RN-to-NP Role transition

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Facing the challenges and improving the outcomes.

In the 2012-2013 academic year, 15,000 nurses began the exciting transition from RN to NP.1 Research shows that these new NPs will experience a significant role transition in their first year of practice. The available research on this topic is limited in defining the factors involved in a successful role transition, especially in examining the relationship between prior RN experience and the transition to NP. Yet, the consensus of admission requirements for entry into NP programs at the top-ranked nursing schools includes at least 1 year of prior RN experience before starting NP clinical rotations.2

This article examines whether prior RN experience is an asset for the new NP to build upon, an obstacle that necessitates attention, or a combination of the two. This exploration is guided by the following questions: What are the scope of practice differences between RN and NP? Is there a significant transition process from RN to NP? Is RN experience a factor in successful RN-to-NP role transition? What are realistic expectations for an experienced RN to consider in the advanced practice role?

Scope of Practice
During clinical rotations, NP students are often asked, “How long have you been a nurse?” NP preceptors ask this question because they may assume that having prior RN experience will lead to a smoother clinical rotation and ultimately an easier transition to becoming an NP. However, the scope of practice of an RN and the scope of practice of an NP are entirely different, which places even the experienced RN in a position to encounter a challenging, yet exciting, transition into this new role.

The scopes of practice for the RN and NP vary according to state laws and boards of nursing, but they are broadly defined by the American Nurses Association, the American Association of Critical-Care Nurses or other specialty nursing organizations, the American Nurses Credentialing Center, and the American Association of Nurse Practitioners.

These associations state that both the RN and NP share the mindful practice of critical thinking and have extensive training in diagnostic reasoning. The RN and NP have both been trained to systematically organize the care of patients using physical assessments, development of care plans, and evaluation of outcomes.3 The RN has the capability, through his or her distinct training, to develop care plans for patients to ensure positive patient outcomes. These care plans are developed through nursing diagnoses.

This CE article is sponsored in part through an education grant from Chamberlain College of Nursing.

For example, the RN can diagnose a patient with “activity impairment related to a pain.” In this example of a nursing diagnosis, the RN can independently decide to give pain medication prior to activity. The RN assesses whether the pain medication relieved the patient’s pain and reports the finding to the NP or physician to collaborate on an alternative plan of care in coordination with the RN’s pain assessment. The notable differences in standards of practice between the RN and NP emerge as the NP student learns advanced assessment skills in order to create a differential medical diagnosis. With this knowledge, the NP can initiate further lab orders, diagnostic studies, and treatment options including prescription medication to be administered by the RN. The NP is also responsible and trained to interpret testing, as well as perform any associated procedures within the NP’s scope of practice to identify patient outcomes in an autonomous and independent fashion.3

In the example above, the NP may diagnose the patient with a femur fracture and subsequently order opioids, obtain diagnostic imaging of the hip, and potentially consult an orthopedist. The NP will examine the testing and outcomes of these treatments, and will independently adjust the plan of care to correlate with the given diagnosis of the patient. This autonomy to implement and adjust the plans of care based on a medical diagnosis exemplifies the significant difference in scope of practice between an RN and NP.

Understanding the Transition
Acknowledging the scope-of-practice differences between these two positions is imperative to understanding the transition that occurs as an experienced RN becomes an NP. Historically, nurses have relied on Benner’s Theory of Transition, which outlines that a nurse begins as a novice and transitions into an expert.4 This theory is widely expressed within nursing practice but does not specifically apply to an expert RN who is transitioning back to the novice role as a new NP.

Benner’s theory can be applied to hypothesize that the experienced RN feels established in his or her role as a nurse and now senses insecurity as a novice NP. To further emphasize this instability, a recent concept analysis of the RN-to-NP role transition describes a loss of confidence and increased anxiety as the expert RN becomes a novice NP.5 In particular, this concept analysis reveals that the height of such an instability occurs within the NP’s first year of practice.

In a more specific study performed in 1997, Brown and Olshansky interviewed 35 RNs-to-NPs at 1, 6 and 12 months after graduation from a family nurse practitioner (FNP) program and described the stages each experienced.6 The authors described the stages as: Laying the Foundation, Launching, Meeting the Challenge, and Broadening the Perspective.6

During the first stage, “Laying the Foundation,” the new NP has recently graduated. He or she is juggling the worry of seeking employment while simultaneously studying for the boards, becoming certified, and navigating the licensing and credentialing process. Within this stage, the novice NP lays the groundwork for future employment and career opportunities by choosing a specialty area and determining the best practice setting.
In the “Launching” stage, the NP starts his or her first job and may feel anxiety about his or her performance. Brown and Olshansky believed that the main issue during this stage is the difficult task of managing anxiety related to the responsibility of diagnosing and treating patients as a new provider.6 In addition to feelings of anxiety, the new-to-practice NP may also experience the “Imposter Phenomenon” in this stage. New NPs have described this phenomenon as having a sense of being fully trained and qualified for the job while simultaneously experiencing feelings of inadequacy.7

