Tom Bush, DNP, FNPBC, FAANP, Associate Professor UNC Chapel Hill presentation on NP Residencies and job satisfaction.

1. Postgraduate NP Education:
Impact on Job Satisfaction
Tom Bush, DNP, FNP-BC, FAANP
Associate Professor
University of North Carolina at Chapel Hill
Schools of Nursing and Medicine
Orthopedic NP Fellowship Director
1

2. IOM/RWJ Future of Nursing
“State boards of nursing, accrediting bodies, the federal government,
and health care organizations should take actions to support nurses’
completion of a transition-to-practice program (nurse residency) after
they have completed a prelicensure or advanced practice degree
program or when they are transitioning into new clinical practice
areas”
IOM, 2011, p. S 9

3. Fellowship or Residency?
•Residency is required for licensure and practice in medicine
and some other disciplines
•Post-graduate education is optional for licensure and
practice in nursing
•NP Roundtable
• Address potential confusion
• Endorsed use of the term “fellowship”
•Transition-to-practice
• Does not suggest regulatory control
AANP 2013; Wiltse Nicely & Fairman, 2015

4. Affordable Care Act
Post-graduate NP demonstration project
• Fund FQHC programs in nurse managed health centers
• DHHS sought input from nursing educators
• NONPF & others voted not to support
• “We thought the money should go to support NP programs to increase the number of NPs”
DHHS funded 5 health centers to increase numbers of NP graduates
No funding for post-graduate NP education
Boyar, 2010; M. Price 2014

5. Cost and Commitment
Post-graduate physician education
• Federally funded by DHHS through CMS
• More than 100k per resident per year
• Can total more than 500k when state Medicaid payments considered
Indirect Federal support for NP programs
• Veterans Health Administration
• Federally Qualified Health Centers
Few employer funded NP programs
• Most employers expect new NP graduates to perform at an advanced level
with little support
Dower, 2012; Bahouth, Blum, & Simone, 2013

6. Cost and Commitment
Most post-graduate NP education programs employer funded
• Recruitment and retention of professionals
• Meet immediate and growing workforce needs
• Costs per trainee can reach 100k annually
• NP salary/benefits, lost preceptor revenue, facility overhead and administrative expenses
• Two thirds support post-graduate NP
• One third supplements lost preceptor productivity
• Expenses offset through billable NP activity
• Employment commitment may be required
Flinter, 2011; D. Taylor, 2014

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

8. Purpose
Determine the impact of post-graduate education on job satisfaction
among NPs
Project Question:
• Is there a difference in job satisfaction between NPs who have
completed post-graduate fellowship education and NPs who have not
participated in formal post-graduate fellowship education?

9. Theory
From “Limbo to Legitimacy”
• Anxiety and accomplishments of novice NPs
• Transition from student to clinician
• Feelings of insecurity and illegitimacy
• Fear of errors and associated anxiety
• Impacts diagnostic reasoning & clinical decisions
• Experience fosters confidence & competence
• Is anxiety due to transitional identity or inadequate environmental support?
Brown & Olshanksy, 1997

10. Methods
A non-equivalent group design
• The Misener Nurse Practitioner Job Satisfaction Scale was administered
to two groups of nurse practitioners
• Formal post-graduate fellowship n = 80
• No formal post-graduate fellowship n = 174
• Demographic tool
• race; gender; age; years of NP experience, highest degree; practice zip code
Misener & Cox 2001

11. Age Distribution All Participants
Boomer 31.5%
Gen X 43.9%
Gen Y 24.3%

12. Age Distribution by Group

13. Mean Years of NP Experience

14. States Represented

15. Median Satisfaction Scores
Table 1
Job Satisfaction Scores
Post-graduate education N Median
Frequency of
satisfied and very
satisfied
Yes 80 5 68.8%
No 174 5 50.5%

16. Satisfaction Distribution
N = 254
Mean = 189
SD = 36
95 percent of
responses are
normally
distributed

17. Data Analysis
Analysis:
• Independent samples t-test of factor scores to compare job
satisfaction between groups
• Compare and contrast post-graduate fellowship training effects within
demographic strata
• Multiple Linear Regression
• Calculated to predict participants’ total job satisfaction based on years of NP
experience, state regulatory environment and completion of a post-graduate
education program

