Nurse Practitioner Job Satisfaction and the Healthy Work Environment.

Abstract

The nurse practitioner (NP) role has evolved since its inception in 1965. Initially focused on primary care, the role has expanded amid the changing health care environment and provider shortages to encompass a variety of specialties and settings, including hospital-based, critical care, and subspecialty fields. Many job satisfaction factors positively and negatively affect NPs, who are integral members of the health care team. A healthy work environment—one in which factors that positively influence job satisfaction are capitalized and negative factors are reduced—can increase job satisfaction and staff retention and can ultimately improve patient outcomes.Almost 270 000 licensed NPs practice in the United States.1 Of these, approximately 42% have been granted hospital privileges. The majority are certified in an area of primary care; only 4.8% are certified in acute care.1The acute care NP (ACNP) role in adult critical care and the acute care pediatric NP role in pediatric critical care are vital for delivering high-quality, cost-effective care to acute and critically ill patients. The scope of practice for NPs in the acute care setting, where they treat patients who require complex acute and critical care, varies from state to state and is determined by each state’s Nurse Practice Act. Many states do not require NPs to have acute care education and certification in order to manage patients with acute and critical conditions. Few NPs have this specialty education and certification, thereby limiting provider availability. In particular, many NPs who practice in hospital settings do not have this specialty training. Consequently, they may require additional support and mentorship with onboarding and continuous learning in order to gain the knowledge they did not obtain through their initial NP educational program.As the NP role has grown to include the management of acutely and critically ill patients, certification has followed. In the 1990s, ACNP programs became available, focusing on treating adult patients. In 2016 more than 15 500 certified ACNPs were reported.2 The ACNP role has been well described in the literature.2–5 The first certification examination for acute care pediatric NPs was not until 2005; thus, given the shorter existence of the program, it is not surprising that the acute care pediatric NP is not depicted in the literature to the same extent as the ACNP.6The Consensus Model for regulating advanced practice registered nurses was developed in 2008.7 This model restricts the term advanced practice registered nurse to 4 roles: (1) certified nurse midwife, (2) certified registered nurse anesthetist, (3) certified clinical nurse specialist, and (4) certified NP. The Consensus Model focuses on 6 patient populations: adult/gerontology, family, pediatrics, neonatal, psychological/mental health, and women’s health. Typical ACNP programs focus on either the adult/gerontology or pediatric population.7 Nevertheless, given the shortage of ACNPs, many NPs who are trained in and certified for primary care work in critical care/acute care settings in states that do not require acute care training and certification. Like scope of practice, standards for practicing vary by state. For example, in Texas an NP must complete an ACNP program and obtain national acute care certification in order to manage patients with acute/critical health care needs,8 whereas in California, similar formal program completion and certification is not yet a requirement.9 With these variations in education and certification for newly hired NPs in the acute care setting, creating formal mentorship and onboarding programs is vital to meeting these learning needs.10Staffing challenges arise when appropriately trained physicians are lacking and resident coverage is low. In 2003 the Accreditation Council for Graduate Medical Education set limits on the number of hours a resident can work.11 Many hospitals hire NPs to fill this gap. Thus NPs are a qualified and integral part of the health care team, provide continuity of care, and as another dedicated member of the team, can decrease stress and burnout among other team members in the acute care setting. Nevertheless, with the variation in clinical nursing experience and the lack of standard clinical education, fellowship programs are urgently needed to help with onboarding.3The growth of the NP workforce in the critical care setting and in multiple subspecialty practice settings requires strategic planning by health care organizations to build policies and programs that support NPs in adapting to this changing work environment. The complex nature of the work requires strong advanced practice registered nurse leadership in order to create an organizational structure that monitors NPs’ satisfaction, develops their knowledge and clinical skill set, and builds resiliency so they can cope with the stressful demands of their work.According to Misener and Cox,12 job satisfaction isThe 44-item Misener Nurse Practitioner Job Satisfaction Scale is a validated and reliable survey that uses a 6-point Likert scale to measure NP job satisfaction. Misener and Cox12 identified items that received the highest satisfaction ratings: actual time spent directly caring for patients, how challenging the work is, being able to provide quality care, the feeling of being successful, and having access to preceptors. The items receiving the lowest satisfaction scores (called “dissatisfiers”) were involvement in research, conflict resolution processes, distribution of rewards, and being able to receive bonuses in addition to one’s salary.12Many NPs enjoy working directly with patients—a central reason for obtaining an advanced degree and NP certification. Nurse practitioners also want to be challenged in their work, and the acute care setting requires rapid assessment, diagnosis, and intervention. Working to the “top of one’s license” and autonomously have been explored in relation to job satisfaction. Athey et al13 found that level of autonomy was linked to work setting, and hospital-based NPs reported less autonomy than NPs in ambulatory settings. In the acute care setting, ACNPs work as part of a multidisciplinary team, not in isolation. Kilpatrick14 found that adding an ACNP to the team improved team communication and coordination of care, which ultimately improved the quality of care delivered to patients.Nurse practitioners know their limitations and consult their physician colleagues when necessary. Because technology, diagnostic modalities, and treatments are rapidly advancing, novice and experienced NPs must continually seek