ORIGINAL RESEARCH
Nurse practitioner graduates “Speak Out” about the adequacy of their educational preparation to care for older adults: A qualitative study Jacqueline Jones, PhD, RN, FRCNA (Associate Professor)1 , Ernestine Kotthoff-Burrell, PhD, RN, ANP-BC, FAANP (Assistant Professor)1 , Jane Kass-Wolff, PhD, RN, FNP-BC, WHNP-BC (Associate Professor)1 , & Vicki Brownrigg, PhD, RN, FNP-BC (Assistant Professor)2 1 2
College of Nursing, University of Colorado Denver, Aurora, Colorado Beth El College of Nursing & Health Sciences, Colorado Springs, Colorado
Keywords Advanced practice nurse (APN); education; curriculum; nurse practitioners; older adult. Correspondence Ernestine Kotthoff-Burrell, PhD, College of Nursing, University of Colorado Denver, 13120 E. 19th Ave., Mail Stop C-288-19, Aurora, CO 80045. Tel: 303-724-8565; Fax: 303-724 8560; E-mail: ernestine.kotthoff-burrell@ ucdenver.edu Received: 18 February 2014; accepted: 23 May 2014 doi: 10.1002/2327-6924.12230
Abstract Purpose: With a shortage of primary care providers prepared to care for an aging U.S. population, nurse practitioner (NP) programs are integrating gerontological content. This qualitative descriptive study explored NP graduate perceptions on the adequacy of their education to prepare them to care for seniors. Methods: Twenty-three graduates of NP program options at two universities in the western U.S. participated in focus group discussions or interviews. Participants shared their perceptions of their NP educational preparation and suggestions for enhancing gerontologic curriculum. Conclusions: Four main domains emerged from analysis of qualitative data: (a) “Getting your boots on and getting into the role”; (b) “Older people are more complex than we were prepared to care for”; (c) “It is very different as a provider, but I am so glad I was a nurse with experience first”; (d) “NPs have a scope of practice, physician assistants (PAs) have a job description-but I wish we had their [procedural] preparation.” Implications for practice: Graduates identified a need for more educational content and clinical experiences specific to the care of older adults. Some suggested a postgraduate residency or mentoring option to assist NP role transition and progression and limit role confusion.
Introduction By the year 2030, the population of adults aged 65 and above is expected to grow from 12% of the total U.S. population to 20% (Administration on Aging [AoA], 2008). In January 2011, the first of the “Baby Boomers” (1946–1965) began to reach the threshold of older age. This demographic shift poses new demands for providers with expertise to address health and social problems of aging adults (Auerhahn, Mezey, Stanley, & Dodge, 2012). These demands include complex primary healthcare needs, multiple comorbid health problems, and polypharmacy (AoA, 2008). Many older adults receive primary care from nurse practitioners (NPs) in clinics and other settings. This trend will continue with the current and projected shortage of primary care physician providers (American College of Physicians, 2009; Auerhahn, Mezey, 698
Stanley, & Dodge, 2012; Institute of Medicine [IOM], 2008; Steinwald, 2008). In 2008, the IOM reported on the need to revamp professional education with respect to caring for older adults. National professional organizations such as the American Association of Colleges of Nursing [AACN] noted that enrollment in geriatric NP (GNP) programs was disappointingly low, particularly in light of the anticipated growth of older adults. Additionally, certified GNPs comprised only 2.6% of all NPs in the United States (American Nurses Credentialing Center [ANCC], 2009; Pearson, 2009). In 2010, the AACN, together with the John A. Hartford Foundation (JAHF) and the National Organization of Nurse Practitioner Faculty (NONPF), revised and updated competencies for preparing students to care for older adults. AACN recommended the closure of “stand alone” GNP programs and the integration of gerontological curriculum Journal of the American Association of Nurse Practitioners 27 (2015) 698–706 C 2015 American Association of Nurse Practitioners
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into adult NP options, creating Adult Gerontological Nurse Practitioner (AGNP) programs.
Overview In 2010, two graduate nursing programs in the western United States were awarded a grant from the United States Department of Health and Human Services to review and revise curriculum for selected NP program options. The two programs were administered at two universities within the same parent educational system. Both programs provided the adult (ANP) and family NP (FNP) options. One of the universities offered a Women’s Health Care option (WHCNP). Details of the five options at the two university programs have been previously described (Kass-Wolff, Kotthoff-Burrell, & Smith, 2012). Graduates from three NP options across the two universities (adult, family, and women’s health practitioner) were evaluated. The purpose of the initiative was to implement curricula that met the revised core competencies for the care of the older adult. All graduates of the APRN options would be prepared to competently care for older adults in their respective population foci. In addition, the combined AGNP options would be eligible to successfully complete the new AGNP certification examination when it became available.
Purpose/aims One grant objective was to explore the experiences of graduates who had completed one of the three options from either institution within the past 5 years. The number of gerontological NPs who had completed the option was small across both university programs so all previous graduates of the five options were invited to participate in the focus groups to assess their preparation to care for older adults within their population foci. The aims of this study were to (a) describe the success and limitations of NP programs in preparing graduates to care for older adults, and (b) identify strategies and direction to enhance gerontologic curriculum in NP programs.
Methods A naturalistic approach to inquiry was used, applying broad constructivist principles to guide this qualitative descriptive study (Sandelowski, 2000). Within this approach, multiple realities and truths are assumed. These result in a text that is historically, culturally, and socially constructed, cocreated by participants and the investigator (Mayan, 2009). All NP graduates (2006–2011) from the adult, family, or women’s health NP courses from both institutions were asked to participate. A moratorium had been placed on admissions to the GNP program as a stand-alone op-
tion several years prior to this grant award. However, some graduates of the GNP option were eligible for study participation. The invitation letter was sent by e-mail on three occasions. Interested graduates were asked to contact the research team. Group discussions were offered at multiple times over an initial 2-week period. One of the NP programs was conducted online and therefore a synchronous webinar format was used for group discussions. Individual telephone interviews were offered to participants when group attendance was not feasible or desired. A total of 280 NP graduates were eligible. This represented the total population for all three NP options at the two institutions, as well as graduates from the standalone GNP program. There were no additional inclusion criteria. Faculty who participated in the education of the graduates was not involved in recruitment or data collection. Approval for the project was granted from the Institutional Review Boards of both institutions. Informed consent included the completion of a demographic questionnaire and digital recording of the group or individual interviews for textual analysis. A semistructured interview guide was developed from both a review of the literature as well as discussions with faculty experts in NP education. These questions were used to focus individual and group discussions around key areas of role preparation as an NP in general and specifically to provide care to older adults. The following questions prompted reflection and discussion: ■
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How well prepared were you for your role as an NP? What was your first appointment or job? How well prepared were you as an NP to care for older adults? What specific aspects of care and context are important in your role? How ill-prepared were you for your role to care for older adults? What strategies did you use to get up to speed? What improvements could you suggest to your preparation? What would you do differently?
