in Graduate School 4 Ss Situation Trigger: What prompted this transition?
Timing: Is this at a good or bad time in the individual's life? Control: What aspects are controllable?
Role change: Does this transition involve role change? Duration: Is this temporary, permanent, or uncertain duration? Previous experiences with similar transitions
Ms. A.
Mr. B.
Knew she wanted to become an FNP since finishing bachelor of science in nursing 3 years ago and current employer offers tuition assistance Good timing, single, no children, support, including some financial from family Studying and course work has led to loss of control over personal time. Living away from family has led to isolation and feeling that school is controlling her life. Graduate school transition involves role change.
Seeking opportunity for advancement and a new employer
Graduate school transition involves role change.
Graduate school is a temporary transition.
Graduate school is a temporary transition.
Past transitions included student role and transition from student to RN. Coped with support of family and friends.
Multiple past transitions including student role and transition to RN, marriage, and fatherhood. Coped with support of family and friends, regular exercise, and participation in “Men in Nursing” organization and in his church. Juggling family, work, and graduate school responsibilities. Wife works part time; both sets of grandparents live nearby and help with childcare. Feeling stressed but manageable. Current transition is positive.
Relocated to attend graduate school; recently broke off a long-term relationship. Would like to meet someone new; feeling stressed by demands of work and school and lonely.
Self-assessment of current transition: as positive, negative, or neutral?
Feeling that current transition will ultimately be positive, but right now, it is not.
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Concurrent stress: Other concurrent stresses and their extent
Timing is not ideal, married, two small children, needs to work full time to support family Careful planning and strict adherence to schedules aids with control of time and sense of control.
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moving out) to FNPs students' stages of program completion may be relevant for enhancing understanding of RN-to-FNP transition during Phase 1. Research with FNP student participants who are moving into graduate school, moving through courses, and moving out after graduation may provide new information. Additional knowledge of the stages of Phase 1 transition from the perspective of those experiencing it could assist faculty to better aid and support student transition during graduate school. This in turn may facilitate new FNPs entry into practice and perhaps decrease the postgraduate time required for transition and assuming the role of primary care provider.
References American College of Nurse Practitioners. (2009). What is a nurse practitioner? Retrieved from http://www.acnpweb.org/ files/public/What_is_a_Nurse_Practitioner.pdf. Barton, T. D. (2007). Student nurse practitioners-a rite of passage? The universality of Van Gennep's model of social transition. Nurse Education in Practice, 7, 338–347. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Benner, P. (2004). Using the Dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education. Bulletin of Science, Technology & Society, 24, 188–199, http://dx.doi.org/ 10.1177/0270467604265061. Bloch, D. P., & Richmond, L. J. (1998). Soul work: Finding the work you love, loving the work you have. Palo Alto, CA: Davies-Black. Bridges, W. (1980). Transitions: Making sense of life's changes. New York: Addison-Wesley. Bridges, W. (1988). Surviving corporate transition. Mill Valley, CA: William Bridges & Associates. Bridges, W. (2004). Transitions: Making sense of life's changes. (2nd ed.). Cambridge, MA: Da Capo Press. Brown, M. A., & Olshansky, E. (1997). From limbo to legitimacy: A theoretical model of the transition to primary care nurse practitioner role. Nursing Research, 46, 46–51. Brown, M. A., & Olshansky, E. (1998). Becoming a primary care nurse practitioner: Challenges of the initial year of practice. The Nurse Practitioner, 23, 46–66. Brykczynski, K. A. (2009). Role development of the advanced practice nurse. In A. B. Hamric, J. A. Spross, C. M. Hanson (Eds.). Advance practice nursing: An integrative approach. (4th ed., pp. 95–120). St. Louis, MO: Saunders/Elsevier. Chick, N., & Meleis, A. I. (1986). Transitions: A nursing concern. In P. L. Chinn (Ed.). Nursing research methodology: Issues and implementation. (pp. 237–257). Rockville, MD: Aspen. Cronenwett, L., & Dzau, V. (2010). Who will provide primary care and how will they be trained? Paper presented at the Josiah Macy, Jr. Foundation. Who will provide primary care and how will they be trained? Durham, N.C. Cusson, R. M., & Viggiano, N. M. (2002). Transition to the neonatal nurse practitioner role: Making the change from the side to the head of the bed. Neonatal Network, 21, 21–28. Dreyfus, H. L., & Dreyfus, S. E. (1996). The relationship of theory and practice in the acquisition of skill. In P. Benner, C. A. Tanner, C. A. Chesla (Eds.). Experience in nursing practice. New York: Springer Publishing Co.
