COVID-19 on New Primary Care Nurse Practitioners: A Qualitative Exploration.

New nurse practitioners (NPs) struggle with the transition to practice and feelings of uncertainty concerning roles and responsibilities. COVID-19 has added a new layer of stress. This pilot study used a qualitative case study design featuring semistructured interviews of 10 newly graduated primary care NPs. Data analysis revealed 2 main themes: (1) emotional burden, and (2) coping and support. Emerging themes highlight the resiliency of NPs, who cope and seek support when faced with emotional burdens. This study informs educators and employers on the needs of new NPs during a global pandemic in order to better support the future workforce.

This activity is designed to augment the knowledge, skills, and attitudes of nurse practitioners as they evaluate how COVID -19 impacted the adjustment of new nurse practitioners to their role of a primary care provider.

At the conclusion of this activity, the participant will be able to:

Identify common barriers and support measures that new NPs report during transition to practice

Evaluate how these barriers and supports differ from pre-pandemic transition to practice

Analyze the workforce and educational implications of these study findings

The authors, reviewers, editors, and nurse planners all report no financial relationships that would pose a conflict of interest. The authors do not present any off-label or non-FDA-approved recommendations for treatment.

This activity has been awarded 1 Contact Hour of which 0 credit is in the area of Pharmacology. The activity is valid for CE credit until July 01, 2024.

To receive CE credit, read the article and pass the CE test online at www.npjournal.org/cme/home for a $5 fee.

New nurse practitioners (NPs) struggle with transition to practice and moving from the experienced nurse to the novice provider. , They battle with uncertainty in their role and responsibilities. The COVID-19 pandemic added a new layer of knowledge, responsibilities, and stress to an already unsteady role. However, little is known about the needs of new NPs emerging since COVID-19. This qualitative case study focused on the experiences of new NPs to identify new barriers and potential resources, informing educators and employers on this changing role and the needs of new NPs during a global pandemic.

Background

From 2019 to 2020, the United States had more than 325,000 licensed NPs, with more than 36,000 new graduate NPs entering the workforce. Of those licensees, 89.9% held a primary care certification. Primary care NPs may care for patients across the lifespan, such as with the family NP (FNP), or within a specific population such as adult-gerontology or women’s health. Regardless, many new NPs report feeling unsure in their role and responsibilities. , COVID-19 added a new layer of uncertainty with unique demands.

Although new NPs report uncertainty regarding particular skills and knowledge, Hart and Bowen found that NP students reported the need for support with the transition to practice and revealed that many (49%) felt they were “practicing outside of their competency level.” Faraz also highlighted the importance of mentorship and support and found that new NPs felt a lack of respect and support, were plagued with an overwhelming workload, and were not allowed adequate time to safely see patients and keep up with administrative tasks.

Little is known about the NP experience specifically in emerging COVID-19 literature. However, a German study by Bohlken et al illuminated increased anxiety and depression among health care workers during COVID-19. In a literature review, Hall described the mental health impact to international frontline workers such as sleep deprivation, anxiety, and depression. Link et al cited worry, fear, and cyclical stress as the main themes of the FNP student experience in a qualitative study during COVID-19. Although valuable, these studies cannot be generalized to the new NP practicing in primary care in the US.

Purpose

The purpose of this qualitative case study was to pilot a study that explored the experiences of new NPs working in primary care in the US during COVID-19. The study aimed to answer the following question: “What is the lived experience of a new NP in the US working in primary care through a global pandemic?” The study also aimed to identify any barriers, gaps in training, and resources that emerged.

Methodology

A qualitative case study approach was selected because it lends itself to exploring a particular issue using a collection of cases. This methodology helped gain a deeper understanding of the new NP facing the challenge of COVID-19, including barriers and potential resources or support measures.