A virtual group process was created in order to enhance participation of NP graduates across the United States for this study (Barbour, 2007). The process was used to build a comprehensive awareness of the nuances of NP preparation in general and specifically with regards to caring for older adults across programs and specialties. This understanding was achieved by iteratively reflecting on the previous group or individual interview discussions to supplement probes and discussions within those that followed. The principal investigator (PI), an experienced qualitative researcher, and the research assistant (RA) collected field notes during the focus groups to capture nonverbal cues, ideas, and perceptions related to the discussion. The PI conducted all one-on-one telephone 699
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interviews and collected field notes related to idea building and iterative contextual connections between interviewees. Digital recordings were subsequently professionally transcribed verbatim. Trustworthiness is the gold standard for qualitative rigor (Beck, 1993). As such, to enhance the authenticity, fittingness, “fitness and credibility of the research findings,” a reflexive journal was maintained by the PI. Debriefing occurred with the RA and team following each focus group, and between interviews. Early analysis and findings were presented to the participants for member checking (Creswell 2012; Koch & Harrington, 1998).
Data analysis A general inductive approach to theme analysis (Creswell, 2012; Thomas, 2006) was applied to the textual data to explore the experience of NP preparation and the realities of NP practice. Analysis focused on the NP role in general, followed by specific aspects related to care of older adults. It was important to remain open to new and unexpected occurrences beyond the interview framework. Data immersion, systematic line-by-line reading of the transcripts, and clustering of similar fragments of information formed the initial analytic steps. Commonalities and differences were noted and broad domains identified within and across group discussions and individual interviews and linked to subthemes. Core meanings related to the research aims are described in terms of the most important themes that emerged (Thomas, 2006).
Results Graduates (n = 23) agreed to interviews in either a group or individual setting. Two onsite focus groups, attended by nine NPs, and 13 one-on-one telephone interviews were completed, producing 7325 lines of transcribed text. One further participant responded by e-mail to research questions and those responses were included. Participant characteristics are presented in Table 1. Four major domains were identified around which graduate experiences and concerns clustered. Participant language illustrated domain themes, to keep as close as possible to the expressions offered of practice. Each domain was described in a narrative style using subthemes and exemplar text. Table 2 highlights NP option participant exemplars for each domain.
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general and specifically in caring for older adults. They shared feelings that this role change brought to their identity as an NP “It’s not that we are not prepared for the role; it’s more not being prepared for a first job.” More than one participant expressed that they “can’t be prepared for every content area; [there is] just too much.” Thus, while the program prepared them as much as possible for being an NP, for some “not as much as [they] had hoped,” graduates expressed concern that adding more content to an already extensive, content-heavy course would not facilitate transition to the context of contemporary NP practice. The three program options emphasized different facets of NP specialty content. Yet, graduates were offered and accepted employment as an NP in a variety of settings despite not being educated specifically for that setting. There was an overwhelming sense that the program equipped them with critical thinking skills, but there was a “need to be prepared to hit the ground running and learn.” The desire to be ready to transition and function competently after graduation was strong. Suggestions about what would assist in the transition included some form of residency program for NPs. Participants said a “residency program would be perfect: if we got paid even better.” Other aspects graduates identified included more information about administrative and systems elements: contract negotiation and coding for reimbursement purposes. New graduate NPs who were able to establish mentor relationships found them vital to successful NP role integration and progression. Mentors were identified through clinical relationships prior to the course, during clinical placement, or during their first employed position as an NP. Frequently, these mentors were physicians associated with the practice; only occasionally were mentors NPs. Mentors could be a “sounding board” or give advice on clinical reasoning or differential diagnosis on site or by telephone. Graduates across all options who were more established (more than 1–2 years’ experience as an NP) often said they would like to mentor new NPs in their population foci, but had not been contacted to do so. In order to function and get up to speed in their NP role, graduates reported using technology, including smartphones, Epocrates, and UpToDate, to access information and provide decision support on a daily basis. Some participants had completed onsite training, external courses, and certification to fill the gaps between their NP course preparation and the clinical context of their NP practice with older adults.
Domain 1: “Getting your boots on and getting into the role”
Domain 2: “Older people are more complex than we were prepared for”
Graduates spoke of their initial feelings of being unprepared for the diversity of their new role, as a provider in
Participants had a range of prior experience working with older adults (e.g., nursing home care) and some
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Table 1 Demographic data (n = 23) Characteristic Years since graduation with BSN
Previous nursing experience with older adults NP program completed
Years since graduating with NP
NP programs Years practicing as an APN
Current position
Percentage of geriatric patients in current setting
Years worked in current role/position
National certifications held (self-reported)
Gender Age
Categories
N (%)
More than 3, but less than 6 years More than 6 and less than 9 years 9–12 years 13–16 years 17–20 years More than 20 years Yes No ANP GNP ANP and GNP WH FNP Less than 1 year More than 1 and less than 2 years 2–3 years More than 3 years NP program no. 1 NP program no. 2 Less than 1 year More than 1 and less than 2 years 2–3 years 4–5 years Over 5 years Primary health care in ambulatory setting Primary care in a long-term care setting Primary care in a private medical practice Acute/hospital Other specialty practice 20% or less
6 (26) 7 (30) 8 (35) 1 (4) 1 (4) 0 18 (78) 4 (17) 1 (4) 3 (13) 2 (9) 1 (4) 16 (70) 4 (17) 7 (30) 5 (22) 7 (30) 11 (49) 12 (52) 8 (35) 3 (13) 3 (13) 4 (30) 2 (9) 5 (22) 3 (13) 5 (22) 2 (9) 9 (39) 7 (30)
21%–40% 41%–60% 61%–80% 81% and above Unanswered Less than 1 year More than 1 and less than 2 years 2–3 years More than 3 years ANCC AANP FNP GNP ANP-BC Other Female Male Mean age: Age range:
4 (17) 4 (17) 3 (13) 4 (17) 1 (4) 7 (30) 4 (17) 10 (43) 2 (9) 6 (26) 6 (26) 6 (26) 2 (9) 2 (9) 9 (39) 13 (78) 5 (22) 40.6 years old 28–59 years old
BSN, bachelor of science in Nursing; AANP, American Academy of Nurse Practitioners; ANP-BC, advanced practice nurse–board certified.
