The role of the nurse practitioner (NP) requires sophisticated clinical skills, critical thinking ability, political savvy, a high level of decision-making and the ability to negotiate terms for job satisfaction (Pearson, 1990, 1995). Often there are few role models, and the job can lead to feelings of isolation (Koelbel, Fuller, & Misener, 1991). The nurse who enters a NP Program is often one who is already confident in her/his present nursing role. Leaving this comfort zone of competence and entering a new position with different expectations can lead to feelings of disorganization, uncertainty, and insecurity (Hayes, 1994).
Because the role is evolving and is influenced by state regulations, the health care delivery system, the nursing profession, the medical profession, and the practice setting of the NP, the academic preparation of the NP should be assessed on a frequent basis. Most colleges and universities do this in a form of a questionnaire sent to the graduates on a yearly or less frequent basis. Few qualitative studies are conducted to assess this transition.
Academic NP programs began in the 1960s in response to the shortage of primary health care physicians (Koch, Pazaki, & Campbell, 1992). The NPs role was to assist clients in meeting their health needs by complementing the physician's role (Mitchell & Grippando, 1993; Pearson, 1990) and emerged in rural and occupational settings with emphasis on primary health care. Such group practices provide cost-effective and care-effective service (Fitzgerald, Jones, Lazar, McHugh, & Wang, 1995).
Legislative restrictions on independent practice, lack of national health care, and unequal power relationship between physicians and nurses are important barriers for nurses who want to practice in the advanced nurse role (Pearson, 1995). Other problem areas are: (a) Nonsupportive attitude of other nurses and the medical community (Hupcey, 1993; Pearson, 1990, 1996); (b) Lack of influence on poUcymaking bodies (Hamric, Spross, & Hanson, 1996; Pearson, 1990, 1995); (O Co-dependent relationships with other health care providers (Pearson, 1990, 1995); (d) Assuming too many responsibilities in a NP position (Hupcey, 1993; Pearson, 1990, 1995); (e) Fear of replacement by other professionals (Pearson, 1990, 1995); and (f) Lack of administrative support (Hupcey, 1993). NPs must be adept at marketing, understand and speak the business language, and be able to play power politics (Hamric, Spross, & Hanson, 1996; Pearson, 1990). There are many sources of stress for a new graduate who is also learning the role of a primary care provider.
Of particular interest in this research was the transition to the NP role. A transition is defined as a dynamic movement between two relatively stable states with phases of entry, passage, and exit, requiring life pattern changes (Chick & Meléis, 1986). Entry begins with the first anticipation of transition and ends when stability has been achieved. At exit, the individual may attain a higher level of stability and functioning as compared to the period before the transition.
A pervasive characteristic of transition is the feeling of disconnectedness (Chick & Meléis, 1986). The loss of previous reference points; the disruption of linkages; incongruity between access and needs; and discrepancy between what was expected and what evolved in the transition contributes to many emotions, especially a sense of insecurity and disequilibrium.
Commonalities in transitions include "changes in identities, roles, relationships, abilities, and patterns of behavior" (Schumacher & Meléis, 1994, p. 121). These "patterns of behaviors" are disorientation, distress, depression, anxiety, and elation and happiness (Chick & Meléis, 1986). Variations in the responses to a transition are brought about by differences in level of planning; emotional and physical well-being; level of knowledge and skill preparation; environmental resources and support; and the perception of the meaning and expectations of the individual (Schumacher & Meléis, 1994).
The purpose of this research was to obtain a better understanding of the transitional process of the graduate to the first position as a NP. The perceptions of the graduate's preparation, gains, losses, and strategies for adjustment were explored.
The research questions that guided the research were: (1) How do NPs perceive their preparation for the transition to their new role? (2) Are there perceived losses as well as gains in the transition to NP? (3) What are the perceived barriers and facilitators in the transitional process to NP? (4) What are the coping strategies perceived as most helpful in the transitional process to NP?
