Sources of satisfaction, dissatisfaction and well-being for UK advanced practice nurses: A qualitative study

Aims: To examine and explore organisational and role conditions that promote or inhibit job satisfaction and workplace well-being for advanced practice nurses. Background: The advanced practice role is common across the world. Research shows it is well regarded by patients and improves patient outcomes, but there is little evidence about what the role is like for nurses. Methods: A subsample of an existing cohort of advanced practice nurses were in-vited for interview. Twenty-two nurses were interviewed over the phone. Interviews transcripts were analysed using thematic analysis. Results: Four themes were derived from the data; ‘the advanced nurse role and professional identity’, ‘feeling exposed’, ‘support for the advancement of the role’ and ‘demonstrating impact’. Conclusion: Nurses report considerable dissatisfaction with role identity and concerns relating to isolation on a daily basis, and these negatively affect well-being. However, they also identified significant satisfaction with the role, particularly when well-supported and able to recognize the unique contribution that they made to the lives of patients and to their organisations. Implications for nursing management: Clear role definitions, provision of high-qual-ity clinical supervision and addressing issues of isolation are likely to improve the job satisfaction of advanced practice nurses.

related to effective leadership include a lack of understanding of role, poor interdisciplinary working, pressure on resources and overload, and structural impediments to strategic posts. Facilitators include the provision of good organisational support, mentorship and frameworks of support (such as clinical supervision) as well as peer support (Elliott, 2017).
The importance of the organisational embeddedness and clarity of role is further reflected in existing evidence concerning levels of job satisfaction for APNs. Role ambiguity and a lack of intra-practice collegiality have been identified as specific forms of dissatisfaction amongst senior practitioners in the USA (Faris et al., 2010). There are correlations between intention to stay in post with job satisfaction, role perception and role ambiguity (Brom et al., 2016). A systematic review identified extrinsic factors, such as autonomy and meaningful work, as important factors in determining levels of job satisfaction amongst APNs (Han et al., 2018). O'Keeffe et al. (2015) identified poor intra-practice collegiality and limited support for role development as the least satisfying aspects of being an APN.
Qualitative papers have sought to explore these issues still further. Jangland et al. (2016) point to 'not being accepted' within an organisation as a source of dissatisfaction. On the other hand, Jangland et al. (2016) highlight patient outcomes as determinant of satisfaction. Workplace well-being is known to be related to workplace satisfaction (Kim et al., 2019). There is a close relationship between satisfaction, work place well-being and intention to leave (De Milt et al., 2011). Similarly, the relationship between job satisfaction and stress for APNs has been noted (Brom et al., 2016). Jangland et al. (2016) note a threat to well-being emerging from 'being caught between two roles'. We sought to explore organisational and role conditions that promote or inhibit job satisfaction and workplace well-being for APNs.

| METHODS
The study utilized a qualitative approach, centred on a thematic analysis. This approach enabled an in-depth exploration of the relational, organisational, professional and contextual factors influencing work-related satisfaction for APNs from their perspective. This allowed us to explore the responses made by participants through close examination of social experiences, meaning and psycho-social processes, enabling explanatory insight (Denzin & Lincoln, 2005).

| Sampling and recruitment
We sampled purposively from the Advanced-Level Nursing Practice Cohort Study (Wood et al., 2020) (total number 143) on the basis of cohort participant responses to job satisfaction and well-being items in the core questionnaire. We chose the range of 15-20 participants after consideration of the factors that contribute to the number of participants required to achieve 'meaning saturation' (Hennink et al., 2017). Participants in the cohort study had consented to be approached via email to consider participation in 'new' studies relating to advanced nursing practice. The email contained a link to an information sheet and consent form, completion of which initiated further contact to arrange a telephone interview.

| Data collection
We carried out semi-structured telephone interviews with participants. The interview schedule consisted of several open-ended questions to encourage participants to talk about stress and wellbeing in the workplace, as well as allowing an exploration of organisational conditions. The questions were designed to explore issues that had arisen from analysis of the cohort's first survey questionnaire. See Appendix S1 for the 'Topic Guide'.
Interviews were conducted in summer 2019, at a time convenient to the participant. They were digitally recorded for transcription and lasted between 20 and 35 min. Interviews were conducted by two of the co-authors [EW and TR]. Field notes were not made during the interviews, but researchers reflected on the interviews afterwards and recorded their thoughts for discussion. Transcripts were not sent to the participant. Participants were offered a complimentary gift voucher after the interview. We adhered to the COnsolidated criteria for REporting Qualitative research (COREQ) reporting standards (Tong et al., 2007).

