Novice nurse practitioners' employment decisions and role transition experiences during COVID-19

Abstract

Background

While it is known how the COVID-19 pandemic affected providers already employed and working in health care settings, there is little data about the effect it may have had on novice nurse practitioners (NPs).

Purpose

The purpose of this study was to describe novice NPs' employment decisions and role transition experiences during the COVID-19 pandemic.

Method

Via an online survey, novice NPs were asked open-ended questions about how the pandemic influenced the decision to take their first position and their role transition experience, as well as what employers did well or could have done better to facilitate this transition.

Findings

Participants described employment challenges that included a difficult job market with limited employment opportunities, decreased pay and benefits, fewer onboarding and mentorship opportunities, and less primary care experience. However, NPs reported the pandemic positively influenced their role transition experiences with decreased patient workload and greater use of telehealth.

Conclusion

Novice NPs were impacted by the COVID-19 pandemic in making employment decisions and transitioning into the NP role.

Introduction

Launching into a career as a nurse practitioner (NP) can be an exciting time filled with considerable professional growth (Barnes, 2015a; Brown & Olshansky, 1997). Prior to the COVID-19 pandemic, a well-established body of literature already described the challenges and stresses novice NPs can experience during transition to the first NP position, including feelings of anxiety, inadequacy, and role ambiguity (Barnes, 2015b; Brown & Olshansky, 1997; Cusson & Strange, 2008; Cusson & Viggiano, 2002; Faraz, 2019; Heitz et al., 2004; Kelly & Mathews, 2001). However, the pandemic has undoubtedly strained the nursing workforce and altered health systems' ability to hire and maintain staff (Grimm, 2020; Melnyk et al., 2022), potentially impacting novice NPs' decisions surrounding accepting their first position and their subsequent role transition in ways not captured in prior research. With rapid growth of the novice NP workforce (Salsberg, 2018) and >36,000 NPs graduating during the first year of the pandemic (American Association of Nurse Practitioners, 2022), research is needed to understand novice NPs' employment decisions and role transition experiences during the COVID-19 pandemic. This knowledge will be valuable to educators, NPs, and employers in planning for workforce needs in a new era of global pandemics and public health emergencies.

Background

The COVID-19 pandemic began in 2019 as a local disease outbreak in Wuhan, China, and rapidly spread throughout the world as a devastating global pandemic. More than one million deaths from COVID-19 were recorded in the United States (U.S.) (Centers for Disease Control and Prevention, 2023). This healthcare crisis caused significant morbidity and mortality, and placed significant stress on health care systems and health care workers. Due to the need to decrease in-person visits to only those that were necessary to reduce the risk of exposure and conserve personal protective equipment (PPE), health care systems reduced ambulatory and outpatient services, physical therapy, and medical imaging (Grimm, 2020). One hospital reported a decreased volume of 80 % for specialty clinics, 50 % for primary care, and cancellation of all elective surgeries (Grimm, 2020). For health care workers, the psychological burden due to the high rates of morbidity and mortality, stress regarding known and especially unknown information, and fear of uncertainty led to high rates of burnout, psychological distress, and suicide (Gupta et al., 2021).

While all clinicians may face challenges when transitioning to a new professional role, research shows that the novice NP role transition experience is often difficult and can be stressful (Barnes, 2015a, Barnes, 2015b; Brown & Olshansky, 1997; Cusson & Strange, 2008; Cusson & Viggiano, 2002; Faraz, 2019; Heitz et al., 2004; Kelly & Mathews, 2001). Novice NP role transition typically takes about one year as the NP moves through the phases of feeling uncertain in the role to increased perceived competence and self-confidence (Brown & Olshansky, 1997; Faraz, 2019). Difficult role transition experiences can lead to feelings of anxiety, inadequacy, and role ambiguity (Barnes, 2015a, Barnes, 2015b; Brown & Olshansky, 1998; Heitz et al., 2004; Kelly & Mathews, 2001). This can in turn impact job satisfaction and lead to turnover (DeMilt et al., 2011; Sargent & Olmedo, 2013).