had additional geriatric intensive coursework. Yet, all were unanimous in expressing that they were not adequately prepared for the complexity of the comorbidities experienced by older adults or the acuity of older adults
seeking care in primary care clinics. They described the challenges of trying to prescribe for patients who may be on 20–30 medications when drug “interactions can be a nightmare.” While overall, they felt they had beneficial 701
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Table 2 Illustrative quotes Domain
FNP exemplar
ANP exemplar
(1) “Getting your boots on and getting into the role”
“ . . . giving nurse practitioners some of those survival skills to make it as a new grad . . . It really takes confidence and the ability to stand tall every day, to really make it in that environment” (no. 14)
(2) “Older people are more complex than we were prepared to care for”
“I have encountered (complex family dynamics); that’s a huge part of caring for this age group. However, I was not prepared at all, in the new role that I was taking on. I was prepared as a nurse and that type of role that I had. However when I became the provider, I had no training and it’s a different role-you’re supposed to kind of direct it, and know where we need to go from here, how to approach this, especially with end-of-life kind of decisions and such, and I don’t think that my training in school covered that at all.” (no. 9) “I had my previous nursing experience to draw on and then the graduate NP program sort of built a little bit on top of that, but sort of relied on it a little bit . . . I would say I relied on it 75%, 80% and then the 20% would change how I would address that as a provider thinking” (no. 6) “ . . . because the PAs that I talked to-we were going over like our different programs. They have a little more ortho; they come out knowing how to do sutures left and right, and shoulder dislocations, and nursemaid’s elbows, and they come out knowing all that, and they have less pediatrics than we do. So I guess that’s just how the programs are different, with PA versus NP.” (no. 18)
“In the hospital you’re expected to act like a physician, I had that same experience the day I started [in clinic]. They gave me 20 patients per day and I had 20 minutes per patient and I was expected to see them just like a physician and I saw complicated belly pain, I saw a chest pain, I saw everything the docs saw. It was not the lower acuity” (no. 5) “So even if you’re in a nursing home or in the hospital, if you’re in primary care, you’re getting them pretty darn sick.” (no. 2) “And what we got, in addition to the adult curriculum, we had a three-hour course on geriatrics and it’s not enough. I’ve had physicians, my private physicians say, ‘Wow, I always thought that geriatrics will be really easy to deal with,’ and they’re not; they’re like the sickest people in the world. They’ve got all these things going on and you have to sort out; okay, what is really the problem here and how can we treat them? So they really are very complex.” ( no. 1)
(3) “It is very different as a provider, but I am so glad I was a nurse with experience first”
(4) “NPs have a scope of practice, physician assistants (PAs) have a job description-but I wish we had their [procedural] preparation”
pharmacology instruction, more was needed in relation to pathophysiology (e.g., kidney and liver function fluctuations) in elders, and prescribing antibiotics. Prescriptive authority and the requisite hours of supervised practice (18:00 h in the study location) limited employment opportunities for graduates. Obtaining supervision in an efficiency-driven environment (with limited time to spare) was a challenge for some. For others, the 18:00 h provided a much-needed “safety net” between prescribing content knowledge and confidence in its application in practice. One issue highlighted was that the drugs covered in class were not necessarily those that could 702
“I can’t imagine treating older people without having that [nursing] background . . . that probably prepared me better to deal with my job than the patho-phys did” (no. 5)
“I worked for about 15 physicians and I worked as adult and geriatric. We had a really high Medicare population in that clinic, as well as a very high college population, so we had a mix of young and old. I didn’t feel really well prepared for was x-rays, reading x-rays and some procedural and technical things like that. Because we had a trauma clinic in the clinic and I wasn’t prepared to set bones or to cast things.” (no. 5) “Some kind of counseling would be helpful in school, first of all, how to deal with the families even more than the patient and then second of all, how to care for yourself, how to unload or release or how to even talk to your peers or your physicians whatever about how to do with that emotional component.” (no. 2)
be safely prescribed for older adults because of type of insurance or indigent status. Medication reduction was identified as an essential skill for contemporary NP practice. Graduates found that as they assumed the role of primary care providers (PCPs), the complexity of decision making was greater than they had encountered as a nurse prior to becoming an NP. As one participant stated, “[older people are] like the sickest people in the world.” For many graduates, family dynamics associated with older adults could include financial or emotional abuse. Because of their role as PCPs, the family looked to them for answers related to end of life issues or hospice
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referral. Many participants relied on the close proximity of physician colleagues for advice; others were supervised by a physician assistant (PA), NP, or another advanced practice registered nurse (APRN). One participant added that sometimes “[she] didn’t have the knowledge to know which questions to ask.” NPs discussed the challenges of mental health issues in older adults and of feeling ill-prepared to care for dementia, depression, or anxiety in this complex population, as well as mental health concerns related to menopause. They gave suggestions of how to address some of these challenges, including observing experienced NPs rounding on nursing home patients and being exposed to urgent care or emergency department experiences to build confidence with acute episodes in primary care settings. Graduates particularly felt a need for greater exposure to meaningful clinical experiences with older adults, including assessment and diagnostic procedures (e.g., vaginal examination, venipuncture in the context of age-related changes to anatomy, and prescribing in the context of comorbidities and multiple medications).
Domain 3: “It’s very different as a provider, but I am so glad I was a nurse with experience first” Graduates spoke at length about the perceived differences between their roles as nurses and as primary healthcare providers. This fostered different opinions about how much clinical nursing experience one should have before becoming an NP. There were those who had gained little experience as a registered nurse (RN), and those with up to 30 years of experience prior to becoming an NP. For many, it was strongly believed that they relied heavily on their knowledge and experience gained prior to undertaking the NP program. Being a nurse with experience helped to fill the gaps in the NP program, “I know about advanced directives from my clinical role before’ or having worked ‘with referrals for palliative care previously” was vital. Overwhelmingly, it was noted they “draw on [their prior] nursing knowledge all the time.” As one participant stated, “I would say I relied on it 75%–80% and then the 20% would change how I would address that as a provider thinking.” Graduates without prior experience said they were not prepared for referring to hospice, nor confident to engage as a PCP in end-of-life issues or advance directives with patients and family members. In general, NPs perceived that they were not adequately prepared for the enhanced communication skills needed for settings with complex family dynamics and expectations of providers, although some family NPs felt they had strengths in this area. Consistently, participants agreed of the need for efficiency as a provider, “you are going to get money or not get money
based on [benchmarks]. I want to take the best care I can of my patients, but if I’m working in that environment, I want to meet all of those standards so that I can make money too.”
Domain 4: “NPs have a scope of practice, PAs have a job description but I wish we had their [procedural] preparation” For the general role of an APRN, participants talked about the tasks and skills they thought were missing from their education. These included being able to interpret x-rays for basic fracture patterns, and conduct an orthopedic joint assessment across the adult life span. However, they specifically related the need to understand metabolic bone disease and the consequences of its course in the context of older adults. Graduates repeatedly compared the limitations of their education to the procedural roles undertaken by PAs. Some shared the perception that the underpinning education of a PA was superior to their own. Participants related that some physicians in their first clinical job commented to NPs about how much more clinical time PAs received during training. They expressed surprise at the limited procedural skill set of the NP when beginning practice. Graduates expressed concern about being labeled “midlevel providers” and claimed NPs approached the care of the older adult in a different fashion, holistically, with a scope of practice. However, when explored further many graduates stated, “we are part of medicine,” “ we diagnose and treat,” “we use the medical model.” One participant stated “I pretty much have to know everything a doctor knows . . . I’m kind of a resident, but like a nonglorified resident.” Others confirmed, “you’re expected to act like a physician.” When asked what could be changed in their courses to accommodate identified deficits, participants said “to take out the fluff’ or ‘busy work of writing papers.” Some participants spoke at length about the “fluff” being theory, and that nursing theory was unnecessary in a productivity-driven clinical environment. Some said theory was important during their undergraduate years, but not currently. In contrast, others shared they used some form of behavior change or change theory, in addition to relying on their intuition and years of nursing experience. One participant confirmed, “I don’t think there is a place for it [theory]. You’re expected to go out there and get your patients taken care of and I do not sit there and make a conscious decision as to what concepts of what theory I’m going use to treat that particular patient. I am not; I have been a nurse for 35 years.” One graduate stated “now that I am a DNP I get theory.” Many participants suggested education should be provided by senior 703
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NPs who are currently practicing in that specialty and can mentor and translate content into clinical and theoretical context.