After the first several months of practice, the new NP may begin to “Meet the Challenge.”6 In this stage, the NP starts to feel more comfortable and excited in the new role and begins to develop strategies to become more efficient. These strategies may include a more systematic approach to reviewing patient results and treatments. It is anticipated that the NP will be able to increase his or her patient load while feeling more independent.
Finally, the theory concludes in the “Broadening the Perspective” stage, in which the NP adds new challenges and becomes more involved in the advanced practice nursing community.6 This may include joining committees in the workplace or joining national, state or local NP organizations.
After examining these transitional theories of the past and scope-of-practice differences, it is evident that even the seasoned or expert RN can experience role confusion from RN to NP. Cusson and Strange surveyed70 experienced neonatal RNs who transitioned into neonatal NPs and found that the new-to-practice NPs experienced increased anxiety related to role confusion during the transition.8 Specifically, the NPs in this survey felt insecurity in having the responsibility and decision making capacity to diagnose and write orders for patients instead of following orders in the RN role.8 These novice NPs explained that the stress of the new role was related to a significant change from nursing care and that the NP role was more centered on the medical diagnostic aspect of care.8

Additional literature produced to describe the transition process from experienced RN to NP emphasizes the importance of integrating the medical model of care with the nursing model of care to facilitate successful role transition. In order to integrate these two very different models of care, an experienced RN should have the skills to use his or her innate ability to organize the care of a patient and mobilize these established skills to become the leader in care implementation as an NP.

In a study of 25 experienced ICU RNs who completed advanced practice studies to become NPs, the NPs who recounted a more positive transition experience had the ability to synthesize their RN experiences with advanced medical expertise as an NP. Furthermore, these RNs believed that having RN experience was a necessary component but not an all-inclusive factor in a successful transition.9 This study illustrates the importance of applying prior RN experience to the medical model while simultaneously alerting the new-to-practice NP that an element of role confusion will persist in the first year of practice.

From these personal accounts of experienced RNs, it is clear that the transition from RN to NP is significant and warrants attention. Yet a gap in research exists with regard to the factors that influence the RN-to-NP transition. More specifically, no current studies support the notion that proficiency as an NP is directly related to the amount of RN experience – even though most graduate schools require RN experience prior to admission.

Although RN experience is considered important for entry into an NP program, some evidence conversely supports that such prior experience may, in fact, hinder the initial new-to-practice NP transition. A study conducted in 2004 indicated that nine RNs with a range of 0 to 32 years of nursing experience reported role confusion during the transition to FNPs.10 These FNPs recalled feeling conflicted between RN approaches to care and NP approaches to care, often feeling compelled to revert back to their practice as confident RNs. Conversely, one RN who continued her education from baccalaureate through graduate studies without any RN experience did not have any role confusion as a new NP.10 This RN stated that her progression into the FNP role was more seamless. She further described the process of going from RN to FNP as a continuous building of her education.10

Supporting Transition
Although research about the RN experience and its impact on the transition to becoming an NP is limited, the general factors involved in NP role transition are being investigated. Recent studies have found positive outcomes associated with smoother transitions in factors such as formal orientations for new NPs, early recognition of role transition during graduate school, and the establishment of a relationship with a mentor.
As of 2015, only one known study has examined the relationship between RN experience and successful NP transition. The descriptive, cross-sectional survey of 352 NPs concluded that the opportunity to experience a formal orientation when starting a new job was a more significant influence on successful transition than having RN clinical experience.11 The NPs in the study who received a formal orientation described a more streamlined transition and said they felt more confident and satisfied in the new role.11

The Institute of Medicine recommends formal orientations, also known as transition-to-practice programs or residencies, for new NPs or experienced NPs who are changing specialty areas.12,13 Research supports that these programs are being developed based on the belief that creating a smoother transition for new-to-practice NPs can also increase the retention of NPs more broadly.13

Even with these recommendations from the IOM, no universal standard for orienting the new-to-practice NP exists, and the structure of NP orientations varies from institution to institution. Further research is needed to define the orientation and training necessary in the first year of practice to increase confidence levels, decrease staff turnover, and ensure support during the transition.

Researchers argue that earlier recognition and anticipation of the change in role from RN to NP is essential to fully prepare the new-to-practice NP. Spoelstra and Robbins performed a qualitative study of 24 NP graduate students that concluded a role development course early in the first semester of the NP program increased student understanding of the new role.15 The course included an interview between the students and an experienced NP, in which the students could ask questions about the new role. Additionally, the students had weekly online discussions about the function of the NP and role transition. Such topics included: building a framework for nursing, direct patient care and understanding of NP professional responsibilities.14

This direct contact with an NP and the consistent dialogue about the particularities of advanced practice nursing allowed the students in this study to clearly identify core elements of the NP role early in their graduate education.14 With earlier recognition in the first semester of graduate study, the researchers concluded that students would become more aware of the difference in scope of practice, and would also learn details about the NP role so that they may sufficiently prepare for the transition.