Ethical Considerations

This study was approved by The George Washington University Institutional Review Board (IRB) and deemed exempt (IRB# NCR202678). The 2 ethical concerns considered were emotional and psychological distress and confidentiality. Due to the sensitive nature of the study topic, the researchers discussed the possibility of uncovering emotional and psychological distress. Participants were encouraged to stop the interview at any time, and mental health services were offered. Moreover, confidentiality was maintained by obtaining only verbal consent, storing subject data, transcripts, and recordings in a secure cloud server, and masking of and avoiding the use of identifying information in the interviews and transcripts.

Population and Sample Selection

The inclusion criteria included NPs who were older than age 18, graduates of a US NP program in Spring 2019 or later, working in primary care, and currently employed before the pandemic onset (December 2019) in hopes of recognizing and highlighting changes that occurred in their transition to practice from their prepandemic experience. Those working outside of primary care or individuals with a secondary NP certificate were excluded.

New NPs were recruited via a closed Facebook NP group, of which one of the researchers is a member, and snowball sampling. Interested participants contacted the study team via email. Additional participants were recruited through recommendation by current participants. Because this study was a pilot, the researchers sought to recruit 10 participants or until recurring responses suggested saturation. Sandelowski suggests that samples sizes of 10 may be adequate for sampling among homogenous groups such as new NPs.

Data Collection

Participants were interviewed for 30 to 60 minutes using a semistructured design and asked, “Describe your experience as a nurse practitioner since the onset of the COVID-19 pandemic.” Follow-up questions were asked to gain deeper understanding of the topic:

How do you feel being in the role of a NP?

What has your mentorship process been like and how has it changed?

Are you in a residency or fellowship program?

What knowledge or skills do you wish you had in your NP education to prepare you for your experience?

What resources or support have you used to fill the gap in your knowledge and/or skills?

The interview concluded with demographic questions and a final question: “Is there anything else you would like to share?”

Two researchers conducted audio interviews via the WebEx web conferencing platform. Questions were asked by a single researcher, while a second researcher listened for themes and missing information. The interviews were automatically transcribed by Otter.ai dictation software. Two researchers read each transcript for accuracy, and corrections were made by reviewing the recording.

Data Analysis

Data analysis was conducted using MAXQDA software. Prefigured and emergent codes were both used in the coding strategy of this study. A prefigured coding strategy and codebook were developed using prepandemic transition to practice and pandemic literature as a framework. , , 5, 6, 7 , Emergent codes were added as necessary after reviews of the transcripts by the researchers (see Supplementary Final Codebook, available online at http://www.npjournal.org). If a coding discrepancy occurred, a third researcher with expertise in qualitative methods remedied it. A member checking process was used to review findings with participants and obtain consensus that the themes were appropriately captured.

Frequency of recurring codes was used to identify final codes and themes. In addition, a code relations analysis was conducted to assess the frequency of recurrent codes that occurred together and further supported the emerging themes. Salient quotes were extracted to highlight themes.

Results

Ten NPs (9 women) participated, ranging in age from 29 to 59 years old, and a range of registered nursing (RN) experience (range, 4-18 years). All were working in primary care settings1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 including internal medicine, family medicine, and women’s health, certified as FNPs (n = 9) or women’s health NP (n = 1). Four participants worked in a rural setting; the remaining participants worked in small or large cities and represented states across the country and Washington, DC.

Data analysis revealed 2 main themes: (1) emotional burden, and (2) coping and support. These themes were embedded within the new NPs’ experiences with the onset of COVID-19 and are described next using the most common codes and salient quotes. The Figure describes the relationships between each code and theme. From this diagram, the reader can also visualize where specific codes occurred together frequently.

Figure

Themes and codes of the new nurse practitioner’s pandemic experience. Note: Codes that have multidirectional arrows are ones that frequently occurred together in the analysis.

Emotional Burden

Emotional burden and negative emotions were apparent. COVID-19 has taken an emotional toll on all health care workers, and this subsample was no exception. This echoed throughout all interviews due to specific stresses such as fear and concerns for individual, family, and patient safety related to the pandemic. Participants also struggled with a lack of support and self-efficacy beyond that of the prepandemic transition to practice.