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Ebaugh, H. R. F. (1988). Becoming an ex: The process of role exit. Chicago: The University of Chicago Press. Evans, N. J., Forney, D. S., & Guido-DiBrito, F. (1998). Student development in college. San Francisco: Jossey-Bass, Inc. Publishers. Forbes, V. J., & Jessup, A. L. (2004). From expert to novice: The unnerving transition from experienced RN to neophyte APN. Journal of Holistic Nursing, 22, 180–185. Goodman, J., Schlossberg, N. K., & Anderson, M. L. (2006). Counseling adults in transition: Linking practice with theory. (3rd ed.). New York: Springer Publishing Company, Inc. Harrington, S. (2011). Mentoring new nurse practitioners to accelerate their development as primary care providers: A literature review. Journal of the American Academy of Nurse Practitioners, 23, 168–174. Hayes, E. F. (2001). Factors that facilitate or hinder mentoring in the nurse practitioner preceptor/student relationship. Clinical Excellence for Nurse Practitioners: The International Journal of NPACE, 5, 111–118. Heitz, L. J., Steiner, S. H., & Burman, M. E. (2004). RN to FNP: A qualitative study of role transition. Journal of Nursing Education, 43, 416–420. Hudson, F. M. (1991). The adult years: Mastering the art of self-renewal. San Francisco: Josey-Bass. Hudson, F. M. (1999). The handbook of coaching: A comprehensive resource guide for managers, executives, consultants, and human resource professionals. San Francisco: Jossey-Bass. Kelly, N. R., & Mathews, M. (2001). The transition to first position as nurse practitioner. Journal of Nursing Education, 40, 156–162. Kralik, D., Visentin, K., & Van Loon, A. (2006). Transition: A literature review. Journal of Advanced Nursing, 55, 320–329. Levinson, D. J. (1986). A conception of adult development. American Psychologist, 41, 3–13. Meleis, A. I. (2007). Theoretical nursing: Development and progress (4th). Philadelphia: Lippincott. Meleis, A. I., Sawyer, L. M., Im, E., Messias, D. K. H., & Schumacher, K. (2000). Experiencing transitions: An emerging middle-range theory. Advances in Nursing Science, 23, 12–28. Neal, T. I. (2008). Mentoring, self-efficacy and nurse practitioner students: A modified replication. (Unpublished doctoral dissertation). Ball State University, Muncie, IN. Pohl, J. (2010). Unleashing nurse practitioners' full potential to address primary care needs of the nation. Paper presented at a Health Affairs Briefing: Reinventing Primary Care; May 4; Washington, DC. Rich, E. R., Jorden, M. E., & Taylor, C. J. (2001). Assessing successful entry into nurse practitioner practice: A literature review. Journal of the New York State Nurses Association, 32, 14–18. Roberts, S. J., Tabloski, P., & Bova, C. (1997). Epigenesis of the nurse practitioner role revisited. Journal of Nursing Education, 36, 67–73. Schlossberg, N. K. (1981). A model for analyzing human adaptation to transition. The Counseling Psychologist, 9(2), 2–18. Schlossberg, N. K. (1984). Counseling adults in transition. New York: Springer. Schlossberg, N. K., Waters, E. B., & Goodman, J. (1995). Counseling adults in transition: Linking practice with theory. (2nd.). New York: Springer Publishing Company, Inc. Schumacher, K. L., & Meleis, A. I. (1994). Transitions: A central concept in nursing. Image: Journal of Nursing Scholarship, 26, 119–127. Sloand, E. D., Feroli, K., Bearss, N., & Beecher, J. (1998). What's happening? Preparing the next generation: Precepting
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Steiner, S. H., McLaughlin, D. G., Hyde, R. S., Brown, R. H., & Burman, M. E. (2008). Role transition during RN-to-FNP education. Journal of Nursing Education, 47, 441–447. Van Gennep, A. (1960). The rites of passage. Chicago: The University of Chicago Press.
T
HE TRANSITION FROM registered nurse (RN) to family nurse practitioner (FNP) requires a change in role from providing patient care to prescribing patient care (Forbes & Jessup, 2004). This journey requires rigorous graduate level academic preparation, acquisition of new knowledge and skills, and major changes in function and scope of practice. Graduate nursing education can be a time of great inspiration and excitement, yet it is also a time of upheaval and challenge for students while they struggle to meet academic demands and begin to make the transition from RN to FNP.