Personal stressors related to the COVID-19 pandemic may further exacerbate the already challenging novice NP role transition. Studies focused on health care workers during the early months of the pandemic revealed increased mental health concern in addition to stress, worry, and fear (Bohlken et al., 2020; Hall, 2020; Link et al., 2021). One study specifically focused on novice NPs found increased emotional burden during role transition, yet NPs expressed high levels of resilience due to the availability of support systems, which included professional leaders, colleagues, and other professional networks (Beebe et al., 2022). Given the increased stress experienced among health care workers during the COVID-19 pandemic, it is important to understand how novice NPs entering practice were impacted in order to support them, not only during a global emergency, but also during the critical role transition period.

There is limited data on the influence of the COVID-19 pandemic on novice NPs' employment decisions, but there have been concerns about an increasingly saturated job market for NPs as the supply of new graduates increases, potentially outpacing the demand (Salsberg, 2018). One study found that job opportunities for novice NPs were limited in some geographic areas, and this impacted career decisions, particularly for many novice NPs who are geographically bound and unwilling to relocate for work (Faraz & Salsberg, 2019). In fact, one-third of novice NPs reported few practice opportunities within 50 miles of their residence, yet nearly two-thirds were unwilling or unable to consider job opportunities >50 miles from their residence (Faraz & Salsberg, 2019). Given these recent trends, it is important to understand whether the novice NPs experienced similar or additional employment challenges during the COVID-19 pandemic.

This study fills an important gap by increasing our knowledge of the impact of the COVID-19 pandemic on novice NPs' employment decisions and role transition experiences. Understanding the experiences of novice NPs during national and global emergencies is important as the pandemic continues, and as new public health crises emerge. Employers and novice NPs will benefit from understanding the factors that influence employment decisions, as well as role transition challenges and opportunities, during the pandemic in order to support novice NPs and to facilitate a successful role transition experience.

Purpose

The purpose of this study was to describe novice NPs' employment decisions and role transition experiences during the COVID-19 pandemic.

Methods

Design

This study used a cross-sectional descriptive design that included open-ended questions.

Sample

After receiving Institutional Review Board approval from the University of Delaware, a convenience sample of 181 novice NPs was recruited through email blasts sent to a professional organization's membership, Facebook posts to private NP groups, and snowballing efforts between February and May 2021. Of note, the survey was deployed a year after the COVID-19 pandemic was declared a global pandemic. Three weekly emails were sent to the membership of Doctors of Nursing Practice (DNP), Inc. (a professional organization for NPs that hold a DNP degree) that described the purpose of the study and a link to the survey. Each email was sent to approximately 10,000 NPs. Additionally, invitations to participate in the study were posted to 14 private NP groups on Facebook for a total of five posts per group over the data collection period. The email blasts and Facebook posts encouraged individuals to share the study information and survey link with any novice NP colleagues.

Instrument

The survey consisted of five researcher-generated open-ended questions that were designed to garner information about factors that impacted participants' employment decisions and role transition experiences during the pandemic. Participants were first asked: “Did the COVID-19 pandemic influence your decision to take your current NP position?” (yes/no). Participants who answered “yes” were asked to explain further using free text. All participants were then asked four additional open-ended questions: “Is your transition to the NP role being positively impacted by the COVID-19 pandemic?”; “Is your transition to the NP role being negatively impacted by the COVID-19 pandemic?”; “What has your employer done well during the COVID-19 pandemic?”; and “What can your employer improve on with regards to management and mitigation of risk to patients and providers during pandemics?”. Participant characteristics (personal and professional) were collected via a demographic survey.

Data collection procedure

The email blasts and Facebook posts provided information about the study and invited interested individuals to follow a link to the survey. Data were collected via an anonymous online Qualtrics survey. After reading the informed consent front page, the study candidate checked a box agreeing to participate. Next, candidates answered four questions to establish study eligibility. Participants needed to be: 1) working as a NP, 2) working in their first NP position, 3) working for fewer than 12 months, and 4) older than 18 years of age. Participants were excluded from the study if they were not working as an NP in their first position for fewer than 12 months, or if they were <18 years old. The survey took approximately 10–15 min to complete as indicated by recorded survey start and end times, and all those who completed the survey had the opportunity to receive a $20 Amazon gift card by providing their email address on a second secured survey that was kept separate from the study responses. In order to prevent multiple entries by a participant, computer IP addresses were used to identify unique visitors and users with the same IP address were prevented from accessing the survey more than once.