A qualitative approach using focus groups was used to explore the experience of the transition to first job position as a NP. Focus groups were chosen because of the quality of data that could be obtained. In-depth perceptions and attitudes are shared. Ideas are generated within the interaction of the group through skillful probing of the moderator (Basch, 1987; Clark, 1997; Kingry, Tiedje, & Friedman, 1990; Krueger, 1998; McDaniel & Bach, 1994).
Names of recent NP graduates of one university program were obtained. Of the 30 recent graduates who were practicing in central Illinois as NPs, 21 alumni agreed to participate in one focus group. The age range was from 33 to 52 years (M = 43); 20 (95%) were married and 1 (5%) was single. Overall nursing experience ranged from 3 to 30 years (M = 18.9) and the years of management experience from O to 24(Af= 7.7). This included 50% (n = 11) of NPs with 1 year or less experience, with the remaining having 3 to 7 years of experience. Belonging to professional organizations were 19 (90%) with most belonging to the American Nursing Association and 15 (71%) of the 21 indicating an affiliation with a NP group such as the Nurse Practitioner Council.
The interviews were guided by a series of open-ended questions that were developed from the transitional and nursing literature. The questions were related to the academic preparation, gains and losses, barriers and facilitators, and coping strategies of a professional transition. An example of an interview question was "What was the most significant gain in your transition?" When the response was, "The relationship with the patient." The follow-up probing question was, "How is this relationship different from other nurse-patient relationships?"
Graduates were sent a letter inquiring about their interest in participating in a focus group followed by a telephone call. Those who were interested participated in one of the four focus groups that were held in four different areas of central Illinois. Notes were taken during the focus sessions by the assistant moderator. The sessions were audiotaped and later transcribed. Participants signed consent forms indicating they could refuse to participate in the study or withdraw at any time with no adverse effects.
While the participants were still in the focus group, inconsistencies and vague comments were probed for understanding. As the session progressed, key points were repeated by the moderator for validation by the participants to establish credibility of data, a process identified by Krueger (1998) as participant verification. The insights from one focus group were presented to the next focus group (with different participants) for further consensus and clarification. First impressions and interpretation of data were discussed between the researchers in debriefing meetings immediately following the focus group sessions, a step in gathering data recommended by Krueger(1998).
Processing and analyzing the data began immediately. Coding categories and themes were developed through a process of constant comparative analysis described by Lincoln & Guba (1985), a technique in which the investigator simultaneously compares one incident to another to generate properties of categories, rearranges coded categories into patterns, and reintegrates the patterned categories into a conceptualization that encompasses the experiences of the subject. Transcriptions of the audiotapes were first individually coded by each researcher. The analysis continued until a consensus by the investigators was achieved.
One researcher, trained in Krueger's methods, was experienced with using focus groups for research studies. The second researcher was a nurse practitioner and familiar with the transition into the NP role. To build trustworthiness, two colleagues, familiar with qualitative method and focus groups, but not involved with the research project, served to further analyze the data at various points and verify the themes and conclusions, a process referred to as peer debriefing by Lincoln and Guba (1985). Four focus group sessions, with different participants, were conducted until no new themes emerged and saturation was believed to be achieved (Krueger, 1998; Lincoln & Guba, 1985).
Although the interview questions were refined, the topical framework of preparation, losses, barriers, facilitators, gains, and coping strategies of the NP remained. The major themes across the focus groups that emerged were the (a) loss of control of time and privacy, (b) sense of isolation, (c) relationship changes and losses, (d) role ambiguity, (e) significant personal satisfaction of role, and (f) importance of a support network.
At the beginning of each interviewing session, the participants were asked to give a word or thought that would describe how they felt during this transition to the role of NP. Their responses included: exciting, nervous, anxiety, overwhelmed, scared, uncertain, panicky, novice, inadequate, halting, stressful, and frustration, indicating the transition was embedded with many emotions. These thoughts and reactions were reflected and expanded in later discussions.