Discussion This qualitative inquiry was conducted to explore the perceived adequacy of the educational preparation of NPs in general as well as the knowledge and skills required to keep pace with the healthcare needs of older adults. The findings demonstrate the participants’ perceived gaps in the preparation of NPs working with older adults. The study’s results suggest that NP education should emphasize the significance and specific nuances of context, including rural settings and family care clinics in which older adults seek urgent care. Previous nursing experience was seen to be a strong underpinning for the NP role when combined with existing NP education programs, particularly as it related to care of older adults.
Nexus between nurse and provider Many graduates emphasized their technical role and the fundamental link with the medical aspects of the role. Less emphasis was given to the blending of their prior nursing knowledge with the additional knowledge and skill of medicine. There were few nursing or advanced practice nursing theoretical frameworks identified, particularly in terms of the older adult. While graduates spoke of being able to draw on their prior nursing knowledge, they identified the discrete domain of being a provider. Brykczynski (2012), in responding to the longstanding controversy of a theory–practice gap for all NP roles, provided insight into how NP faculty teach students about the melding of prior nursing knowledge and skills with the newly acquired medical and technical skills to provide an added dimension of patient-centered, comprehensive, and continuous primary care. Brykcznski included an emphasis on health promotion and disease prevention as well as the diagnosis, treatment, and management of acute and chronic illnesses. She argued that the nursing focus must not be lost in the drive for increased volume, shortened visit times, and reimbursement. The graduates described course work that prepared them to provide health promotion and disease prevention services, but these services may get lost in dealing with the multimorbidity, polypharmacy, and complexity of conditions present in older adults. These perspectives were congruent with findings from a national study on GNPs (KennedyMalone, Penny, & Fleming, 2008). However, Burman et al. (2009) state that health promotion and disease prevention in the healthy and the chronically ill person are the heart of APRN practice. Both nursing and medical 704
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aspects of primary care need to be emphasized in order for APRN practice to demonstrate the “differences” in care and patient outcomes (Burman et al., 2009). Educators must teach and role model the integration of nursing and medical aspects of care in APRN preparation. Additionally, other theoretical models, including the social ecological model, the chronic care model, behavior change, systems, organizational, and leadership theories, are an integral part of moving APRN preparation to the doctoral level.
Strategies for teaching and learning This study highlighted the need to reconsider teaching strategies and potential enhancements that could be made to all NP clinical placements, but specifically to the care of older adults. Greater integration of knowledge and practice is needed. Preparation for the complexity of caring for the elderly population presenting with acute illness, chronic illnesses, and acute-on-chronic illness (i.e., exacerbations of disease) are the realities of practice. Published reports suggest the potential for using simulation and health assessments based on older adults in order to integrate theory into practice in a meaningful manner. Coaching, role modeling, and narrative case examples are argued as ways to imbue practical NP knowledge (Benner, Sutphen, Leonard, & Day, 2010; Brykczynski, 2012) across all NP options. Auerhahn et al. (2012) who are GNPs identified the need for innovative teaching and learning approaches to both didactic coursework and clinical experiences. This research corroborates other findings reported in the literature regarding needed changes in nursing education, namely, enhanced curricular content on the specific and unique aspects of caring for older adults (AACN, 2010; Auerhahn et al., 2012; KennedyMalone et al., 2008; Silva-Smith & Kotthoff-Burrell, 2009) and content and practicums on clinical procedures (i.e., electrocardiograms and x-ray interpretations) such as suturing, incision and drainage, microscopy, and skin tag removal (Lausten, 2013).
Role transition and role progression In light of Benner’s (1984) novice to expert conceptualization of clinical competence, one can examine how new graduates experience role transition and role conflict. What factors influence role progression when the typical model expressed in this study involves medical provider mentorship? The main objective of advanced practice nursing mentoring is “to promote development . . . not cultivate dependency” (Barker, 2006, p. 59). Sullivan-Bentz et al. (2010) argued that the transition for newly graduated NPs is complicated when the clinical
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environment does not foster interprofessional relationships and lacks NP role orientation and mentorship. This study added an apparent reliance by physicians on an understanding of what PAs can do rather than NPs in primary care settings. The lack of stated value for the use of nursing theoretical frameworks in the conduct of graduate’s practice is concerning, but may be consistent with the demands of role transition in environments that are more interested in productivity- and efficiency-based models of care. However, if NPs and other APRNs are to demonstrate the differences in patient-centered care and patient outcomes, NP role models must reinforce the need for emphasis on the meaning of health and illness events to the patient and family who provide the bulk of daily care needs. Thus, equal attention to both the physiological as well as the biobehavioral aspects of health and illness must be balanced.
Limitations There were several limitations to the study. The sample size, while adequate for qualitative design, captured the perspectives of two different universities within the same parent educational system in the western United States with a strong heritage of traditional NP preparation. Geographic and types of practice varied among participants. Some stayed in the west, others were practicing in the east. Graduates worked in a variety of settings, including primary care, rural, acute hospital clinics, family-care clinics, urgent care, on-call home visitation, and in nursing homes. Recruitment of graduates occurred after they left the university system and therefore limited access to practicing NPs. This sample suggested a positive bias of interested and accessible nurses. The range and variety in program specialty reflected the breadth of NP roles; however, the respondents were self-selected. Additionally, the employment choice after graduation and prior experience with older adult needs could not be controlled. Some responses therefore may reflect inexperience in nursing or dissatisfaction with current employer. Combining virtual groups with individual and group discussions could limit features specific to one program or the other, but the iterative inclusion of participant concerns allowed for “on the go” member checking that ultimately enhanced credibility and authenticity of the findings.
Conclusions and implications This study provided an initial step in exploring the preparation desired by NPs to undertake roles that involve the provision of primary health care to older adults. Participants shared the complexity of the knowledge, skills, and
attitudes needed to practice in settings in which they find employment, including primary care, urgent-care clinics, acute-care hospitals, subacute rehabilitation, long-term care, palliative care, and hospice. A number of graduates expressed concern that perceived deficits in educational programs could not be accomplished by adding courses to an already dense curriculum. Instead, more integration and application of topical material specific to older adults and enhanced clinical experiences (e.g., simulation) were suggested. As APRNs embark on dramatic changes in healthcare delivery, and growing primary healthcare demands, nursing and nurse educators must meet the challenge of preparing the workforce to meet those demands and to demonstrate the added value of the “registered nurse” in the APRN roles. A broader survey that can assist with validating the authenticity of graduate experiences in this study across geographical distance and NP curricula is a prudent next step.
Acknowledgments This study was made possible through funding from the U.S. Department of Health and Human Services (HRSA), Advanced Education in Nursing grant D09 HP18968. The authors acknowledge Rebecca Speer for her assistance with the IRB approval process and conduction of focus groups.