Background Attainment of the FNP advanced practice nurse (APN) role evolves over time. The paradigm shift in role from RN to an APN has been depicted as “moving from the side of the bed to the head of the bed” (Cusson & Viggiano, 2002, p. 21). Although this change in role is dramatic, there is ∗Assistant Professor and Director of the Family Nurse Practitioner Program, Marcella Niehoff School of Nursing, Loyola University, Chicago, IL. Address correspondence to Dr. Poronsky: Loyola University Chicago, Marcella Niehoff School of Nursing, 2160 S. 1st Avenue, 125-4500, Maywood, IL 60153. E-mail: [email protected] 8755-7223/12/$ - see front matter 350 http://dx.doi.org/10.1016/j.profnurs.2012.10.011
limited information in the literature about the process of transition from RN to FNP (Spoelstra & Robbins, 2010). Information is even more limited with regard to transition during graduate education (Rich, Jorden, & Taylor, 2001; Steiner, McLaughlin, Hyde, Brown, & Burman, 2008). According to Heitz, Steiner, and Burman (2004) and Brykczynski (2009), transition is a two-phase process. Phase 1 begins upon entry to graduate school and continues through program completion and graduation. This period of learning the FNP role is termed acquisition (Brykczynski, 2009). Phase 2, the implementation phase (Brykczynski, 2009), begins after graduation when the new FNP moves into the workplace as an APN. Phase 2 lasts anywhere from 6 months to 2 years postgraduation (Brykczynski, 2009; Heitz et al., 2004). Kelly and Mathews (2001) suggested that new FNPs may lack awareness about the transition process, which in turn may lead to a longer role adjustment period, whereas an enhanced awareness could lead to a shorter adjustment period. New FNPs starting out in practice who have not progressed through Phase 1 of role transition during graduate school may be at risk for greater disconnectedness, isolation, and prolonged disequilibrium during Phase 2 of the transition process than those who began transition during graduate school.
Journal of Professional Nursing, Vol 29, No. 6 (November/December), 2013: pp 350–358 © 2013 Elsevier Inc. All rights reserved.
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Kelly and Matthews recommended that faculty in academic institutions educate FNP students about transition and actively facilitate the transitional process during graduate school. However, for faculty who seek to do this, there is very limited information in the literature about Phase 1 or of successful methods to facilitate RN-to-FNP transition. No recent studies were found that included the transition experience of FNP students during graduate education. Absent from the literature reviewed for this article was information about the steps that FNP students take to navigate acquisition of the APN role. This article aims to provide insight into the transition process and make recommendations for additional research. The findings presented here seek to add to the body of knowledge about RN-to-FNP transition.
Method Using the key words family nurse practitioner role transition, nurse practitioner students, graduate nursing education, and transition theories, the following electronic databases were searched: the Cumulative Index to Nursing and Applied Health Literature, Educational Resources Information Center, the medical index (Medline), ProQuest database of theses and dissertations, the Psychological Literature, and World Catalog from 1988 through 2011. The review of the literature included theses, dissertations, reviewed articles, and books in order to encompass a wide variety of theoretical and research literature.
Findings Transition in Adults Adults experience various types of transitions over the course of their lives including developmental, situational, and health-related transitions (Meleis, 2007). Theorists have described transitions in adulthood as turning points or interludes between two periods of stability (Bridges, 1988; Goodman, Schlossberg, & Anderson, 2006; Levinson, 1986). Theoretically, the process of transition requires an individual to let go of former roles, disconnect from previous social links and support, experience a loss of familiar reference points (objects or persons), integrate new knowledge, alter behavior, learn new roles, deal with new needs and/or the inability to meet old needs in familiar ways, make adjustments between former sets of expectations and those that exist in the new situation, and ultimately change his or her definition of self (Bridges, 2004; Meleis, Sawyer, Im, Messias, & Schumacher, 2000; Schlossberg, Waters, & Goodman, 1995). The changes and upheavals inherent with transition can bring about unwelcome feelings. For some individuals, the transition process can be frightening or traumatic (Goodman et al., 2006). The ensuing changes in patterns of behavior brought about by transition can include disorientation, distress, and anxiety, as well as elation and happiness (Chick & Meleis, 1986). This wide array of emotions can leave individuals feeling off balance.