| Data analysis
Data were analysed using an approach informed by thematic analysis (Braun & Clarke, 2014). This approach has six stages: familiarization, generating initial codes, searching for themes, reviewing themes, confirming themes and reporting. The data were coded and categorized primarily by one researcher (TR), and a subsample was then analysed independently by two others (EW and RK). All authors assisted in finalizing the themes. All researchers used Quirkos (www. quirk os.com) v2.1 software to manage the data.

| Ethical considerations
This research was reviewed by the Institutional ethics committee and given approval on September 3rd 2018 (reference number 022736). Informed consent was gained from all participants. This research was carried out in accordance with the principles of the Helsinki Declaration.

| FINDINGS
Of the 29 cohort members approached, 22 agreed to be interviewed of whom three were male. Twelve worked in primary care settings, eight in secondary care settings and two across both settings. Most had advanced practitioner in their job title (e.g. advanced nurse practitioner, advanced clinical practitioner), but other advanced roles were also named including nurse practitioner, community matron, specialized clinical educator and professional lead. They had been working at an advanced practice level for between three and 15 years, often across multiple settings.
Four super-ordinate themes were derived from the data: 'the APN role and professional identity', 'feeling exposed', 'support for the advancement of the APN role' and 'demonstrating impact'.
Each of the four themes are comprised of a number of subordinate themes and are presented below. The four themes cannot be understood in isolation from one another. Each theme relates to our primary concerns about the conditions, which might inhibit or promote role satisfaction, dissatisfaction and overall workplace well-being.

| THE APN ROLE AND PROFESSIONAL IDENTITY
There is a well-established understanding that nursing has a strong professional identity and there exists a robust sense of belonging within the profession. Role definition is key to this process, but there is also evidence that hierarchical and organisational positioning influenced how participants were perceived by others. Role confusion furthered the process of dislocation from a stable professional identity and is identified here as a source of dissatisfaction.

| Professional and work related identity
Participants spoke about the identity of APNs and reflected on how nurses had transitioned from traditional roles, into those perceived as previously located within the medical field. This shift challenged the social and professional identity of some participants leading to a sense of loss of identity, resulting in a sense of liminality and isolation. The participant below had recently changed title from nurse to Advanced Clinical Practitioner: We fall under the medical team, didn't want us to work as a nurse, so I found that quite difficult. They didn't want us to think of ourselves as nurses anymore, but also, the senior nurses in the department didn't really want that much to do with us because we'd left the nursing workforce, as they saw it. So you kind of feel like you're in the middle of nowhere.

(APN 12)
For some, there remained a robust link with the nursing profession, remarking upon a feeling that they will 'always be a nurse' (APN16).
Professional isolation, however, often stemmed from changes in daily routines and practices. Often, newly formed daily routines were at odds with those that they had undertaken in the past, creating discontinuity with established ways of working, professional networks and patterns of work presence.

| Role confusion
Participants repeatedly commented that fellow professionals were often unsure of the nature of their role. The notion of pushing boundaries of competence is noted below, but alongside this, participants also noted an inefficiency about this failure to clearly identify roles and responsibilities.

| FEELING EXPOSED
APNs talked of the clinical risk associated with their expanded scope of practice and, in the absence of a national framework, the personal accountability for regulating their own practice. This theme is primarily concerned with the transition to new roles.

| Accountability for autonomous practice
The emerging APN role was viewed as considerably altered and laden with additional responsibilities and practices. Participants In light of this, APNs were acutely aware of their responsibility to remain within scope of their own practice competences. Participants reported instances where, by virtue of the APN status, fellow professionals were encouraging them to work beyond their competencies.

| Team expectations
Exposure to the strain of managing one's own clinical practice, within the context of an absence of a regulatory framework, was exacer- APNs recognize that their role involves high levels of uncertainty and lack of support and this threatens work place well-being and role satisfaction. This, alongside self-regulation and a lack of standardized training, leads some to experience stress and perhaps a self-imposed reduced scope of practice to minimize the risk associated with more challenging consultations.

| IMPORTANCE OF SUPPORT FOR THE ADVANCEMENT OF THE APN ROLE
Support for the APN role was recognized as a key mechanism in enabling productive, safe and efficient clinical practice. Those sources of support were, however, variable in quality and diverse in source.
Physical location, the presence or absence of robust policies and resources to provide support were identified as important factors in the availability of support, particularly in relation to clinical supervision.

| Clinical supervision
Participants in the study reported that they received good clinical supervision, although it was observed that community-based APNs were at risk of not being supported in this way. Good clinical supervision contributed to positive well-being. Once again, differences between employing organisations were highlighted. In some areas, this was mandatory, in others an optional extra to be sought in one's own time. This further 'individualization' of clinical supervision practices placed further burden and responsibility on participants.
I sought out and I receive clinical supervision. It's one of those things. There is a policy in our Trust, it's not mandatory, it's up to people to seek it out.

| Other sources of support
A supportive network of fellow professionals was a key element of peer support within the APN role and participants valued these professional connections. Participants spoke about peer support as a key condition upon which effective advanced practice was based, the existence of which allowed participants to 'work at the level I do (APN11).
Geographical isolation, however, brought challenges to the maintenance of such networks, especially in primary care and rural areas. However, even in large, busy urban surgeries isolation still occurred: The one thing I do find, the one thing that doesn't help, is the fact you feel quite isolated, because you're in a room on your own and you may not see anybody all day apart from your patients.