Data analysis

Descriptive statistics (e.g., frequencies, percentages, means, range) were used to describe the sample; analyses were completed using STATA 17.0/SE. Responses to the open-ended questions were analyzed in aggregate for themes using the Krippendorff (2013) content analysis method. This method allows for inferences to be drawn from trends and patterns in the text provided by participants in a systematic and replicable manner (Krippendorff, 2013). By engaging with the text through an iterative process, the researchers were able to identify the emergence of topics and categories.

Results

Sample characteristics

The sample included 181 novice NPs (Table 1 ). Most of the sample was female (97.2 %) and the average age was 35 (standard deviation = 8.2, range = 23–65), and 79.6 % held a master's degree in nursing. About half of the sample (50.6 %) practiced in primary care, with about a quarter (25.6 %) in women's health and the rest in pediatrics (13.9 %), acute care (5.0 %), or psych-mental health (4.4 %). Practice settings were primarily private physician office (35.6 %) and community health center or federally-qualified health center (19.4 %). The majority (92.3 %) of the sample had prior experience as a registered nurse (RN), with 30.7 % having more than ten years of RN experience. Geographic representation of the sample was diverse, with 16.1 % practicing in the West, 26.7 % practicing in the Midwest, 37.8 % practicing in the South, and 19.4 % practicing in the Northeast. Most of the sample (61.5 %) secured their first position within six months, but a large percentage (38.5 %) reported that it took more than six months to find their first job. Nearly 41 % reported that the COVID-19 pandemic influenced their decision to take their current NP position.

Table 1.

Sample characteristics.

Characteristic	N	%
Gender
Female	173	97.2 %
Male	4	2.3 %
Other	1	0.5 %
Race/ethnicity
White	138	77.5 %
Black or African American	17	9.5 %
Hispanic or Latino	9	5.1 %
Asian	9	5.1 %
Prefer not to answer	5	2.8 %
Highest degree
Master of Science in Nursing (MSN)	144	79.6 %
Doctor of Nursing Practice (DNP)	36	19.9 %
Prior RN experience
Yes	167	92.3 %
No	14	7.7 %
Years of RN employment
1–2 years	8	4.8 %
3–4 years	29	17.5 %
5–6 years	38	22.9 %
7–8 years	25	15.1 %
9–10 years	15	9.0 %
>10 years	51	30.7 %
National certification
Primary Care	91	50.6 %
Women's Health/Certified Nurse Midwife (CNM)	46	25.6 %
Pediatrics	25	13.9 %
Acute Care	9	5.0 %
Psychiatric-Mental Health	8	4.4 %
Clinical Nurse Specialist (CNS)	1	0.5 %
Practice region
West	29	16.1 %
Midwest	48	26.7 %
South	68	37.8 %
Northeast	35	19.4 %
Practice setting
Private Physician Office/Practice	64	35.6 %
Community Health Center/FQHC	35	19.4 %
Non-ED Hospital Outpatient Clinic	13	7.2 %
Private Nurse Practitioner Office/Practice	9	5.0 %
Medical/Surgical Inpatient Unit	8	4.4 %
Retail Clinic	5	2.8 %
Rural Health Clinic	5	2.8 %
Urgent Care	5	2.8 %
Other	36	20.0 %
Time to secure first position
<1 month	9	6.9 %
1–2 months	17	13.1 %
3–4 months	32	24.6 %
5–6 months	22	16.9 %
7–8 months	18	13.9 %
9–10 months	13	10.0 %
11–12 months	10	7.7 %
>12 months	9	6.9 %

N = 181.

Note. N may not equal 181 and percent may not total 100 due to missing or multiple response questions.

FQHC=Federally Qualified Health Center.

ED = Emergency Department.