Safety/Fear

Personal protective equipment (PPE) evoked safety and fear issues. Fear and safety concerns often manifested in a discussion of PPE—either the use or lack of use in their practices. One NP cited friction in their practice over PPE use: “Some of us were on the side of ‘Hey, we need to properly protect ourselves,’ and some were like, ‘Oh, you can just wear a bandana or the same mask for three weeks in a row.’”

Like many health care providers, NPs feared for their individual, families’, and patients’ safety. One NP responded, “We were trying to mitigate as much risk as possible,” which highlights the constant assessment by providers to evaluate the risks of providing care. They weighed these risks both clinically and in their personal lives.

Family Impact

The family impact of COVID-19 was a significant source of emotional burden. One NP’s response—”At the end of the day, you go home, and you jump in the shower and pray to God you’re not going to give it to your family”—demonstrated anxiety about work impacting their family. These sentiments were shared by other participants as well, with quotes such as “the emotional impact was profound. I mean, my kids are still getting over it.” Another shared,

My [partner’s] a teacher… Me not being here definitely has [added] a tremendous amount of stress, because it’s not only [that they were] designing a whole new lesson plan and everything for school, [they were] also taking care of both kids.

Isolation

Isolation instituted as a protective factor for friends and family created significant emotional burden. Many of these NPs resorted to self-isolation, avoidance of physical contact, and displacement from family and friends. One participant moved out of their home: “And so I was able to just move into [a] house for two months or so while I was going through this, [so] as to not expose my family.” Another NP reported, “So for me, it was very scary… but it more affected me seeing people outside. I didn’t feel comfortable seeing friends and family.” Another stated,

[There was] no physical contact with anybody for a couple months. For somebody who hugs everybody, I hug my patients, I shake their hands, I do all of that. And to not have any physical contact with anybody for a couple of months was emotional—very, very strange for me.

Moreover, participants were emotionally isolated from loved ones who did not encounter the same experience. As one NP described it:

I feel [it] sometimes, being a part of the medical community, especially during this shelter in place order. And just everything that I’m reading, just how serious this is, and then seeing family, friends, acquaintances, just being so blatantly disrespectful of the recommendation, and it’s hard as a person who is literally dealing with this every single day and seeing sick people.

Lack of Support

Lack of support was a resultant factor of isolation and displacement. Isolation and displacement occurred professionally as well, leading to lack of support. Most of the participants reported that previously planned orientations were shortened or mentor and colleague support was lost with the onset of COVID-19. One participant stated, “There were many times in the beginning and even still now where I’m the only provider in the office.” Practices limited the number of providers on site, moved providers to other sites or roles, and furloughed or lost providers. One NP reported moving to a different practice based on workforce and patient care needs. While in the new practice and working with suspected COVID patients, they were further isolated to a different part of the building away from colleagues and staff. Another participant stated,

When COVID hit, everything went away. My supervisor basically disappeared because he was working on the COVID side…. I didn’t see him for a few months… they took away… those kinds of cushions…. I didn’t have anyone to turn to.

Self-Efficacy and Clinical Uncertainty

COVID also gave rise to struggles with self-efficacy, confidence, and clinical uncertainty. Most participants cited struggles with self-efficacy, confidence, and clinical uncertainty, consistent with pandemic new NPs. , , , These new NPs associated decreased confidence and clinical uncertainty with loss of their mentors and support, struggles with technology, educational gaps, and changes in processes and roles due to pandemic-related changes. One NP described their clinical uncertainty in conducting telehealth visits: “When I can’t lay hands on patients… I’m going to miss something.”

Many participants also reported uncertainty due to constant changes in COVID care and clinical processes. One participant said, “Patients with a new hip, that’s easy compared to COVID… [usually] there are guidelines you can check… COVID didn’t really have that.” Many participants reported ongoing struggles with confidence and clinical uncertainty and, even after a year, still had areas of weakness because of the effects of COVID-19 on their typical practice.