When participants were asked about their academic preparation, they generally reported feeling prepared for the NP role, although feelings of guilt, uncertainty, and inadequacy derived from the tension between knowing and not knowing information were expressed.
I don't know if you ever feel completely adequate. . . In my case, I practiced with five dînèrent physicians, and none of them did the same thing. I had no protocols. . . being the first nurse practitioner was very difficult. I felt like I had to prove myself, not only to me, but to them also. What happens if I give the patient something and he has a bad reaction, or he actually dies because I missed something I should have treated. That is kind of overwhelming, but you get through that.
Many participants expressed that previous nursing experience provided a strong foundation of confidence, composure, and ability to integrate knowledge and make good decisions. Filling in knowledge gaps and consulting when necessary were identified as important.
The consensus of the participants was that their strength as NPs was their ability to teach health maintenance, but much of their time was spent with episodic illnesses, an area where they felt less prepared. They frequently mentioned they were often functioning from a medical model, instead of a nursing model, but felt this was necessary, at least at the beginning.
Loss of Control
Personal Time. When asked what was most difficult in the NP role, "loss of time" appeared in many different ways. Long work hours and few breaks led to fatigue but were viewed as part of the job. Many times the needs of the patients contributed to the time crunch. Since every patient must be seen by the end of the day, all of the personnel in an office could have their schedules changed with work-in clients.
They (patients) call and say they have a cold, and they come in and they start crying- just sobbing- what can you do? . . . You are already 35 minutes behind, you are just going to get another 35 minutes behind.
Interestingly, the nurses who had been in practice longer indicated the time constraints do not necessarily lessen. The following comment indicated the exhaustion and frustration with the lack of control of the situation.
A lot of people call the office and say they only want to talk to me, so when I get done at the end of the day, I have all of these phone calls. I don't want to discourage them. Some of them are unimportant. . . I am so exhausted. I go home and can hardly do anything. I really want to be involved in other things, but I can't keep up. So I think how can I cut back, and there is just no way.
Privacy. When discussing the loss of control, privacy issues were also communicated. Most participants were functioning in a small community where everyone knew who they were. When a client met the NP in a public place, this was an opportunity for discussion of a particular medical problem.
Occasionally, I see people out at the grocery store or wherever. And they say "My blood sugars have been running. . ." I will say "Call me tomorrow at the office, and I will look at your chart."
Some participants acknowledged they must go out of town to do their shopping, because it was so difficult to deal with the loss of privacy.
You can't go to the mall anymore. . . They just dial the phone and call me at home. . . They don't think they can talk to anybody else. . . If they call, I take care of their problems. . . But it is a real issue.
Although the participants perceived the benefits of living in a small community far outweighed the disadvantages, practicing as an NP had changed their Ufe. A protective barrier or space between themselves and the public had to be instituted to gain some control over the situation.
Many participants identified themselves as pioneers because they were often the first NPs in their community; yet, they perceived a loss of identity since they were neither a traditional nurse nor a physician, but a member of a unique group within the health care community. Tb establish a role that was their own, respondents stated that it was necessary to distance themselves from other nurses and physicians. Thus, feelings of not belonging developed. In their personal life, the lack of time to invest in close friendships also contributed to feelings of loneliness and isolation.
In our office we have over 50 employees, it is a big practice. The physicians formed a corporation, and they have corporation meetings once a month, the office staff have their office meetings, and the nurses have their nurse meetings once a month. I don't go anywhere. . . I hear more things from the receptionist. I don't belong anywhere. . . We don't fit anywhere. . . I'm it.
This lack of organizational fît was correlated with less professional respect and lack of decision-making participation.
We are planning a new building. Do you think I have seen those plans? Oh, no. Every doctor has approved those plans. . .interviewing new residents to come to the practice, do you think I get invited to those lunches? I will be seeing his patients. We aleo have memos that are sent out to all the doctors about this speaker coming to the hospital and everybody in the whole hospital can go to these things. Do you think I get a memo? I was so furious.