Categories

Content analyses revealed categories related to the employment decisions of novice NPs, the positive and negative impacts of the COVID-19 pandemic on role transition, and what employers did well or could have improved (Table 2 ). Employment decisions were hindered by hiring freezes, limited opportunities, and decreased compensation. Positive impacts of the COVID-19 pandemic on role transition included more time for the transition and increased use of telehealth. Negative impacts of the COVID-19 pandemic on role transition included the barrier posed by the use of PPE for connecting with patients and colleagues, less primary care experience, and fewer opportunities for onboarding and mentorship. When asked what employers did well or could have improved on, four categories emerged: providing adequate PPE and maintaining a safe environment, good communication, offering telehealth visits, and greater flexibility. We will discuss each of these topics and categories in greater detail below.

Table 2.

Analysis categories.

Topic	Categories
Employment decisions	Hiring freezes
	Limited options Decreased pay and benefits
Positive aspects	More time for transition
	Telehealth visits
Negative aspects	Personal protective equipment (PPE) as a barrier to connecting with patients and coworkers
	Less primary care experience
	Fewer opportunities for onboarding and
	mentorship
What employers did well or could improvea	Provide adequate PPE and maintain a safe environment
	Communication
	Offer telehealth visits
	Schedule flexibility

^aDenotes responses indicated categories fell under both topics.

Employment decisions

The COVID-19 pandemic had an impact on the employment decisions of novice NPs. Categories that emerged from the data include hiring freezes, limited options, and decreased pay and benefits.

Hiring freezes. “I had a job offer in my home town that was eventually revoked due to a hiring freeze.”

The impact of the COVID-19 pandemic on available positions was apparent from novice NPs' responses. Many cited rescinded offers and position eliminations during their job search process. Hiring freezes at many organizations had an impact on job opportunities for novice NPs. One respondent stated, “I had verbal offers for two jobs prior to graduation. Due to COVID's financial impact on the hospital, those positions were cut.” Another stated, “I had a job offer in my town that evaporated when COVID started shutting things down. So I had to go nationwide in my job search. Multiple places I inquired with said they were under a hiring freeze due to COVID too so my job was the only offer I got.” Feeling pressure to accept roles due to a lack of open positions and an uncertain future job market was something many novice NPs faced when entering the job market. Many participants expressed this sentiment: “I took the first job I was offered being that I thought I would not get another job in the current market.”

Limited options. “I was forced to move over 10 hours away due to a saturated market during COVID with limited job opportunities for new graduates.”

Many novice NPs reported finding themselves in a bad job market with limited positions. A common refrain was having to take an undesirable position, long commutes, or relocation in order to start working. One respondent stated, “COVID limited what was available in terms of options. I needed a position so took what was available near me rather than what was a good fit and was interested in.” Another stated, “I was unable to find any jobs and this was the only job that I was able to find and get an offer for. It is not a role I was/am interested in long-term.” Novice NPs did not feel like they were able to select the best fit from a number of positions, but rather taking whatever they could get out of fear that there would not be another opportunity. One respondent stated, “I took the role because my husband was furloughed and we needed the money. I would not have accepted the position I was offered otherwise. It was not a fit for me nor a good role for a new grad.” Many participants reported it took nine months to a year to find their first position during the pandemic.

Decreased pay and benefits. “This job was actually a big pay cut for me going from working as an RN to an NP.”

The COVID-19 pandemic resulted in financial impacts for new NPs. Many took pay cuts or accepted a position that was not a good fit for financial reasons. One respondent stated, “I didn't look around for other jobs as much as I could have. I felt lucky to have found a job with good salary and benefits.” Some took a position to support their families, while others settled for part-time positions due to limited full-time opportunities. One respondent stated, “There was no jobs offered in my area. So I accepted a very part-time job that has taken quite a while to increase my hours. My pay is not ideal. As well as benefits are lacking.” New NPs did not feel they had negotiating power due to a lack of positions and accepted the pay and benefits they were offered, even if they felt the compensation was unfair. One respondent stated, “I was having a hard time finding an NP position, so I took the current position because I needed income ASAP. I am being underpaid and overworked as a new grad NP.”

Positive aspects

There were, however, positive impacts of the COVID-19 pandemic on novice NPs' role transition. These categories included more time for the transition and increased use of telehealth visits.

More time for transition. “Our patient load was significantly lighter which gave me time to acclimate.”