Stress

Stress was a psychological reaction to COVID-19. All of these factors caused additional stress for each NP. The term stress was used to describe concerns for safety, family impact, isolation, workload, and rapid changes in processes and roles. One NP described their stress:

Stress at home… having to really juggle, having small children, and a [partner] that is home with them and trying to work… and then being needed so much at work. So, it was definitely a multifaceted sort of impact on my life, and… it hasn’t gone away, it’s still there.

Sense of Duty

Sense of duty fostered resilience. Nurses and NPs alike have a strong drive to provide care to patients in spite of the most challenging situations and environments. COVID-19 has not changed that approach. New NPs have demonstrated a significant sense of duty, a code that emerged early in the interview process and pandemic:

I had to embrace my role, which was doing my part in primary care to keep parents and children out… of the hospital.… That meant, you know just working a little longer hours, being more available on call, and things like that.

Coping and Support

COVID19 necessitated more self-reliance. Although all participants cited numerous negative experiences throughout COVID-19, they also reported finding ways to cope and unexpected resources and support. One participant said, “That amount of stress and kind of learning to work as efficiently as possible and being able to get the most out of everything really desensitized me and helped me through this.”

Many NPs relied on past experiences as RNs to adjust to their new role. One participant leaned heavily on their experience as a triage nurse to adjust to changes at their clinic: “[I worked] RN triage… for like five years. I mean, it’s not that much of a difference except the care, like the treatment plans and stuff that we have to do, are by ourselves.”

Resources and Support

Consistent with previous transition to practice literature, social networks were a source for resources and support. However, these NPs reported support and resources in terms of pandemic-related needs and changes. The participants reported finding support from family, friends, and professional contacts. One NP chuckled and said, “Fortunately, we have a very supportive family and a good WI-FI connection.” More prominently, the interviewees discussed the support they received from their professional leadership, colleagues, and other professional networks.

Frequent communication with leaders and administrators and feeling that leadership was providing the support, tools, and resources they needed was cited as crucial for coping in the workplace. One NP reported, “Everybody just came from a big place of understanding,” while another stated, “I actually felt pretty fortunate with my employer because I think they handled it really well.… I felt like [they had] a plan, and that made me feel much better.”

Support from colleagues and other professionals was also crucial. This form of support was best described by this participant’s comment: “We’ll sit there for an hour and talk about, you know, what studies we read, what things we heard, concerning things, happy things. And that’s kind of what I think kept us all afloat.”

When asked about mentoring relationships, all of the NPs reported they had mentors, but the relationships with these individuals evolved or changed because of the pandemic. Many NPs reported that they received support from their more experienced peers, but peers and mentors also relied on them. One NP said, “[The more experienced providers in my practice were] not totally 100% expert either, so we’re all doing really well, and I’m so thankful to have that support as a new provider.” Another NP believed their previous experience with technology and a triage setting gave them the ability to provide support to their mentors within the new clinical environment.

Many participants reported unexpected support from specialty providers and outside sources, such as pharmacists. In fact, the code support/mentorship most frequently occurred with the code collaboration. One participant stated, “[The pandemic] definitely forced me to do more and also invited me to develop these relationships with the specialists, who were 99% of the time more than happy to advise and assist in any way they could.” Another reported, “One of my resources [are] the pharmacists here.… They have my back.” Many participants found increased confidence and satisfaction in their role and practice by having the ability to reach out to these resources directly.

Technology

Technology seen as a mechanism for coping andsupport. All of the NPs reported a reliance on technology for coping and support. Many cited clinical practice resources such as Up-To-Date and the Centers for Disease Control and Prevention website. Technology was cited as a way of connecting to resources and emotional support through social media groups and websites. One NP described the support they found in an advanced practice provider and physician Facebook group by sharing and exchanging information and experiences about what they were seeing in practice.