Professional Relationships Changes
In describing the barriers to the acceptance and performance of their role as NPs, the relationship with physicians and nurses frequently surfaced as an issue. Support, encouragement, and assistance from professional colleagues was an expectation learned from past experience. Now, support was not always present, which gave feelings of incongruity between expectations and what occurred. This led to feelings of disconnectedness, anger, and frustration.
Physician. Physicians were identified as essential in helping to establish credibility with clients. Their support and encouragement were key to the NPs confidence.
I nave a very supportive staff of doctors that love to teach. They complement me on my decisione. They will say, "If you ever have a question, just ask." You need that behind you.
When support was not present, frustrations were apparent.
I have repressed all those feelings (of resentment of not getting equal treatment) for eo long, it will probably take therapy to get them out. [This was followed by laughter and agreement.]
In school, they teach us. . . "You dont always have to treat with antibiotics." I would say [to the patient], This is not necessary. I really think what you have is a viral illness." I tell them to do all those nice "nurse practitioner things," and then "if you are not better, let me know." They [clients] call the doctor the following day, and he prescribes antibiotics. The next time [the patient] says, "You know, what you did for me didn't work, and I talked to the doctor. He gave me [antibiotic], and I got better the next day."
Nurses. A frequent and unanticipated barrier was the relationship with other nurses that left them with a feeling of betrayal and séparation. Nurses were in a central position to help them function more efficiently, but could also undermine the NPs confidence and effectiveness.
If they get behind during the day, guess who gets priority with help? I will have to go to the waiting room and get my patients.
They frequently had regrets as to how they handled their first work situation. They stressed the importance of earning the respect of the other nurses, which takes time.
With the two situations that I've been in, I think it would have been helpful to do some things to help [nurses]. . just to kind of let the nurses know that you are in there with them- that you support them. I didn't, and I really regret that.
Changes in the NPs role also resulted in the loss of old friends and a sense of isolation. One articulated eloquently the sadness of leaving her job as a nurse in the hospital.
Leaving my friends in "Open Heart"- ten people I had been with for three years, had a baby with, built a house with. I cried my whole last day. I still have that loss. It took me six months to clean out my locker, but there is no way I can ever go back.
Also communicated was the inevitability of not being able to go back in the process because it was now a different situation. Another participant expressed the special collegiality that was lost.
I miss being with my old friends at the hospital. You had emergencies going. Patients with diarrhea. You were running, and you were tired and were laughing with one another. I kind of miss that. Once I get to the office, all I think about are my patients and what I am doing. It is not real often that I do take time to joke with the other people, because I dont feel like I have that luxury.
Another barrier communicated by the participants was the ambiguity of the NP role. Parameters of the NP role are obscure. NPs not only function differently from state to state, from rural to urban, but also differently in the same locality. This made it especially difficult for the new graduate to carve out his or her role.
The participants expressed that it was difficult to adhere to the ideals of holistic care and health promotion, while responding to perceived physicians' expectations. One respondent indicated that her physician felt she asked too many questions of the client, which gave "a laundry list of problems'* too difficult to integrate into one visit. The respondents expressed the constant struggle with holding onto "who they were" and "what they did," which created stress in the physician-NP relationship. The participants suggested that a more collaborative educational experience while in school would have contributed to a greater understanding of each other's roles.
I found that the first few months, the physician was very intimidating. . . I wasn't sure what he thought of me at that point, and whenever he did go over my charts, he would ask me, "Why did you do this?" and "Why did you do that?" Now, he seldom questions what is on the chart. I found it was hard for me to be confident. I knew that what I put down was right and what we had learned. But to come across to him as really confident, I needed more skills on being assertive.
Several participants spoke of the frustration and anxiety that resulted from not knowing the safety borders of their practice associated with the lack of clear practice guidelines and legal parameters. Hearing that other NPs across town were doing different things made them question whether they were doing the "right" thing.
Because of pressures of the situation, the nurse often felt it was difficult to hold to the NP ideals and establish a role that was different from the physician.