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Transitions in Nursing Chick and Meleis (1986) identified three transitions relevant to nursing: situational, developmental, and health–illness. Situational transitions include professional and educational role transitions. Examples cited by Schumacher and Meleis (1994) include advancing from new graduate to staff nurse, making changes in practice settings or types of patients, and moving from clinician to administrator. Meleis et al. (2000) built on earlier work (Chick & Meleis, 1986; Schumacher & Meleis, 1994) to develop a middle range theory of transition. Using grounded theory methodology, Meleis et al. explored the transitions of pregnancy, motherhood, menopause, migration, and care giving in African American women and Korean and Brazilian immigrant women. They proposed a framework for exploring transition based on four types of transition: developmental, situational, health–illness, or organizational transition. Their framework used patterns and properties to develop nursing therapeutics and included facilitating and inhibiting factors that affect the transition process. Outcome indicators of a successful transition included by Meleis et al. were developing confidence and coping, feeling connected, and mastery. Although this work was carried out with the aim of expanding nursing therapeutics, an overarching goal was to generate a healthy response to transition. Meleis et al. concluded that each transition is a unique, multidimensional and complex experience and that more research is needed “to discover the levels and nature of vulnerability at different points during transitions” (p. 27).
FNP Transition The transition from an RN into an FNP APN role may generate anxiety, conflict, loss of confidence in clinical skills, and feelings of incompetence (Brykczynski, 2009). RN-to-FNP transition has been described as occurring either in stages or in phases; the work of several authors is presented in Table 1. In the literature reviewed, the terms phases and stages were not defined. According to the Encarta English Dictionary, a phase is a clearly distinguishable period in the development of something or in a sequence of events, whereas a stage is a step or level in the development or progress of something. Stages. Brown and Olshansky (1997) carried out a longitudinal grounded theory study of new nurse practitioner's (NP) role transition. They interviewed 35 novice NPs at 1 month, 6 months, and 12 months during their first year of practice. Transition was conceptualized by participants in their study as a four-stage process that begins with laying the foundation for NP practice. This first stage commenced after completing NP education and included preparing and sitting for the certification examination. Next, in the launching stage as new NPs began their APN career, many felt overwhelmed and as imposters in their new NP role. As time went on, these new NPs moved into the phase of meeting the challenge where feelings of anxiety lessened and an increase in
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This study laid the groundwork for research about NP role transition, which was conceptualized as moving from “limbo to legitimacy” during the first year of practice.
RN-to-FNP transition as separate phases occurring during specific time periods was new information.
Maintain peer support network, anticipate need for time to adjust to new role, positive self-talk, seek mentor support
Optimistic self-talk, accepting responsibility for self-learning and independence, networking with colleagues outside of work Development of a network of support people, including physicians, family, and patients Anticipatory guidance from faculty, use of case studies in the classroom, and clinical conferences. Roberts, Tabloski, Qualitative and Bova (1997)
Kelly and Matthews Qualitative (2001)
Qualitative Heitz, Steiner, and Burman (2004)
Brown and Qualitative Olshansky (1997)
35 Novice NPs
Four stages: Laying the foundation, launching, meeting the challenge, broadening the perspective
Anxiety, role confusion, stress, insecurity during the first two stages. Stages 3 had ↓ anxiety, ↑ competence and confidence and, 4, a solid feeling of competence and legitimacy Phase 1: Need to let go of the 9 NPs who had Two phases: Phase RN role, sense of loss Phase 2: graduated within 1 = graduate school, self-doubt, apprehension, emotional the past 5 years Phase 2 at start of turmoil re: independent role FNP employment 21 FNPs who had Study focused on Feelings of anxiety, distress, graduated within Phase 2 isolation, and sense of the past 1–7 years disconnection Initial stages: Loss of 100 NP students Four stages: Complete confidence, role confusion dependence, developing competence, independence, and anxiety. Stages 3 and 4: Increasing confidence, and interdependence competency→role acquisition
State of disequilibrium continued years after graduation.
Significance of findings Strategies for coping Associated characteristics Phases/Stages Participants n Type of study Citation
Table 1. RN-to-FNP Transition Stages and Phases
Students were most stressed at the end of their first clinical practicum. Role acquisition includes appreciation of interdependence of nursing and medicine.