Conclusions

The data of this study described the experience of new primary care NPs during the onset of COVID-19. Although the typical, prepandemic transition to practice period is loaded with obstacles and stress, , new NPs during the pandemic experienced new fears and stressors unlike any other in recent history. They experienced fear for their safety and the safety of their patients and family, isolation both professional and personally, and additional clinical uncertainty. However, the themes that emerged highlight the resilience of nurses, specifically NPs. Resiliency is a process in which an individual is able to adapt and bounce back from a major source of stress, trauma, or adversity.

Previous studies have investigated resilience in health care and other professions. However, these studies fail to identify specific factors in the current climate of health care, and limited evidence exists in the NP population. Waddimba et al found that satisfaction, needs gratification, tolerance with uncertainty, lighter workloads, and support from colleagues all contribute to higher resilience in physicians and advanced practice providers. In a literature review, Walsh et al found the following additional contributing attributes: self-efficacy, confidence, reflective ability, educational programs to develop resilience, and supporting transition to practice. Many of these factors are consistent with those cited by the NPs in this study.

Richardson’s meta-theory of resilience and resiliency provides a model for this process. As individuals—new NPs during COVID-19 in this case (Figure)—experience stressors, trauma, or adversity, existing protective factors aid them in keeping their biopsychospiritual homeostasis. However, these individuals also rely on past experiences, new insights, and growth to bounce back or reintegrate after significant stressors. The goal is that they reintegrate back to their homeostasis level, but that can be affected by their level of resilience and the complexity and timing of the stressors that they are experiencing. Based on this model and previous studies, it is evident that a need exists to focus on improving and developing resiliency in new and practicing NPs.

Study Strengths and Limitations

Owing to the small sample size (N = 10), some codes and themes may not be fully explored, thus limiting the generalizability of the study. Importantly, this study is an initial step in exploring the needs and strengths of primary care NPs and highlighting the resilience of this population. Very few, if any, studies have investigated the new primary care NP population, their resiliency, and their experience during COVID-19.

Implications/Recommendations

This pandemic was in its acute infancy when these NPs transitioned to practice. It is expected that the more stressors providers are exposed to, the more their resiliency will be tested. Therefore, consideration in maintaining NPs’ biopsychospiritual homeostasis should be given to new and practicing NPs. NP educators and employers should focus on programs that promote and develop coping and adaptability strategies in changing clinical environments, including relationship building, identifying resources and support, and methods that build confidence and self-efficacy.

One solution for new NPs is the use of an employer-based postgraduate NP program or a residency/fellowship. Faraz found that those who participated in a postgraduate program reported a more positive transition to practice experience with feelings of support and mentoring. The number of NP residency/fellowship programs is growing, from 68 identifiable programs reported in 2019 to 88 in 2020. Benefits such as increased communication and mentoring have been cited. However, these programs are limited, especially in rural areas.

Data from this study support the need to investigate resiliency in new and practicing NPs, particularly in times of extreme stress and adversity. Further study is also needed on interventions and education that promote resiliency in this and other NP populations to support and maintain the NP workforce.

Code System	Frequency
Resources/support	61
Support/mentorship	42
(−)Safety/fear	39
Process change	36
Lack of support	35
(−)Self-efficacy	32
Technology	32
Adaptability	29
Educational gap	27
Clinical uncertainty	26
Emotional burden	26
Experience	26
(−)Stress	23
Family impact	23
Isolation	22
Learning/professional growth	21
Collaboration	20
Change in role	18
Protection/personal protective equipment	16
Health policy/promotion	13
Sense of duty	13
Academic preparedness	11
Trust	11
Workload	11
Patient acuity/level of care	10
Self-care	10
Meaning in work	8
Motivation	7
Work-life balance	7
Polarization	6
Role ambiguity	6
Displacement	4
Information overload	4
Regret	4
Rewarding	4
Time management	4
(−)Compensation	3
Relationship strain	3
Inquiry	2
Exhaustion	1