In school, nurse practitioners had to incorporate prevention into every visit, but when I actually started practicing, there was no time. . . So after the first week, I said to myself, I am going to make one statement per patient per visit about prevention. First it started out "Do you wear your eeatbelt" and then "When did you have your last pap smear," etc. and it kept building. Now, I can say it all in 1 to 2 minutes or it is already documented. It takes a conscious effort to maintain your standard of practice.
The challenge of keeping abreast with new medical information especially in the area of treatment, such as pharmaceutical intervention, contributed to guilt feelings and stress.
There were 50 new drugs everyday. I was always looking up drugs. I did. . .lots of reading after I started. I felt that there was a lot of learning still to be had.
I still have an insert file. There is just so much medicine out, drugs to know. . .if I ever have a question about a drug or treatment, I always go find the doctor. . .1 wait till the doctor is free. Then I get behind [in my work].
Several participants expressed the belief that it was not the amount of information, but the ability to use this information efficiently.
Trying to follow particular physicians guidelines with prescribing medications was a source of stress.
He [physician] didn't use the drugs in the books. . .it was very frustrating. Today he uses this drug, tomorrow, he would use that drug. I thought my God what am I gonna do. I felt like pulling out my hair. I need some stability. I work with two doctors and one would always use the same thing, the other one would be all over the place. If it was his patient I would have to ask, because I really didn't know what was the drug of the day. I felt very confusedmy Ufe was stressed.
The NPs worried about their responsibilities and expressed the stress created.
At least for my first few years, I would say at least a couple times a week, "What if [client] had an acute abdomen? Fd go home and worry about all this stuff all weekend. . . I think that is one downside of being a nurse practitioner. You have to take that responsibility and a lot of times that turns into anxiety and worry. . . It took about two or three years before I finally felt that I wasn't going to endanger the patient.
Gains in Personal Satisfaction
The participants had no difficulty in clarifying why they loved being a NP: the increased self-confidence and changes within themselves; the autonomy and being able to expand their role; but most of all the special bond of trust with their patients, the satisfaction of helping and touching the lives of others.
I really feel like I can spread my wings. . . It is the most rewarding job I've ever had. . . It is the relationship with the patient. . . Granted, it is a little more frustrating, but there's one or two clients every day that just keep you going.
You are making a difference in the patient yourself . . . . You know you have this rapport and relationship that you can develop over the years. . .1 couldn't imagine doing anything else, and I have had a lot of high paying jobs, and I didn't dislike them, but I knew this wasn't something I was going to do forever.
I feel fortunate that people trust me with the deepest secrets of their Uves that they never tell anybody, not to other family members. No one! That is such a gift.
The dynamic quality of the job also contributed to the challenge, excitement, and satisfaction.
That's part of the advanced role. It keeps you on your toes. You are always learning, and that's part of what is good about it.
Network of Support
The most frequently mentioned coping strategy that was useful throughout the transition was the development of a network of support people. All but two of the participants met with other NPs in semistructured sessions or in an informal manner on a monthly basis. In these groups, strategies for educational support and profit sharing were planned. It was important to them to be united and to have their "ducks in a row." They frequently called each other to share concerns or questions. Peers were perceived as the most important people to understand their situation. Family and patients were mentioned as support people who also helped them at various tunes. Physicians were perceived as important people Ui coping with this transition.
The feeling I had wae anxiety, but I also knew that I had a support system. I had a physician that I could call upon, who in the beginning was here more than he is now. I think it is critical that you have a person, a mentor, or a collaborative physician, someone with experience, that you have confidence in, that you can go to.
This study adds to the conceptualization of the profesaional transition to the first position as a NP. Findings suggest that this transition had elements of disconnectedness; changes in identities and role relationships; losses; distress and anxiety; as well as the gain of satisfaction and happiness that has been profiled in transitional theory described by Meléis and others.