education in order to stay abreast of current practices and new technologies. Onboarding and orienting new hires and encouraging activities for professional growth require experienced preceptors and mentors.Having access to preceptors is one job satisfier identified by NPs.12,15 This access is especially important for new ACNPs in order to ensure that they can easily transition from students to novices in the fast-paced and complex acute care/critical care environment.10 One health care organization recognized that its turnover rate for advanced clinical practitioners (eg, NPs, physician assistants) was surpassing the national average of 10%; thus the organization created a 1-year postgraduate fellowship program.16 After implementing the program, the organization’s turnover rate was reduced by 50%. Its vacancy rate also decreased, as many fellowship graduates remained employed at the facility upon completing the program.16For experienced ACNPs who are in a new setting, a nurse mentor/preceptor is beneficial, aiding in onboarding and teaching policies and procedures at the new organization. Experienced NPs in an organization may benefit from mentorship with a doctorally prepared nurse for continued professional growth and opportunities for participating in research. Mentored growth activities might include leading a performance improvement project, applying for a research grant, writing an abstract for a poster or oral presentation at a national meeting, or writing a manuscript for publication in a peer-reviewed journal. These professional growth activities may improve NPs’ job satisfaction; however, NPs would need office time in which to work on these professional endeavors.Effective leadership is a crucial component of a healthy work environment; the presence and actions of a leader may be the most influential factor in the health care work setting.17 Many health care organizations have directors of advanced nursing or advanced practice providers (NPs might be grouped with physician assistants, nurse midwives, nurse anesthetists, and clinical nurse specialists). This centralized approach to leadership has been recommended as the demand for NPs in the health care environment has increased.18 Bahouth et al18 compiled various resources for new NP leaders, including budgetary considerations, characteristics considered to be important for new leaders, and a start-up activity checklist for the new NP leader.The director is typically an NP and thus knows the state’s scope of practice for advanced practice registered nurses. Policies can be developed that enable NPs to practice to the “top of their license.” The NP director can streamline processes for onboarding, credentialing, mentoring, and evaluating NPs. Equitable and flexible scheduling can be developed with input from NPs in each specialty area. Protected time for professional growth activities and funds for attending conferences can be explored and developed.Some health care organizations have implemented NP clinical ladders to advance professional practice. Clinical ladders for registered nurses have been in use for more than 25 years.19 A recent article described one institution’s process of developing and implementing a clinical ladder for its NPs; the authors also conducted a satisfaction survey after the ladder had been implemented.20 They surveyed the NPs again 2 years after the first survey and found that NPs responded more favorably to the ladder over time. On the basis of the surveys, the authors modified some of the processes used to advance up the ladder.As more NPs practice in complex health care environments, nursing leadership must monitor the “pulse” of this group. This can happen through surveys or with more effective focus groups or small group meetings. Nurse practitioners must feel that their concerns are heard and that action will be taken if changes are necessary. Some organizations use staff surveys, but staff may feel that their responses will not lead to change and consequently might choose not to participate. With strong leadership, however, NPs know that their voices and concerns are heard and that cultural or environmental changes will be made.Health care organizations without a director of advanced practice nursing can explore creating such a position. The director would be the “champion” of the NPs and can bring issues that impact NPs to the attention of the executive leadership team. In organizations without a director of advanced practice nursing, the various divisions might have different hiring practices and varying onboarding and mentoring practices. This lack of consistency within the same facility might result in negative feelings if, for example, an NP in one area finds that an NP in a different area has different benefits, such as protected time in which to conduct research or reimbursement for costs associated with attending a national conference. The “silo effect” must also be considered; it happens when an NP is the only one in his or her work area, and no efforts are made to bring NPs together for a formal, regularly scheduled meeting.Health care organizations have learned that registered nurse residency programs positively affect retention of nursing staff, and similar residency or fellowship programs can be developed for novice NPs. An integral component of an NP residency program is formal men-torship. Navigating a new health care environment can be stressful for both novice and experienced NPs, and a mentor might help to alleviate some of the stress.Health care institutions need to recognize that schedule flexibility is vital to recruiting and retaining NPs. Some NPs desire long 12-hour shifts, whereas others want 8-hour shifts; some want to work only part-time, whereas others want to work full-time. In addition, some NPs might want to moonlight in other critical care/acute care areas at their facility. Critical care areas may need NPs they hire to cover overnight or weekend shifts. Organizations cannot cater to each NP, but leadership must recognize that some areas may require more flexible scheduling practices.Healthy work environments are critical not only to NPs but also to the patients and families entrusted to their care. Supporting knowledge acquisition, strong mentorship programs, involvement in direct patient care, flexible scheduling, and professional growth opportunities are some of the NP job satisfiers that have been identified. Nursing leadership and NPs must work together to create a healthy work setting. As respected and important members of the multidisciplinary health care delivery team, NPs can flourish in a healthy work environment and provide high-quality care to acutely and critically ill patients.