18. Independent Samples t Test
Table 2
Independent samples t test of factor scores and Cronbach alpha (N = 254)
Post-graduate education
Yes (n = 80) No (n = 174)
Factors α M SD M SD t Sig.(2 tailed)
Collegiality 0.95 4.33 1.03 3.94 1.05 2.74 .007*
Autonomy 0.91 4.93 0.75 4.57 0.87 3.19 .002*
Interaction 0.87 4.72 0.76 4.42 0.82 2.79 .006*
Growth 0.89 4.38 1.11 3.78 1.16 3.84 <.001**
Time 0.85 4.36 1.03 4.40 1.03 -0.28 0.78
Benefits 0.82 4.67 1.08 4.49 1.15 1.20 0.23
Note. * p < .05.
** p < .001.

19. Years of Experience
p = .030

20. Years of Experience/Post-grad. Ed
Statistically significant in No post-graduate
education group only (p = .019)

21. Statistically insignificant
State Regulatory Environment

22. State Regulation/Post-grad. Ed
Statistically insignificant

23. Post-graduate Education
p < .001

24. Regulation/Experience/Post-grad. Education
More than 3 years experience, post-graduate
education & full practice authority
VS.
More than 3 years experience, post-graduate
education & restricted practice
p = .018

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

26. Limitations
Participants recruited by email invitation
• Indirectly through program directors
Comparison group recruited through an online community of professionals
Parametric tests on ordinal data may be considered a study limitation
• Distribution nearly normal with few outliers
• Supports the use of parametric tests in this study

27. Post-graduate NP Education
Significance:
• Post-graduate fellowship training significantly impacts NP satisfaction with
professional growth, autonomy, collegiality and interaction
• Satisfaction with work time and job benefits is less apparent in this study
• Knowledge of factors that influence job satisfaction is advantageous:
• NPs considering fellowship education
• Employers considering program development
• Policy makers

28. References
Boyar, K. L. (2010). Nurse practitioner residency programs and healthcare reform on
ADVANCE for NPs & PAs. Retrieved from http://nurse-practitioners-and-physician-
assistants.advanceweb.com/Features/Articles/Nurse-Practitioner-Residency-Programs-
and-Healthcare-Reform.aspx
Brown, M., & Olshansky, E. F. (1997). From limbo to legitimacy: A theoretical model of
the transition to the primary care nurse practitioner role. Nursing Research, 46(1), 46-51.
Dower, C., & Christian, S. (2009). Physician assistants and nurse practitioners in specialty
care: Six practices make it work. San Francisco: University of California.
Flinter, M. (2011). From new nurse practitioner to primary care provider: Bridging the
transition through FQHC-based residency training. Online Journal of Issues in Nursing,
17(1), 6.

29. References
Kapu, A. N., Kleinpell, R., & Pilon, B. (2014). Quality and financial impact of adding nurse practitioners to
inpatient care teams. The Journal of Nursing Administration, 44(2), 87-96.
doi:10.1097/NNA.0000000000000031; 10.1097/NNA.0000000000000031
IOM (Institute of Medicine). (2011). The future of nursing: Leading change, advancing health. Washington,
DC: The National Academies Press.
Landivar, L. (2013). Men in nursing occupations. Washington, DC: U.S. Census Bureau.
Misener, T. R., & Cox, D. L. (2001). Development of the misener nurse practitioner job satisfaction scale.
Journal of Nursing Measurement, 9(1), 91-108.
Wilcox, M. A., Broyhill, B. H., Taylor, D. A., & Williamson, S. B. (2015). The lifecycle of the advanced clinical
practitioner. Nurse Leader, 13(2), 27-30. doi:http://dx.doi.org/10.1016/j.mnl.2015.01.015
Wiltse Nicely, K. L., & Fairman, J. (2015). Postgraduate nurse practitioner residency programs: Supporting
transition to practice. Academic Medicine : Journal of the Association of American Medical Colleges, 90(6),
707-709. doi:10.1097/ACM.0000000000000567 [doi]