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Pearson, L. (2009). The Pearson report: A national overview of NP legislation and healthcare issues. American Journal of Nurse Practitioners, 13(12), 8–82. Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing and Health, 23, 334–340. Silva-Smith, A., & Kotthoff-Burrell, E. (2009). Geriatric content for all nurse practitioners programs: A population-driven imperative. Topics in Advanced Practice Nursing (e-journal). Retrieved from http://www.medscape.com/ viewarticle/709454 Steinwald, A. B. (2008). Primary care professionals: Recent supply trends, projections and valuation of services. Testimony to Committee on Health Education, Labor and Pensions, U.S. Senate, February 12, 2008. Government Accountability Office, Washington, DC (GAO-08–472T). Retrieved from www.gao.gov/products/GAO-08-4721T Sullivan-Bentz, M., Humbert, J., Cragg, B., Legault, F., Laflamme, C., Bailey, P. H., & Doucette, S. (2010). Supporting primary health care nurse practitioners’ transition to practice. Canadian Family Physician, 56, 1176–82. Thomas, D. R. (2006). A general inductive approach for analyzing qualitative evaluation data. American Journal of Evaluation, 27, 2, 237–246.
Nurse practitioner graduates “Speak Out” about the adequacy of their educational preparation to care for older adults: A qualitative study Jacqueline Jones, PhD, RN, FRCNA (Associate Professor)1 , Ernestine Kotthoff-Burrell, PhD, RN, ANP-BC, FAANP (Assistant Professor)1 , Jane Kass-Wolff, PhD, RN, FNP-BC, WHNP-BC (Associate Professor)1 , & Vicki Brownrigg, PhD, RN, FNP-BC (Assistant Professor)2 1 2
College of Nursing, University of Colorado Denver, Aurora, Colorado Beth El College of Nursing & Health Sciences, Colorado Springs, Colorado
Keywords Advanced practice nurse (APN); education; curriculum; nurse practitioners; older adult. Correspondence Ernestine Kotthoff-Burrell, PhD, College of Nursing, University of Colorado Denver, 13120 E. 19th Ave., Mail Stop C-288-19, Aurora, CO 80045. Tel: 303-724-8565; Fax: 303-724 8560; E-mail: ernestine.kotthoff-burrell@ ucdenver.edu Received: 18 February 2014; accepted: 23 May 2014 doi: 10.1002/2327-6924.12230
Abstract Purpose: With a shortage of primary care providers prepared to care for an aging U.S. population, nurse practitioner (NP) programs are integrating gerontological content. This qualitative descriptive study explored NP graduate perceptions on the adequacy of their education to prepare them to care for seniors. Methods: Twenty-three graduates of NP program options at two universities in the western U.S. participated in focus group discussions or interviews. Participants shared their perceptions of their NP educational preparation and suggestions for enhancing gerontologic curriculum. Conclusions: Four main domains emerged from analysis of qualitative data: (a) “Getting your boots on and getting into the role”; (b) “Older people are more complex than we were prepared to care for”; (c) “It is very different as a provider, but I am so glad I was a nurse with experience first”; (d) “NPs have a scope of practice, physician assistants (PAs) have a job description-but I wish we had their [procedural] preparation.” Implications for practice: Graduates identified a need for more educational content and clinical experiences specific to the care of older adults. Some suggested a postgraduate residency or mentoring option to assist NP role transition and progression and limit role confusion.
Introduction By the year 2030, the population of adults aged 65 and above is expected to grow from 12% of the total U.S. population to 20% (Administration on Aging [AoA], 2008). In January 2011, the first of the “Baby Boomers” (1946–1965) began to reach the threshold of older age. This demographic shift poses new demands for providers with expertise to address health and social problems of aging adults (Auerhahn, Mezey, Stanley, & Dodge, 2012). These demands include complex primary healthcare needs, multiple comorbid health problems, and polypharmacy (AoA, 2008). Many older adults receive primary care from nurse practitioners (NPs) in clinics and other settings. This trend will continue with the current and projected shortage of primary care physician providers (American College of Physicians, 2009; Auerhahn, Mezey, 698
Stanley, & Dodge, 2012; Institute of Medicine [IOM], 2008; Steinwald, 2008). In 2008, the IOM reported on the need to revamp professional education with respect to caring for older adults. National professional organizations such as the American Association of Colleges of Nursing [AACN] noted that enrollment in geriatric NP (GNP) programs was disappointingly low, particularly in light of the anticipated growth of older adults. Additionally, certified GNPs comprised only 2.6% of all NPs in the United States (American Nurses Credentialing Center [ANCC], 2009; Pearson, 2009). In 2010, the AACN, together with the John A. Hartford Foundation (JAHF) and the National Organization of Nurse Practitioner Faculty (NONPF), revised and updated competencies for preparing students to care for older adults. AACN recommended the closure of “stand alone” GNP programs and the integration of gerontological curriculum Journal of the American Association of Nurse Practitioners 27 (2015) 698–706 C 2015 American Association of Nurse Practitioners
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into adult NP options, creating Adult Gerontological Nurse Practitioner (AGNP) programs.
Overview In 2010, two graduate nursing programs in the western United States were awarded a grant from the United States Department of Health and Human Services to review and revise curriculum for selected NP program options. The two programs were administered at two universities within the same parent educational system. Both programs provided the adult (ANP) and family NP (FNP) options. One of the universities offered a Women’s Health Care option (WHCNP). Details of the five options at the two university programs have been previously described (Kass-Wolff, Kotthoff-Burrell, & Smith, 2012). Graduates from three NP options across the two universities (adult, family, and women’s health practitioner) were evaluated. The purpose of the initiative was to implement curricula that met the revised core competencies for the care of the older adult. All graduates of the APRN options would be prepared to competently care for older adults in their respective population foci. In addition, the combined AGNP options would be eligible to successfully complete the new AGNP certification examination when it became available.
Purpose/aims One grant objective was to explore the experiences of graduates who had completed one of the three options from either institution within the past 5 years. The number of gerontological NPs who had completed the option was small across both university programs so all previous graduates of the five options were invited to participate in the focus groups to assess their preparation to care for older adults within their population foci. The aims of this study were to (a) describe the success and limitations of NP programs in preparing graduates to care for older adults, and (b) identify strategies and direction to enhance gerontologic curriculum in NP programs.
Methods A naturalistic approach to inquiry was used, applying broad constructivist principles to guide this qualitative descriptive study (Sandelowski, 2000). Within this approach, multiple realities and truths are assumed. These result in a text that is historically, culturally, and socially constructed, cocreated by participants and the investigator (Mayan, 2009). All NP graduates (2006–2011) from the adult, family, or women’s health NP courses from both institutions were asked to participate. A moratorium had been placed on admissions to the GNP program as a stand-alone op-
tion several years prior to this grant award. However, some graduates of the GNP option were eligible for study participation. The invitation letter was sent by e-mail on three occasions. Interested graduates were asked to contact the research team. Group discussions were offered at multiple times over an initial 2-week period. One of the NP programs was conducted online and therefore a synchronous webinar format was used for group discussions. Individual telephone interviews were offered to participants when group attendance was not feasible or desired. A total of 280 NP graduates were eligible. This represented the total population for all three NP options at the two institutions, as well as graduates from the standalone GNP program. There were no additional inclusion criteria. Faculty who participated in the education of the graduates was not involved in recruitment or data collection. Approval for the project was granted from the Institutional Review Boards of both institutions. Informed consent included the completion of a demographic questionnaire and digital recording of the group or individual interviews for textual analysis. A semistructured interview guide was developed from both a review of the literature as well as discussions with faculty experts in NP education. These questions were used to focus individual and group discussions around key areas of role preparation as an NP in general and specifically to provide care to older adults. The following questions prompted reflection and discussion: ■
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How well prepared were you for your role as an NP? What was your first appointment or job? How well prepared were you as an NP to care for older adults? What specific aspects of care and context are important in your role? How ill-prepared were you for your role to care for older adults? What strategies did you use to get up to speed? What improvements could you suggest to your preparation? What would you do differently?