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confidence developed. The final stage was broadening the perspective, where many now had a sense of legitimacy in the NP role and competence in their skills. Roberts, Tabloski, and Bova (1997) described an identity crisis of NP students that occurred in four stages. Roberts et al. presented their findings not as the result of a formal research project but as a description of their observations and review of more than 100 NP students' clinical journals. Roberts et al. described the first stage as one of complete dependence, accompanied by a feeling of incompetence when NP students started clinical practicum courses. During the second stage, developing competence, students experienced role confusion with regard to their identity as nurses. As they progressed in clinical courses, they moved onto the third stage of independence. The third stage was accompanied by anxiety due to the growing awareness about the responsibilities and limitations of being a primary care provider. In the fourth and final stage, clinical practice was more independent, and although anxiety was still present, it was to a lesser degree than in Stage 3. The final stage was described as interdependence, a stage of awareness that APN practice was entwined with other professions and patients. Roberts et al.'s (1997) student participants were limited to those in clinical practicum courses. Students in other stages of their educational program were not included in their observations. Phases. Heitz, Steiner, and Burman (2004) explored RN-to-FNP transition from the perspective of recent FNP graduates. They interviewed nine practicing FNPs who had graduated within the past 5 years and asked them to reflect back on their transition. Participants described two distinct phases of transition: Phase 1 occurred during graduate school and Phase 2 began after graduation and at the start of employment as an FNP. Heitz et al. (2004) were the first to describe RN-to-FNP transition as separate phases or periods of development occurring during specific time periods. Participants in Heitz et al.'s study indicated that each phase presented different challenges. During Phase 1 in graduate school, participants recalled that while acquiring new knowledge to become an FNP, there was a simultaneous realization of the need to let go of the RN role. This produced a feeling of loss that was accompanied by a sense of “bouncing back and forth between nursing and FNP [roles]” (Heitz et al., 2004, p. 417). The necessity to switch back and forth between roles was more difficult for those with greater RN experience than for the one study participant who went directly from her undergraduate education into graduate school. Limited information is available regarding the transition experience of graduate students (Rich et al., 2001; Steiner et al., 2008); no additional information regarding Phase 1 was found in the literature reviewed for this article. More information was available about Phase 2. In addition to Heitz et al. (2004), multiple authors revealed that when a new FNP accepted the first job as an APN,
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they experienced a turbulent and stressful period (Barton, 2007; Cusson & Viggiano, 2002; Hayes, 2001; Sloand, Feroli, Bearss, & Beecher, 1998). In addition, Heitz et al.'s participants experienced feelings of self-doubt, apprehension, and emotional turmoil with regard to their new independent role responsibilities. Kelly and Mathews (2001) also explored Phase 2 of RN-to-FNP transition. They used focus groups with 21 practicing FNPs who had graduated in the past 1– 7 years. In addition to anxiety and distress, participants in their study experienced feeling disconnected and isolated while making the transition into APN practice. Unfortunately, some new FNPs continued to perceive themselves in a state of disequilibrium many years after graduation.
Exploring Transition The transition process for RN to FNP has been described as a multiphase and a multistage process (Brown & Olshansky, 1997; Heitz et al., 2004; Kelly & Mathews, 2001; Roberts et al., 1997). Several researchers described Phase 2 as a turbulent and stressful period (Cusson & Viggiano, 2002; Hayes, 2001; Sloand et al., 1998). With the exception of Roberts et al. (1997) who observed NP students' stages or steps in skill acquisition in the clinical setting, little is known about the experience of FNP students during graduate school. In order to aid FNP students with Phase 1 of transition, more information is needed. Information about what Meleis et al. (2000) termed as the vulnerable points during transition is not available and warrants additional research. The literature examined for this article included theoretical frameworks for exploring transition, and two are presented here.
Skill Acquisition The process of knowledge and skill acquisition, as described by Dreyfus and Dreyfus (1996), takes place in stages beginning at the novice level and progressing to the expert level of performance. Benner's (1984, 2004) application of this model to nursing practice is well known and often discussed with regard to new nurses' progression in clinical practice. This model is situation based; a function of the nurse's experience with a particular situation and his or her educational preparation. According to Benner (2004), clinical judgment comes from experiential learning based on specific cases “in a complex and undetermined field over time” (p. 189). Progression from novice to expert, although incremental, is not necessarily stepwise or linear. Notably, not all individuals are able progress to an expert level of skill attainment. The transition in role from RN to FNP may encompass more than skill acquisition alone. Recent researchers (Steiner et al., 2008) determined that RN-to-FNP transition is more complex than the novice-to-expert framework. For experienced RNs, this transition requires a “step backward in expertise” (Brown and Olshansky, 1998, p. 55) to a novice level of skill as beginning NPs. Roberts et al. (1997) theorized that some of the anxiety,
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stress, and discomfort of transition stemmed from the requirement for expert RNs to revert backwards. This step backwards can lead to role confusion or a sense of being in between roles, no longer an RN but not yet an NP. In Brown and Olshansky's (1997) study, some new NPs described themselves as imposters or fakes acting as “pretenders in their new role” (p. 49). This in-between period was said to be the most painful period of their first year of practice.