Many new NPs cited having fewer patients and more time for patients visits as a facilitator to their role transition. Fewer patient visits allowed for more time to ease into their new clinician role, something that was recognized by new NPs who felt they needed the additional time to transition. One stated, “Sick visits aren't nearly as busy as the last year…gives me more time with my patients and to figure out my flow without being rushed.” Another stated, “My first few months were when the pandemic first hit. Our patient load was significantly lighter which gave me time to acclimate and to slowly take on a greater patient load without feeling like I wasn't doing my share.” Smaller patient panels and more time between patients were conducive to a longer transition period that felt more comfortable to new NPs. A commonly shared sentiment was, “because we have a decreased census, I feel I was able to slowly grow in my role which was great.”

Telehealth visits. “I have had the opportunity to learn how to use telehealth and use it regularly now.”

The use of telehealth was viewed as a positive aspect of the pandemic by new NPs. They reported enjoying the use of telehealth to conduct patient visits, something that would not have been as readily available pre-pandemic. Specifically, problem-focused telehealth visits were implemented by many clinics, which often take less time than in-person visits and allowed for simultaneous charting. The utilization of telehealth visits also improved daily clinic flow, decreasing burden on clinical staff. One respondent stated, “one positive impact is that we have established more telemedicine visits with patients. This has helped our outpatient clinic's daily flow.” In particular, telehealth was seen as important for the treatment of patients with mental health concerns, creating more opportunities for these patients to receive care comfortably. More options for patients were seen as a positive aspect of increased telehealth visits. Many respondents shared the following sentiment: “COVID 19 has brought telemedicine more often into my practice and it seems as though it is here to stay, which I think provides more options for patients.”

Negative aspects

There were several negative impacts of the COVID-19 pandemic on novice NPs' role transition experience. Categories included PPE as a barrier to connecting with patients and coworkers, less primary care experience, and fewer opportunities for onboarding and mentorship.

Personal protective equipment as a barrier to connecting with patients and coworkers. “I feel wearing a mask hampers my ability to socially connect with my patients.”

Novice NPs described difficulty bonding with patients as a result of wearing masks and social distancing. They also felt it was challenging to connect with new coworkers through the layers of PPE required in the clinical setting. One respondent stated, “In some ways, it is hard to build connections with coworkers and get a read on them because the PPE can be a physical barrier to emotional connection.” Communication was also hindered because of PPE requirements.

Less primary care experience. “Many of my daily visits are for COVID so I haven't gotten a ton of actual primary care experience.”

Many new NPs found themselves doing only COVID-related work such as testing and some even doing nursing tasks. One respondent stated, “My workplace has started getting NPs doing the RNs' duties.” Additionally, patient visits for issues other than COVID, in particular, routine preventive care declined. New NPs expressed concern for losing their broad knowledge base in primary care as a result of a focused practice and lack of physical patient care opportunities. Frequently cited was, “All I do is COVID testing. Not solidifying my primary care knowledge.”

Fewer opportunities for onboarding and mentorship. “There are not a lot of people in the office and my orientation was affected. I was not given the traditional on the job training.”

Novice NPs felt like they were expected to hit the ground running in their first position and many expressed a lack of orientation or training. Fewer practices were willing to train novice NPs, expecting them to take on a full load of patients immediately. One respondent stated, “I feel like my training is being rushed because of COVID.” If training opportunities were available, they were via telemedicine, which novice NPs explained were not as effective for learning as in-person visits. There were also fewer colleagues in the office for mentoring or clinical questions. One respondent stated, “[There is] no contact with other providers in the organization, no opportunities for education…” Another stated, “[There are fewer] providers in [the] office to ask questions of (more of them are home doing telehealth).” Overall, novice NPs felt their onboarding was negatively impacted by the pandemic, particularly in light of the shift to virtual versus physical patient care.

What employers did well or could have improved

Novice NPs provided an assessment of what their employers did well or could have improved on during the COVID-19 pandemic. Main categories included providing adequate PPE and maintaining a safe environment, good communication, offering telehealth visits, and greater flexibility.

Provide adequate PPE and maintain a safe environment. “Created a COVID task force to discuss updates weekly and adjust clinical practice as needed to keep all staff safe.”