A virtual group process was created in order to enhance participation of NP graduates across the United States for this study (Barbour, 2007). The process was used to build a comprehensive awareness of the nuances of NP preparation in general and specifically with regards to caring for older adults across programs and specialties. This understanding was achieved by iteratively reflecting on the previous group or individual interview discussions to supplement probes and discussions within those that followed. The principal investigator (PI), an experienced qualitative researcher, and the research assistant (RA) collected field notes during the focus groups to capture nonverbal cues, ideas, and perceptions related to the discussion. The PI conducted all one-on-one telephone 699
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interviews and collected field notes related to idea building and iterative contextual connections between interviewees. Digital recordings were subsequently professionally transcribed verbatim. Trustworthiness is the gold standard for qualitative rigor (Beck, 1993). As such, to enhance the authenticity, fittingness, “fitness and credibility of the research findings,” a reflexive journal was maintained by the PI. Debriefing occurred with the RA and team following each focus group, and between interviews. Early analysis and findings were presented to the participants for member checking (Creswell 2012; Koch & Harrington, 1998).
Data analysis A general inductive approach to theme analysis (Creswell, 2012; Thomas, 2006) was applied to the textual data to explore the experience of NP preparation and the realities of NP practice. Analysis focused on the NP role in general, followed by specific aspects related to care of older adults. It was important to remain open to new and unexpected occurrences beyond the interview framework. Data immersion, systematic line-by-line reading of the transcripts, and clustering of similar fragments of information formed the initial analytic steps. Commonalities and differences were noted and broad domains identified within and across group discussions and individual interviews and linked to subthemes. Core meanings related to the research aims are described in terms of the most important themes that emerged (Thomas, 2006).
Results Graduates (n = 23) agreed to interviews in either a group or individual setting. Two onsite focus groups, attended by nine NPs, and 13 one-on-one telephone interviews were completed, producing 7325 lines of transcribed text. One further participant responded by e-mail to research questions and those responses were included. Participant characteristics are presented in Table 1. Four major domains were identified around which graduate experiences and concerns clustered. Participant language illustrated domain themes, to keep as close as possible to the expressions offered of practice. Each domain was described in a narrative style using subthemes and exemplar text. Table 2 highlights NP option participant exemplars for each domain.
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general and specifically in caring for older adults. They shared feelings that this role change brought to their identity as an NP “It’s not that we are not prepared for the role; it’s more not being prepared for a first job.” More than one participant expressed that they “can’t be prepared for every content area; [there is] just too much.” Thus, while the program prepared them as much as possible for being an NP, for some “not as much as [they] had hoped,” graduates expressed concern that adding more content to an already extensive, content-heavy course would not facilitate transition to the context of contemporary NP practice. The three program options emphasized different facets of NP specialty content. Yet, graduates were offered and accepted employment as an NP in a variety of settings despite not being educated specifically for that setting. There was an overwhelming sense that the program equipped them with critical thinking skills, but there was a “need to be prepared to hit the ground running and learn.” The desire to be ready to transition and function competently after graduation was strong. Suggestions about what would assist in the transition included some form of residency program for NPs. Participants said a “residency program would be perfect: if we got paid even better.” Other aspects graduates identified included more information about administrative and systems elements: contract negotiation and coding for reimbursement purposes. New graduate NPs who were able to establish mentor relationships found them vital to successful NP role integration and progression. Mentors were identified through clinical relationships prior to the course, during clinical placement, or during their first employed position as an NP. Frequently, these mentors were physicians associated with the practice; only occasionally were mentors NPs. Mentors could be a “sounding board” or give advice on clinical reasoning or differential diagnosis on site or by telephone. Graduates across all options who were more established (more than 1–2 years’ experience as an NP) often said they would like to mentor new NPs in their population foci, but had not been contacted to do so. In order to function and get up to speed in their NP role, graduates reported using technology, including smartphones, Epocrates, and UpToDate, to access information and provide decision support on a daily basis. Some participants had completed onsite training, external courses, and certification to fill the gaps between their NP course preparation and the clinical context of their NP practice with older adults.
Domain 1: “Getting your boots on and getting into the role”
Domain 2: “Older people are more complex than we were prepared for”
Graduates spoke of their initial feelings of being unprepared for the diversity of their new role, as a provider in
Participants had a range of prior experience working with older adults (e.g., nursing home care) and some
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Table 1 Demographic data (n = 23) Characteristic Years since graduation with BSN
Previous nursing experience with older adults NP program completed
Years since graduating with NP
NP programs Years practicing as an APN
Current position
Percentage of geriatric patients in current setting
Years worked in current role/position
National certifications held (self-reported)
Gender Age
Categories
N (%)
More than 3, but less than 6 years More than 6 and less than 9 years 9–12 years 13–16 years 17–20 years More than 20 years Yes No ANP GNP ANP and GNP WH FNP Less than 1 year More than 1 and less than 2 years 2–3 years More than 3 years NP program no. 1 NP program no. 2 Less than 1 year More than 1 and less than 2 years 2–3 years 4–5 years Over 5 years Primary health care in ambulatory setting Primary care in a long-term care setting Primary care in a private medical practice Acute/hospital Other specialty practice 20% or less
6 (26) 7 (30) 8 (35) 1 (4) 1 (4) 0 18 (78) 4 (17) 1 (4) 3 (13) 2 (9) 1 (4) 16 (70) 4 (17) 7 (30) 5 (22) 7 (30) 11 (49) 12 (52) 8 (35) 3 (13) 3 (13) 4 (30) 2 (9) 5 (22) 3 (13) 5 (22) 2 (9) 9 (39) 7 (30)
21%–40% 41%–60% 61%–80% 81% and above Unanswered Less than 1 year More than 1 and less than 2 years 2–3 years More than 3 years ANCC AANP FNP GNP ANP-BC Other Female Male Mean age: Age range:
4 (17) 4 (17) 3 (13) 4 (17) 1 (4) 7 (30) 4 (17) 10 (43) 2 (9) 6 (26) 6 (26) 6 (26) 2 (9) 2 (9) 9 (39) 13 (78) 5 (22) 40.6 years old 28–59 years old
BSN, bachelor of science in Nursing; AANP, American Academy of Nurse Practitioners; ANP-BC, advanced practice nurse–board certified.