Transition Theory Transition theory (Schlossberg, 1981; 1984; Schlossberg, Waters, & Goodman, 1995) was developed based on research studies of adults in transition and provides a framework to study the transition process of adults. According to transition theory, all transitions in life, whether positive or negative and planned or unplanned, produce stress, and individuals cope with the stress of transition in varying ways (Schlossberg, 1984). There are multiple factors that can influence an individual's balance during transition including the situation itself, the individual's personal attributes, available support, and the individual's strategies for coping (Schlossberg et al., 1995). Transition theory views transition as having no end point. Adults are continuously experiencing transitions, and in the process, they leave behind one set of roles, relationships, routines, and assumptions and establish new ones (Goodman et al., 2006). Transition theory (Schlossberg et al., 1995) integrates the work of several theorists. These include Frederick Hudson (1991, 1999), who conceptualized transitions as a normal and inevitable part of living; Arnold Van Gennep (1960), an anthropologist who identified rites of passage as a process common to all societies; Helen Rose Ebaugh (1988), a sociologist who concentrated on endings or the process of leaving a role; Bloch and Richmond (1998), who focused on energy and hope used in situations of change or transition and, most notably, William Bridges (1980, 1988, 2004), who described a three-stage transition process. Bridges' (1988, 2004) three-stage transition process of endings, neutral zones, and beginnings is a cornerstone of Schlossberg's Transition Theory (Goodman et al., 2006). In Bridges' model, every transition begins with an ending. The individual in transition must recognize the significance of deidentifying with a previous role in order to make the transition toward a new identity. He or she then moves into the second phase or neutral zone, which is a time of confusion and stress. This is a period of leaving old roles, routines, and relationships and entering into new roles, routines, and relationships, which have yet to be established. The in-between period is distressing and challenging for all individuals in transition. It is only when the time of neutrality is finished that the third stage, beginnings, starts. This is a time of breaking up habits, patterns, routines, and roles and establishing new ones. According to Bridges (1980), career changes are the most common type of beginnings.
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Stages in Transition Theory Transition theory was developed as a framework for counselors, social workers, and psychologists to aid adults in coping with life's transition. Like Bridges' (1980) model, transition theory is a three-stage model for adults in transition (Goodman et al., 2006; Schlossberg et al., 1995). Transition theory uses the terms moving in, moving through, or moving out of the transition to identify the three distinct stages of the transition process. The significance and impact of the transition, as well as the ability to maintain balance varies over time depending on an individual's stage of transition. Applying the theoretical model of transition theory to the transition process begins with an individual making a determination about which stage (moving in, moving through, or moving out) he or she is in (Goodman et al., 2006). If at the moving in stage, then balance requires becoming familiar with new rules, regulations, expectations, and norms of behavior. Examples cited by the authors include transition into a new marriage, job, or educational environment. When adults in the new situation begin to learn the ropes, they are moving through transition and dealing with issues such as how to better balance the new situation with other parts of their lives (Goodman et al., 2006). Moving out is an ending of one series of transitions and an exploration of what comes next; this stage may be accompanied by grief. Schlossberg et al. (1995) cited changing jobs and returning to school as examples of “transitions in which adults mourn the loss of former goals, friends and structure” (p. 45). The letting go required to make the transition can cause unexpected feelings and unanticipated struggles with the new role.
Coping With Transition After an individual is guided to identify his or her stage of transition (moving in, moving through, or moving out), the next step is to identify resources for coping with the transition, termed taking stock, by using the four Ss (4 Ss) of situation, self, support, and strategies (Schlossberg et al., 1995). Through an assessment of the 4 Ss, (a) the situation itself, (b) one's own self characteristics, (c) available sources of support, and (d) strategies for coping, the individual in transition determines his or her assets and deficits for managing the current transition. According to transition theory, “No matter where one is in the transition process, no matter what the transition is, one deals with it differently depending on these 4 Ss ” (Schlossberg et al., 1995, p. 27). The 4 Ss are designed to assess assets and deficits for coping with situational transitions, relationship transitions, and personal transitions. The 4 Ss. The 4 Ss are described by Schlossberg et al. (1995) as follows: The first S, the situation, refers to what is happening and considers a number of following factors to be important: Trigger: Was there a trigger for this transition, or what set it off?