Participants perceived themselves as still in an phase of disequilibrium even years after graduation with the first year being the most difficult. Even though they felt prepared for the role, they experienced anxiety, feelings of insecurity, inadequacy, and uncertainty. Their past nursing experience and assessment skills were perceived as their strengths and health promotion as uniqueness.
A theme identified was the respondent's struggle with the loss of control of personal time and privacy. Being new as a health care provider in a community generated performance pressure and stress. Accepting whatever challenge the client offered even at the cost of time and energy was a constant conflict. Difficulties in managing time and in confronting anxiety in the initial year of practice were also findings of Brown and Olshansky (1998).
There were many reasons for the sense of isolation: a disconnection from the wide-world group of nurses; invisibility because they are shunned and treated differently than other nurses and physicians; the need to distance themselves from other health care providers; the loss of old friends and professional life style; and changes in relationships. The loss of personal privacy in a small community led to a perceived need to construct a protective barrier. The interesting paradox is the NPs struggle to be different, autonomous, carve their unique role, and maintain privacy only further highlighted the feelings of disconnectedness, isolation, and loneliness. The losses were most difficult and very similar to the loss expressed by nurses who were in the transition of retiring (Kelly & Swisher, 1998).
Changes in professional relationships were often unexpected and difficult. Other nurses contributed to the development of the NP1S self-confidence and ability to be efficient. Yet, the nurse often was perceived as resenting the NFs position and role. A source of frustration was not being accepted and treated as an equal member of the team.
Role ambiguity was accentuated by the unclear boundaries and awareness that there was a wide range of how NPs practice. This situation left them unsure, but cognizant of the importance of professional nursing organizations to acknowledge and support the needs of the nurse practitioner with political clout. The continuous challenge of keeping abreast of medical and nursing knowledge left the respondents with a sense of frustration and guilt in their role development. There was considerable tension between what they perceived they knew and what they should know. A key person to assist with this adjustment was the collaborating physician. The importance of a mentor was a conclusion articulated by others (Brown & Olshansky, 1998; Hupcey, 1993; Talarczyk & Milbrandt, 1988; Wirth, Kahn, & Storm, 1977).
Although there were many concerns and apprehensions, the participants expressed repeatedly their love for what they do, the pride and satisfaction in what they had accomplished, and the reward of a bond of trust with clients on a level not experienced previously. This motivated them to excel and make whatever sacrifices necessary to pursue their goal. They perceived that this was the "best Life of all" and could not imagine doing anything else.
The sample size was small and the graduates were predominantly practicing in rural areas that limit the generalizability of the findings. Recommendations for further study include investigating ways to socialize the NP into the role during the educational experience; finding ways to condense the plethora of newly published material and use it in a more efficient manner; and replicating the study with other advanced practitioner graduates, as well as NPs in more urban areas. Another interesting comparison would be the transitional phase of the nurse practitioner and the family practice physician in the initial urban position.
Findings suggest implications for the individual graduate, other health care providers, and faculty in academic institutions who can facilitate and influence this transitional process. The assumption is that a better awareness of the transitional process will lead to greater understanding and a shorter adjustment period For new graduates, there may be perceptions of disconnectedness, anxiety, and insecurity. Recognizing these feelings as normal and time limited is a step in understanding the process. Becoming involved in professional groups and organizations will prevent feelings of isolation.
The careful selection of a mentor to facilitate role development and job satisfaction is important. Professional colleagues need to be patient, give verbal support, and consistent guidelines during this transitional period because their encouragement is important in the professional growth and acceptance of the NP. Education of the functions of the NP may be necessary for the community if the role is unfamiliar.
Ways in which academic facility can facilitate the NP graduate's transitional adjustment period are (a) introducing the students to professional organizations and other possible support people; (b) seeking avenues of staying connected to the new graduate such as through innovative technology and continuing education programs; (c) establishing curricula with increased collaboration between medical and NP students during the school years to assist in a mutual understanding of roles; (d) planning seminars with the students emphasizing the adjustment phase of moving from expert, to novice, and back to expert; (e) sharing tips on how to manage limited time when in practice; (f) exploring methods with the students on how to manage and synthesize the volumes of journal readings; (g) discussing with students the loss of privacy that may occur and the need for a protective barrier; and (h) emphasizing the gains in personal satisfaction that will onset any negatives.