had additional geriatric intensive coursework. Yet, all were unanimous in expressing that they were not adequately prepared for the complexity of the comorbidities experienced by older adults or the acuity of older adults
seeking care in primary care clinics. They described the challenges of trying to prescribe for patients who may be on 20–30 medications when drug “interactions can be a nightmare.” While overall, they felt they had beneficial 701
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Table 2 Illustrative quotes Domain
FNP exemplar
ANP exemplar
(1) “Getting your boots on and getting into the role”
“ . . . giving nurse practitioners some of those survival skills to make it as a new grad . . . It really takes confidence and the ability to stand tall every day, to really make it in that environment” (no. 14)
(2) “Older people are more complex than we were prepared to care for”
“I have encountered (complex family dynamics); that’s a huge part of caring for this age group. However, I was not prepared at all, in the new role that I was taking on. I was prepared as a nurse and that type of role that I had. However when I became the provider, I had no training and it’s a different role-you’re supposed to kind of direct it, and know where we need to go from here, how to approach this, especially with end-of-life kind of decisions and such, and I don’t think that my training in school covered that at all.” (no. 9) “I had my previous nursing experience to draw on and then the graduate NP program sort of built a little bit on top of that, but sort of relied on it a little bit . . . I would say I relied on it 75%, 80% and then the 20% would change how I would address that as a provider thinking” (no. 6) “ . . . because the PAs that I talked to-we were going over like our different programs. They have a little more ortho; they come out knowing how to do sutures left and right, and shoulder dislocations, and nursemaid’s elbows, and they come out knowing all that, and they have less pediatrics than we do. So I guess that’s just how the programs are different, with PA versus NP.” (no. 18)
“In the hospital you’re expected to act like a physician, I had that same experience the day I started [in clinic]. They gave me 20 patients per day and I had 20 minutes per patient and I was expected to see them just like a physician and I saw complicated belly pain, I saw a chest pain, I saw everything the docs saw. It was not the lower acuity” (no. 5) “So even if you’re in a nursing home or in the hospital, if you’re in primary care, you’re getting them pretty darn sick.” (no. 2) “And what we got, in addition to the adult curriculum, we had a three-hour course on geriatrics and it’s not enough. I’ve had physicians, my private physicians say, ‘Wow, I always thought that geriatrics will be really easy to deal with,’ and they’re not; they’re like the sickest people in the world. They’ve got all these things going on and you have to sort out; okay, what is really the problem here and how can we treat them? So they really are very complex.” ( no. 1)
(3) “It is very different as a provider, but I am so glad I was a nurse with experience first”
(4) “NPs have a scope of practice, physician assistants (PAs) have a job description-but I wish we had their [procedural] preparation”
pharmacology instruction, more was needed in relation to pathophysiology (e.g., kidney and liver function fluctuations) in elders, and prescribing antibiotics. Prescriptive authority and the requisite hours of supervised practice (18:00 h in the study location) limited employment opportunities for graduates. Obtaining supervision in an efficiency-driven environment (with limited time to spare) was a challenge for some. For others, the 18:00 h provided a much-needed “safety net” between prescribing content knowledge and confidence in its application in practice. One issue highlighted was that the drugs covered in class were not necessarily those that could 702
“I can’t imagine treating older people without having that [nursing] background . . . that probably prepared me better to deal with my job than the patho-phys did” (no. 5)
“I worked for about 15 physicians and I worked as adult and geriatric. We had a really high Medicare population in that clinic, as well as a very high college population, so we had a mix of young and old. I didn’t feel really well prepared for was x-rays, reading x-rays and some procedural and technical things like that. Because we had a trauma clinic in the clinic and I wasn’t prepared to set bones or to cast things.” (no. 5) “Some kind of counseling would be helpful in school, first of all, how to deal with the families even more than the patient and then second of all, how to care for yourself, how to unload or release or how to even talk to your peers or your physicians whatever about how to do with that emotional component.” (no. 2)
be safely prescribed for older adults because of type of insurance or indigent status. Medication reduction was identified as an essential skill for contemporary NP practice. Graduates found that as they assumed the role of primary care providers (PCPs), the complexity of decision making was greater than they had encountered as a nurse prior to becoming an NP. As one participant stated, “[older people are] like the sickest people in the world.” For many graduates, family dynamics associated with older adults could include financial or emotional abuse. Because of their role as PCPs, the family looked to them for answers related to end of life issues or hospice
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referral. Many participants relied on the close proximity of physician colleagues for advice; others were supervised by a physician assistant (PA), NP, or another advanced practice registered nurse (APRN). One participant added that sometimes “[she] didn’t have the knowledge to know which questions to ask.” NPs discussed the challenges of mental health issues in older adults and of feeling ill-prepared to care for dementia, depression, or anxiety in this complex population, as well as mental health concerns related to menopause. They gave suggestions of how to address some of these challenges, including observing experienced NPs rounding on nursing home patients and being exposed to urgent care or emergency department experiences to build confidence with acute episodes in primary care settings. Graduates particularly felt a need for greater exposure to meaningful clinical experiences with older adults, including assessment and diagnostic procedures (e.g., vaginal examination, venipuncture in the context of age-related changes to anatomy, and prescribing in the context of comorbidities and multiple medications).
Domain 3: “It’s very different as a provider, but I am so glad I was a nurse with experience first” Graduates spoke at length about the perceived differences between their roles as nurses and as primary healthcare providers. This fostered different opinions about how much clinical nursing experience one should have before becoming an NP. There were those who had gained little experience as a registered nurse (RN), and those with up to 30 years of experience prior to becoming an NP. For many, it was strongly believed that they relied heavily on their knowledge and experience gained prior to undertaking the NP program. Being a nurse with experience helped to fill the gaps in the NP program, “I know about advanced directives from my clinical role before’ or having worked ‘with referrals for palliative care previously” was vital. Overwhelmingly, it was noted they “draw on [their prior] nursing knowledge all the time.” As one participant stated, “I would say I relied on it 75%–80% and then the 20% would change how I would address that as a provider thinking.” Graduates without prior experience said they were not prepared for referring to hospice, nor confident to engage as a PCP in end-of-life issues or advance directives with patients and family members. In general, NPs perceived that they were not adequately prepared for the enhanced communication skills needed for settings with complex family dynamics and expectations of providers, although some family NPs felt they had strengths in this area. Consistently, participants agreed of the need for efficiency as a provider, “you are going to get money or not get money
based on [benchmarks]. I want to take the best care I can of my patients, but if I’m working in that environment, I want to meet all of those standards so that I can make money too.”
Domain 4: “NPs have a scope of practice, PAs have a job description but I wish we had their [procedural] preparation” For the general role of an APRN, participants talked about the tasks and skills they thought were missing from their education. These included being able to interpret x-rays for basic fracture patterns, and conduct an orthopedic joint assessment across the adult life span. However, they specifically related the need to understand metabolic bone disease and the consequences of its course in the context of older adults. Graduates repeatedly compared the limitations of their education to the procedural roles undertaken by PAs. Some shared the perception that the underpinning education of a PA was superior to their own. Participants related that some physicians in their first clinical job commented to NPs about how much more clinical time PAs received during training. They expressed surprise at the limited procedural skill set of the NP when beginning practice. Graduates expressed concern about being labeled “midlevel providers” and claimed NPs approached the care of the older adult in a different fashion, holistically, with a scope of practice. However, when explored further many graduates stated, “we are part of medicine,” “ we diagnose and treat,” “we use the medical model.” One participant stated “I pretty much have to know everything a doctor knows . . . I’m kind of a resident, but like a nonglorified resident.” Others confirmed, “you’re expected to act like a physician.” When asked what could be changed in their courses to accommodate identified deficits, participants said “to take out the fluff’ or ‘busy work of writing papers.” Some participants spoke at length about the “fluff” being theory, and that nursing theory was unnecessary in a productivity-driven clinical environment. Some said theory was important during their undergraduate years, but not currently. In contrast, others shared they used some form of behavior change or change theory, in addition to relying on their intuition and years of nursing experience. One participant confirmed, “I don’t think there is a place for it [theory]. You’re expected to go out there and get your patients taken care of and I do not sit there and make a conscious decision as to what concepts of what theory I’m going use to treat that particular patient. I am not; I have been a nurse for 35 years.” One graduate stated “now that I am a DNP I get theory.” Many participants suggested education should be provided by senior 703
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NPs who are currently practicing in that specialty and can mentor and translate content into clinical and theoretical context.