Mentoring is a foundational component for a successful transition from RN to NP. A mentor acts as an advisor and resource through the entire NP role transition. A mentor to a novice NP can guide the learning and education necessary for acclimating into the new NP role, and help the NP student develop increased confidence and capability in performing new skills.15 Cusson and Viggiano highlight that mentors create a “safety net” for the NP student, foster personal and professional growth, and enhance their transition into practice.15 These authors believe that the responsibility for developing a network of mentorship should begin at the graduate educational level and extend into the novice NP’s place of employment to create a “mentoring culture” throughout the transition process.18 Within this network, the mentor is able to function as a guiding resource for the new-to-practice NP and can serve as a performance model for emulation.

In addition to these established influencing factors of NP role transition, this article proposes that new-to-practice NP develops individual transitional tools in order to decrease anxiety, help anticipate and prevent role confusion, and most importantly, embrace and enjoy the new role.

Although no formal guidelines exist for novice NPs, based on the available research about RN-to-NP role transition, this article offers five guiding principles for prospective NPs that may lead to a successful future in advanced practice:

Understand the Transition: The student should familiarize him- or herself with the scope of practice differences between the RN and NP role early. If this is not included in the provided advanced practice curriculum, as an independent learner, the student should educate him- or herself about the preliminary research and other previous works written on the transition process. The American Association of Nurse Practitioners is one example of a resource for novice NPs to learn the scope of practice on a state-to-state level. It may also be helpful to collaborate withany available clinical faculty to arrange an opportunity to shadow an NP to further investigate and learn the role of the provider. NP students may also want to take the time to reflect on the transition during clinical rotations by speaking with clinical faculty on a weekly basis to specifically discuss role transition.
Use Your Experience Carefully: RN clinical experience prior to NP practice is useful in particular clinical settings. An experienced RN possesses ingrained familiarity in how to communicate and treat patients. That being said, during the student NP’s first clinical rotation or experience, the student may be comfortable and have “intuition” to continue to care for the provided patients as they would in an RN role. The student may remain focused more on the execution of a given plan than being the implementer of the care and treatment plan. When possible, it may be helpful to draw from that RN experience in this new role, but to always be proactive and prepared with a medically-driven plan in mind.
Set Realistic Expectations: RNs with years of clinical experience should still expect to encounter a transition back to a novice advanced nursing provider after years of being an expert registered nurse. Based on the research and data provided, the student NP should prepare and expect to have feelings of being new or inexperienced in this specialty field. The student should embrace new knowledge and be conscious of feelings of insecurity. The student should also welcome challenges in the learning experience. The RN-to-NP transition phase may last for several months or years after initial certification, but knowledge will consistently be gained throughout the NP practice in a continuously changing and enhancing healthcare field.
Seek a Formal Orientation: The new NP interviewing for his or her first NP job should inquire about the possibility of a formal orientation and length of time provided for employer-provided learning. It can be beneficial to seek out an employer that will support the NP during this transitional period. In a situation where a formal orientation is not offered, a preceptor, mentor or assigned clinical leader should provide adequate feedback to ensure the success of the NP. The NP should request that feedback be predicted by setting weekly goals to assess achievement and progression. The NP-produced goals and employer feedback will help keep expectations for transition in perspective and ensure active learning and open communication between the employer and the NP. Open communication should remain established between the NP’s employer, peers and colleagues to obtain guidance about expectations and ensure a productive working environment.
• Find a Mentor: Mentors help navigate elements of the job that may not be articulated in a textbook or a lecture. Mentors can be preceptors, professors, colleagues or anyone who can offer insight into the details of the NP role. Mentors have experienced the transition and can provide personal insight on the subject. Incorporating multiple mentors allows the NP to gain a variety of perspectives during the advanced practice transition.

RN-to-NP role transition remains an underexamined area of research. However, the existing literature proves how important it is to recognize and to prepare for this transition. The new-to-practice NP who is prepared to embrace the challenges during RN-to-NP transition will be able to navigate successfully within his or her new career. This recognition will not only improve the NP’s performance on the job, but also extend to improvements in patient care.

Melissa Burke is a currently navigating the transition process from an emergency medicine RN to a nurse practitioner on a medical transplant service at the Hospital of the University of Pennsylvania in Philadelphia. She has completed a disclosure statement and reports no relationships related to this article.

References

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Melissa Burke

Melissa Burke is a currently navigating the transition process from an emergency medicine RN to a nurse practitioner on a medical transplant service at the Hospital of the University of Pennsylvania in Philadelphia. She has completed a disclosure statement and reports no relationships related to this article.

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