Timing: Is the transition happening at a good or bad time in the individual's life, and is it on time or off time in terms of that individual's social clock? Control: What aspects of the transition does the individual perceive as being controllable? Role change: Does this transition involve role change? Duration of the transition: Is this transition seen as temporary or permanent, or is the duration uncertain? Previous experiences with similar transitions: How did the individual cope with similar transitions? Was that effective, and what are the implications for this transition? Concurrent stress: Are there other stresses this individual is facing now, and if so, what is the extent of those stressors? Assessment of the transition: Does the individual view the current transition as positive, negative, or neutral? The second S, the self, refers to the individual to whom the transition is happening. Each individual's personal, cultural, and psychological factors are unique characteristics that comprise what that individual brings to the transition. The authors of transition theory identified two categories of factors in their model to describe the self. The first is personal and demographic characteristics and included gender, age, ethnicity, socioeconomic status, stage of life, and state of health. The second category is psychological resources and aids to coping that included ego development, outlook, commitment, optimism, and self-efficacy (Evans, Forney, & Guido-DiBrito, 1998; Schlossberg et al., 1995). Support, the third S, refers to what help is available and is composed of three factors: types, functions, and measurement. Support in this model refers to the types of social support available from the relationships of family, networks of friends, and institutions (Evans et al., 1998; Schlossberg et al., 1995). The functions of support are affection, affirmation, assistance, and honest feedback. Measurement of support takes place by identifying which sources of support are available. Strategies are the fourth S and refer to the ways in which a person copes. Strategies include tactics that modify the situation, control the meaning of the transition, and aid in managing stress. Strategies employ four modes of coping: seeking information, taking direct action, inhibiting or not taking action, and intrapsychic behavior (Schlossberg et al., 1995). According to Goodman et al. (2006), the first three modes in the model are self-explanatory, and the fourth, intrapsychic, refers to mechanisms that enable people to carry on such as denial, wishful thinking, and distortion. After taking stock utilizing the 4 Ss, the individual in transition is then prepared to take charge and strengthen his or her resources for coping with transition. Each individual's transition, even if it is the same kind of transition, will differ, and individuals will move through transitions differently. Thus, RNs in graduate school may each be in transition toward the FNP APN role, but their ability to successfully manage the transition will vary
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depending on where they are in terms of progression in school, their 4 S factors, and their resources for taking charge of the transition process.
Application to FNP Transition Application of transition theory is illustrated by a presenting a hypothetical transition experience of two FNP students, Ms. A. and Mr. B. Although both students are in Phase 1 of RN-to-FNP transition graduate school, they are in different stages. Ms. A is in her first year of the program; she is in the moving in stage. Mr. B. is halfway through his clinical practicum courses; he is in the moving through stage. Each student utilized the 4 Ss to take stock of their graduate school transition. An application of taking stock of the first S, the situation, is portrayed in Table 2; each situation differs, which in turn may affect these FNP students' ability to maintain balance during transition. The other three Ss, self, support, and strategies are discussed below. Taking stock of the second S, the self, shows differences in personal and demographic characteristics. Ms. A. is female, age 25 years, of Asian ethnicity, single, upper middle-class socioeconomic status, young adult stage of life, and excellent state of health. In contrast, Mr. B is male, age 36 years, of Caucasian ethnicity, married, middle-class socioeconomic status, middle adult stage of life, and good state of health. Taking stock of support, the third S, reveals that Ms. A. has limited available social support. She relocated to a new city to attend graduate school, and her family is living in another city. Her network of friends is limited to a small group of coworkers; she has recently sought institutional support from the university by joining the graduate student nurses association. Mr. B. has lived in the same community all of his adult life. He has a strong social support network of family, friends, and colleagues. He is active in his church and finds this a source of institutional support. The fourth S, strategies, encompasses coping mechanisms of seeking information, taking direct action, inhibiting or not taking action, and intrapsychic behavior (Schlossberg et al., 1995). By taking stock, Ms. A. sees that she copes by not taking action and tends to engage in intrapsychic mechanisms of denial and wishful thinking. Mr. B. sees his coping mechanisms as seeking information and taking direct action. By completing this selfassessment of their assets and deficits for balancing transition, both hypothetical students are now better prepared to take charge and strengthen their resources for balancing transition.