Discussion This qualitative inquiry was conducted to explore the perceived adequacy of the educational preparation of NPs in general as well as the knowledge and skills required to keep pace with the healthcare needs of older adults. The findings demonstrate the participants’ perceived gaps in the preparation of NPs working with older adults. The study’s results suggest that NP education should emphasize the significance and specific nuances of context, including rural settings and family care clinics in which older adults seek urgent care. Previous nursing experience was seen to be a strong underpinning for the NP role when combined with existing NP education programs, particularly as it related to care of older adults.
Nexus between nurse and provider Many graduates emphasized their technical role and the fundamental link with the medical aspects of the role. Less emphasis was given to the blending of their prior nursing knowledge with the additional knowledge and skill of medicine. There were few nursing or advanced practice nursing theoretical frameworks identified, particularly in terms of the older adult. While graduates spoke of being able to draw on their prior nursing knowledge, they identified the discrete domain of being a provider. Brykczynski (2012), in responding to the longstanding controversy of a theory–practice gap for all NP roles, provided insight into how NP faculty teach students about the melding of prior nursing knowledge and skills with the newly acquired medical and technical skills to provide an added dimension of patient-centered, comprehensive, and continuous primary care. Brykcznski included an emphasis on health promotion and disease prevention as well as the diagnosis, treatment, and management of acute and chronic illnesses. She argued that the nursing focus must not be lost in the drive for increased volume, shortened visit times, and reimbursement. The graduates described course work that prepared them to provide health promotion and disease prevention services, but these services may get lost in dealing with the multimorbidity, polypharmacy, and complexity of conditions present in older adults. These perspectives were congruent with findings from a national study on GNPs (KennedyMalone, Penny, & Fleming, 2008). However, Burman et al. (2009) state that health promotion and disease prevention in the healthy and the chronically ill person are the heart of APRN practice. Both nursing and medical 704
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aspects of primary care need to be emphasized in order for APRN practice to demonstrate the “differences” in care and patient outcomes (Burman et al., 2009). Educators must teach and role model the integration of nursing and medical aspects of care in APRN preparation. Additionally, other theoretical models, including the social ecological model, the chronic care model, behavior change, systems, organizational, and leadership theories, are an integral part of moving APRN preparation to the doctoral level.
Strategies for teaching and learning This study highlighted the need to reconsider teaching strategies and potential enhancements that could be made to all NP clinical placements, but specifically to the care of older adults. Greater integration of knowledge and practice is needed. Preparation for the complexity of caring for the elderly population presenting with acute illness, chronic illnesses, and acute-on-chronic illness (i.e., exacerbations of disease) are the realities of practice. Published reports suggest the potential for using simulation and health assessments based on older adults in order to integrate theory into practice in a meaningful manner. Coaching, role modeling, and narrative case examples are argued as ways to imbue practical NP knowledge (Benner, Sutphen, Leonard, & Day, 2010; Brykczynski, 2012) across all NP options. Auerhahn et al. (2012) who are GNPs identified the need for innovative teaching and learning approaches to both didactic coursework and clinical experiences. This research corroborates other findings reported in the literature regarding needed changes in nursing education, namely, enhanced curricular content on the specific and unique aspects of caring for older adults (AACN, 2010; Auerhahn et al., 2012; KennedyMalone et al., 2008; Silva-Smith & Kotthoff-Burrell, 2009) and content and practicums on clinical procedures (i.e., electrocardiograms and x-ray interpretations) such as suturing, incision and drainage, microscopy, and skin tag removal (Lausten, 2013).
Role transition and role progression In light of Benner’s (1984) novice to expert conceptualization of clinical competence, one can examine how new graduates experience role transition and role conflict. What factors influence role progression when the typical model expressed in this study involves medical provider mentorship? The main objective of advanced practice nursing mentoring is “to promote development . . . not cultivate dependency” (Barker, 2006, p. 59). Sullivan-Bentz et al. (2010) argued that the transition for newly graduated NPs is complicated when the clinical
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environment does not foster interprofessional relationships and lacks NP role orientation and mentorship. This study added an apparent reliance by physicians on an understanding of what PAs can do rather than NPs in primary care settings. The lack of stated value for the use of nursing theoretical frameworks in the conduct of graduate’s practice is concerning, but may be consistent with the demands of role transition in environments that are more interested in productivity- and efficiency-based models of care. However, if NPs and other APRNs are to demonstrate the differences in patient-centered care and patient outcomes, NP role models must reinforce the need for emphasis on the meaning of health and illness events to the patient and family who provide the bulk of daily care needs. Thus, equal attention to both the physiological as well as the biobehavioral aspects of health and illness must be balanced.
Limitations There were several limitations to the study. The sample size, while adequate for qualitative design, captured the perspectives of two different universities within the same parent educational system in the western United States with a strong heritage of traditional NP preparation. Geographic and types of practice varied among participants. Some stayed in the west, others were practicing in the east. Graduates worked in a variety of settings, including primary care, rural, acute hospital clinics, family-care clinics, urgent care, on-call home visitation, and in nursing homes. Recruitment of graduates occurred after they left the university system and therefore limited access to practicing NPs. This sample suggested a positive bias of interested and accessible nurses. The range and variety in program specialty reflected the breadth of NP roles; however, the respondents were self-selected. Additionally, the employment choice after graduation and prior experience with older adult needs could not be controlled. Some responses therefore may reflect inexperience in nursing or dissatisfaction with current employer. Combining virtual groups with individual and group discussions could limit features specific to one program or the other, but the iterative inclusion of participant concerns allowed for “on the go” member checking that ultimately enhanced credibility and authenticity of the findings.
Conclusions and implications This study provided an initial step in exploring the preparation desired by NPs to undertake roles that involve the provision of primary health care to older adults. Participants shared the complexity of the knowledge, skills, and
attitudes needed to practice in settings in which they find employment, including primary care, urgent-care clinics, acute-care hospitals, subacute rehabilitation, long-term care, palliative care, and hospice. A number of graduates expressed concern that perceived deficits in educational programs could not be accomplished by adding courses to an already dense curriculum. Instead, more integration and application of topical material specific to older adults and enhanced clinical experiences (e.g., simulation) were suggested. As APRNs embark on dramatic changes in healthcare delivery, and growing primary healthcare demands, nursing and nurse educators must meet the challenge of preparing the workforce to meet those demands and to demonstrate the added value of the “registered nurse” in the APRN roles. A broader survey that can assist with validating the authenticity of graduate experiences in this study across geographical distance and NP curricula is a prudent next step.
Acknowledgments This study was made possible through funding from the U.S. Department of Health and Human Services (HRSA), Advanced Education in Nursing grant D09 HP18968. The authors acknowledge Rebecca Speer for her assistance with the IRB approval process and conduction of focus groups.
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