A main refrain when asked about what employers did well or could have improved was related to implementing safety measures to keep staff and patients healthy. Screening for COVID-19 symptoms, requiring masks in the clinic and providing adequate PPE were all cited as important by novice NPs. Some of the employers also offered COVID testing and access to the vaccine when it became available. Limiting visitors and separating sick and well patients were also noted safety precautions in many settings. Some novice NPs wanted more PPE, COVID testing, enforcing of mask mandates, as well as following guidelines related to quarantining for exposed individuals. One respondent stated, “My employer could have stayed more informed on COVID-19 screening, testing and treatment recommendations.”

Good communication. “My employer has done a fantastic job communicating all updates, protocols, procedures.”

Communication about COVID-19 protocols and general information related to the virus were appreciated by novice NPs. One respondent commented, “Expectations [were] clearly communicated with patients and staff. Daily survey to rule out symptoms and travel.” A common method of communicating was either through daily emails or weekly/biweekly meetings to provide updates. Adapting to the latest evidence-based recommendations while notifying clinicians of these changes was seen as positive actions by employers. Novice NPs also appreciated being asked for their input regarding COVID patients and concerns about protecting themselves and their colleagues. However, some novice NPs felt their employer could do a better job of providing more frequent COVID-related expert availability and resources.

Offer telehealth visits. “The employer has worked hard to ensure that all telehealth and phone options are in place to care for our patients.”

Telehealth was seen as a way to improve access to care for patients, yet keep staff safe. Many employers had to implement or expand their telehealth services and train clinicians to use it. A quick transition to offering virtual care was universally seen as a beneficial effect of employers' response to the pandemic. However, some novice NPs reported a lack of telehealth utilization and/or training on best practices in providing telehealth visits. One respondent suggested their employer, “Maybe [provide] a class or seminar on best practices (legal and medical) for telehealth visits.”

Greater flexibility. “My employer has been extremely flexible and understanding of family commitments.”

Novice NPs reported their employers allowed additional paid time off if they were infected with COVID or had to care for family members. They also appreciated the clinics staying open, continuing to offer full-time employment and being able to work from home. One respondent stated, “They have been supportive and transparent allowing full-time work, no lay- offs, and providing additional PTO days.” Some novice NPs needed more flexibility in their schedules due to lack of childcare. Others noted flexibility in terms of changing clinic structure and flow, and hiring additional staff, in order to maintain safety and help with patient load. Some desired more flexibility in terms of remote work options when not engaged in direct patient care. One respondent suggested, “Allowing non-patient care hours and charting to be done remotely.”

Discussion

This is one of the first studies to explore the impact of the COVID-19 pandemic on novice NPs' employment decisions and provides additional insight into the pandemic's impact on the novice NP role transition. Only one other study has looked specifically at novice NP role transition during the COVID-19 pandemic to date (Beebe et al., 2022). The COVID-19 pandemic had a substantial impact on novice NP employment decisions and role transition experience. Novice NPs reported settling for less than ideal positions due to limited opportunities. They also reported accepting lower pay and not having opportunities for salary or benefits negotiations as a result of fewer available positions.

Additionally, novice NP role transition was affected by less primary care experience, as well as fewer onboarding and mentorship opportunities. These findings, coupled with delayed career starts due to a lack of positions and hiring freezes, may affect novice NPs' momentum in applying educational knowledge in real-world practice settings. Onboarding and mentorship are a critical aspect and cited as facilitators of novice NP role transition (Faraz, 2019; Ortiz Pate et al., 2023; Sargent & Olmedo, 2013; Zapatka et al., 2014), and social support in the form of mentorship has been found to be especially important during the COVID-19 pandemic (Beebe et al., 2022). It has been theorized that onboarding and mentorship may lead to increased self-efficacy, improved job satisfaction and retention (Barnes, 2015a, Barnes, 2015b; Harrington, 2011; Hill & Sawatzky, 2011). Likewise, new graduate nurses also expressed the need for mentorship and support as they feared errors in patient care (Smith et al., 2021). A lack of onboarding and mentorship due to the COVID-19 pandemic has the potential to have a negative impact on novice NPs' transition to practice.