Discussion NPs play a key role in providing care and have demonstrated their ability to increase access to costeffective, comprehensive, and high-quality care (American College of Nurse Practitioners, 2009). The shortage of providers and recent changes in the health care delivery system indicate a need for more NPs to provide
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primary care (Pohl, 2010). The increased demand requires that FNP students be able to function effectively in the APN role after graduation. FNPs have become important players in the health care system of the 21st century (Cronenwett & Dzau, 2010; Rich et al., 2001). While there are more new potential FNP primary care providers being educated, entry into practice must include navigating the gap between educational preparation and the primary care setting (Harrington, 2011). Neal (2008) also recognized that RN-to-FNP transition begins during graduate education. Her unpublished doctoral dissertation confirmed the work of other researchers’ findings (Heitz et al., 2004; Roberts et al., 1997) and brought to light the significance for practice. According to Neal (2008), if transition to the FNP role does not begin during graduate school then “the likelihood of pursuing the transition to practitioner following graduation is minimal” (p. 6). However, awareness precedes engagement. In order for FNP students to become actively engaged in making this transition, they must have awareness about the process. According to Kralik, Visentin, and van Loon (2006), once an individual is aware, the individual can then become “immersed in the transition process and undertake activities such as seeking information or support, modifying former activities, and making sense of the circumstances” (p. 323). FNP students may be unaware of the transition process and, thus, unable to engage or seek out productive ways to incorporate the changes and disruptions that RN-to-FNP transition may entail in their personal and professional lives during graduate school. Faculty could aid FNP students by raising awareness about the transition process and guiding them on how to better navigate and balance the transition (Kelly & Mathews, 2001). If FNP graduates fail to begin the role transition process during graduate education and do not transition into practice, the societal need for increased primary care providers will continue to go unmet
Conclusion In the literature reviewed for this article, transition is depicted as a part of life, and the capacity to balance transitions are dependent on multiple factors including the nature of the transition itself and the surrounding environment, an individual's personality, and available resources and supports (Goodman et al., 2006; Schlossberg et al., 1995). Regardless of the type of the transition, it is a process that takes place in phases and/or stages, occurs over time, and involves movement from one state to another (Bridges, 2004; Chick & Meleis, 1986; Schlossberg et al.). The concept of FNP role transition is not well researched. Development of a model based on additional research could aid in identifying key ideas about the transition from RN-toFNP APN practice. Transition theory (Schlossberg et al., 1995) may offer a framework for better understanding the stages and vulnerable points of each phase of the transition to FNP nursing practice in a more complete way. Applying Schlossberg et al.'s (1995) model of transition stages (moving in, moving through, and
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Table 2. Hypothetical Example of Transition Theory to RN-to-FNP Transition in Graduate School 4 Ss Situation Trigger: What prompted this transition?
Timing: Is this at a good or bad time in the individual's life? Control: What aspects are controllable?
Role change: Does this transition involve role change? Duration: Is this temporary, permanent, or uncertain duration? Previous experiences with similar transitions
Ms. A.
Mr. B.
Knew she wanted to become an FNP since finishing bachelor of science in nursing 3 years ago and current employer offers tuition assistance Good timing, single, no children, support, including some financial from family Studying and course work has led to loss of control over personal time. Living away from family has led to isolation and feeling that school is controlling her life. Graduate school transition involves role change.
Seeking opportunity for advancement and a new employer
Graduate school transition involves role change.
Graduate school is a temporary transition.
Graduate school is a temporary transition.
Past transitions included student role and transition from student to RN. Coped with support of family and friends.
Multiple past transitions including student role and transition to RN, marriage, and fatherhood. Coped with support of family and friends, regular exercise, and participation in “Men in Nursing” organization and in his church. Juggling family, work, and graduate school responsibilities. Wife works part time; both sets of grandparents live nearby and help with childcare. Feeling stressed but manageable. Current transition is positive.
Relocated to attend graduate school; recently broke off a long-term relationship. Would like to meet someone new; feeling stressed by demands of work and school and lonely.
Self-assessment of current transition: as positive, negative, or neutral?
Feeling that current transition will ultimately be positive, but right now, it is not.
CATHLIN BUCKINGHAM PORONSKY
Concurrent stress: Other concurrent stresses and their extent
Timing is not ideal, married, two small children, needs to work full time to support family Careful planning and strict adherence to schedules aids with control of time and sense of control.
EXPLORING RN-TO-FNP TRANSITION
moving out) to FNPs students' stages of program completion may be relevant for enhancing understanding of RN-to-FNP transition during Phase 1. Research with FNP student participants who are moving into graduate school, moving through courses, and moving out after graduation may provide new information. Additional knowledge of the stages of Phase 1 transition from the perspective of those experiencing it could assist faculty to better aid and support student transition during graduate school. This in turn may facilitate new FNPs entry into practice and perhaps decrease the postgraduate time required for transition and assuming the role of primary care provider.
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