Grant received from the Illinois League for Nursing.
- Baech, C. (1987). Focus group interview: An underutilized research technique for improving theory and practice in health education. Health Education Quarterly, 14(4), 411-447.
- Brown, M., & Olshansky, E. (1998). Becoming a primary care nurse practitioner: Challenges of the initial year of practice. The Nurse Practitioner, 23(7), 46-66.
- Chick, N., & Meléis, A.I. (1986). Transitions: A nursing concern. In Peggy L. Chinn (Ed.), Nursing research methodology: Issues and implementation (pp. 237-257). Rockville, Maryland: Aspen Publishers, Inc.
- Clark, M. (1997). Nursing education: Focus on flexibility. Journal of Nursing Education, 36(3), 108-113.
- Fitzgerald, M., Jones, P.E., Lazar, B., McHugh, M., & Wang, C. (1995, January 15). The midlevel provider: Colleague or competitor? Patient Care, 20-37.
- Hamric, A., Spross, J., & Hanson, C. (1996). Advanced nursing practice: An integrative approach. Philadelphia: W.B. Saunders.
- Hayes, E. (1994). Helping preceptors mentor the next generation of nurse practitioners. Nurse Practitioner, 19(G), 62-66.
- Hupcey, J. (1993). Factors and work settings that may influence nurse practitioner practice. Nursing Outlook, 41(4), 181-185.
- Kelly, N., & Swisher, L. (1998). The transitional process of retirement for nurses. Journal of Professional Nursing, 14(1), 5361.
- Kingry, M., Tiedje, L., & Friedman, L. (1990). Focus groupe: A research technique for nursing. Nursing Research, 39(2), 124125.
- Koch, L" Pazaki, S.H., & Campbell, J. (1992). The first 20 years of nurse practitioner literature: An evolution of joint practice issues. Nurse Practitioner, 17(2), 62, 64-66, 68.
- Koelbel, P., Fuller, S., & Misener, T. (1991). Job satisfaction of nurse practitioners: An analysis using Herzberg's theory. Nurse Practitioner, 16(4), 43-56.
- Krueger, R. (1998). Analyzing and reporting focus group results. Vol. 6. InD. Morgan, & R. Krueger (Eds.), The focus group kit. Thousand Oaks: Sage Publications.
- Lincoln, Y-, & Guba, E. (1985). Naturalistic inquiry, Beverly Hills: Sage Publications.
- McDaniel, R., & Bach, C.A. (1994). Focus groups: A data-gathering strategy for nursing research. Nursing Science Quarterly, 7(1), 4-5.
- Mitchell, P., & Grippando, G. (1993). Nursing perspectives and issues. (5th ed.). Albany, New York: Delmar Publishers, Inc.
- Pearson, L. (1990). 25 years later: 25 exceptional NPs look at the movement's evolution and consider future challenges for the role. Nurse Practitioner, 15(9), 9-31.
- Pearson, L. (1995). Annual update of how each state stands on legislative issues affecting advanced nursing practice. Nurse Practitioner, 20(1), 13-18.
- Schumacher, K., & Meléis, A, (1994). Transitions: A central concept in nursing. IMAGE: Journal of Nursing Scholarship, 26(2), 119-127.
- Talarczyk, G., & Milbrandt, D. (1988). A collaborative effort to facilitate role transition from student to registered nurse practitioner. Nursing Management, 19(2), 30-32.
- Wirth, P., Kahn, L., & Storm, E. (1977, November-December). An analysis of 50 graduates of the Washington University Pediatrie NP Program: Part 3: Perceptions and expectations of the role in the health care system. Nurse Practitioner, 3(9), 16-18.