On the other hand, there were positive effects of the COVID-19 pandemic. These included increased telehealth opportunities and more time for role transition as a result of decreased patient volumes. Being trained in telehealth was viewed as a positive experience by novice NPs, many of whom did not gain this experience in their NP education programs. Additionally, having more time with patients and to complete administrative tasks eased the transition. These positive role transition experiences should be considered by employers in onboarding novice NPs to their positions (Ortiz Pate et al., 2023). Providing specific training in telehealth and allowing for a ramp-up period of patient care would be beneficial for novice NPs.

With regard to what employers did well or could have improved, the main issue was related to maintaining safety via proper evidence-based protocols, and providing adequate PPE, regular testing, and vaccines to staff. Communication was also important during this time, due to the changing nature of recommendations, and novice NPs felt it was important to stay informed via regular emails or meetings. This is consistent with the study by Beebe et al. (2022), which found frequent communication with leaders and administrators to be a source of support during the pandemic. Clear communication with leadership was also found to be important for new graduate nurses during the COVID-19 pandemic (Smith et al., 2021). Providing telehealth access, resources and training was again emphasized as critical in maintaining patient access to care, but also for keeping patients and staff safe. Remaining flexible was also identified as vital during the COVID-19 pandemic, with hybrid schedules and additional paid time off being highly desired by novice NPs. Prior research has also found increased job flexibility, decreased patient volume, and increased compensation as important factors in the novice NP role transition (Faraz, 2019). Employers should ensure good communication and provisions for safe work environments, as well as increased use of telehealth, flexible work schedules, and adequate compensation during pandemics and beyond.

A concerning finding from this research was a lack of job opportunities and hiring freezes encountered by novice NPs. The majority of participants in this study reported having to adjust their expectations and accept job offers that were either not a good fit or in an undesirable location. In short, novice NPs felt they had to settle for any offer they could get, leaving no room for finding the best fit or negotiating compensation packages. Future research should investigate the challenging job market reported by novice NPs to ascertain if it was a temporary result of the pandemic or part of a larger trend in NP employment (Salsberg, 2018).

Limitations

This study is not without limitations. The sample was recruited primarily through one major professional organization, which limits the participants to those who are members of that professional organization. A response rate cannot be calculated since the total number of NPs in the target population who received the survey is unknown due to the use of social media and snowball recruitment methods. Additionally, NPs who responded “no” to the first question, “Did the COVID-19 pandemic influence your decision to take your current NP position?” were not asked to provide an open-ended response. This limits our understanding of novice NPs who were not impacted in their employment decision by the COVID-19 pandemic. Although our sample was geographically diverse, it was not representative; therefore, findings related to the job market and employment decisions may be unique to certain parts of the country.

Implications

This study has several important implications. Preparing NPs for a new era in health care that involves greater use of telehealth is clearly imperative. Educational programs for NPs should incorporate telehealth education into curricula to provide necessary competencies to all novice NPs. Studies of telehealth education for NPs revealed a lack of preparation and competence for telehealth (Gartz & O'Rourke, 2020). Telehealth-focused didactic content, simulations, and clinical experiences have been shown to improve the competence and preparation of NPs to deliver care remotely (Gartz & O'Rourke, 2020). Additionally, prior to selecting an NP program, students would benefit from assessing the local job market if they are unwilling or unable to relocate following the completion of their program. Finally, employers may consider the benefits of lower patient volumes during the onboarding period to allow time for NP role transition.

Conclusions

The COVID-19 pandemic has had a tremendous impact on health care professionals. This study demonstrated there were impacts on novice NPs' employment decisions and role transition experiences as a result of the COVID-19 pandemic. Novice NPs faced a difficult job market with limited opportunities and decreased compensation, having to accept positions that were not a good fit for them due to these circumstances. Once in the NP role, novice NPs had less mentorship, which could have implications for their workforce transition trajectory. Silver linings of the pandemic for novice NPs were increased use of telehealth and more time for the transition due to lower patient volumes. Employers should consider the importance of safe work environments, good communication, flexible work schedules, and expanded use of telehealth as opportunities for improving novice NP role transition during pandemics and beyond.

Funding

This study was supported through pilot grants from the Sigma Theta Tau Phi Epsilon Chapter and the George Washington University School of Nursing.