(APN 09)'
Participants also spoke of other sources of support from within the team, acting as informal clinical supervision, prompting a sense of satisfaction with one's role. Some had been especially proactive in setting up ways to give and receive support. This was often more common in primary care as a response to the physical and professional isolation experienced in that environment: I've actually set up in our area a Nurse Practitioner Forum. And part of it is just for that, speaking to peers, bouncing things off, having that contact, even just knowing what training courses are out there.
Just so we can support one another. And I use social media a lot for that. There's a lot of advanced practice groups on Facebook and closed groups that are used for that.

(APN 01)
Social media and face-to-face forums were essential to consolidating the professional identity of APNs and for sharing knowledge and training opportunities. It is interesting to note, however, the perceived need to orchestrate such opportunities in response to isolation and an absence of organisational forms of support.

| DEMONSTRATING IMPACT
The final super-ordinate theme addresses the ways in which participants described an awareness of the impact of the role of APN, enhancing work satisfaction. Impact can be identified at three levels: the personal, the interpersonal and the organisational.

| Bridging in the work environment
Decision-making in the arena of patient care is identified as a territory where relationships have been mediated via complex interactions between nurses and medical colleagues. The changing role of nurses, via advanced roles, has contributed to this complexity. The position of nurses in decision-making situations, and the subsequent impact, can be attributed here to APN status, via the notion of 'bridging' between that of the Registered Nurse and medical professional: Simple things like that, having the clinical presence to actually say to relatively senior doctors, no we're not going to do that, we don't need to, she's fine… and then afterwards being able to actually explain why that decision was made and why I overruled it and said, no we're not going to do anything until she can at least help us and then we'll look at it. So, that kind of bridging between nursing and medicine is actually quite an ideal role for the [APN].

(APN 06)
The participant is recalling an encounter where 'overruling' was identified as a moment when the status of advanced practice was crucial to this process of gaining professional autonomy, in part through having access to comprehensive knowledge about the patient.
Furthermore, the participant notes that the role allows for 'bridging' between the disciplines, contributing to impact on patient outcomes.
The second example of the changing power within working relationships is identified via the negotiation of role. APN impact was viewed as being enhanced when the idea that the role was an adjunct to medicine was challenged. In such circumstances, APNs preferred to identify a clear nursing skillset and identity: Well actually, no we are not taking doctors' job roles, we are lead nurses. We are nurses who are working to a higher level, but also there to support other nurses and lead with other nurses. We are not taking any doctors' job role at all. (APN 18)

2 | Essence of advance practice nursing
The second subordinate theme identified within the theme of the impact of APN is concerned with what participants began to view as the essence of Advanced Practice nursing. This idea is concerned again with challenging the notion of substitution. It is reflected in these data and suggests that being an APN draws centrally upon one's biography as a nurse, utilizing tacit knowledge, yet enabling and facilitating the confident execution of advanced competencies. The provision of continuity of care for patients was also established as a key feature of the APN role. This continuity is transferred into the role of the APN, whilst also demonstrating the advanced competencies already described, as APN participants also referred to being able to respond to a 'complete episode of care' (APN 09) for patients.

3 | 'Strategic influence'
Finally, impact can be evidenced through reports of influence at an organisational level. Participants described how organisations had now come to know the value of APNs, recognizing that 'they've

| DISCUSSION
This exploration into the organisational and role conditions that promote or inhibit job satisfaction and workplace well-being for APNs has highlighted four key themes: 'the APN role and professional identity', 'feeling exposed', 'support for the advancement of the APN role' and 'demonstrating impact'. Each theme relates to our primary concerns about the condition that may inhibit or facilitate role satisfaction, dissatisfaction and overall workplace well-being. We encountered APNs in a range of circumstances, some benefiting from a wealth of experience and others capitalizing on formal and informal support. The data note that some APN participants here were experiencing the burden of the elevated expectation of colleagues, whilst others were struggling to maintain work satisfaction as a result of confused role definition and altered workplace identity.
A failure to feel accepted by one's medical and nursing colleagues, leaving a sense of liminality for some participants, is important. This feature of APN experience has been previously identified in Nurse Practitioners in Sweden (Jangland et al., 2016).
The absence of intra-practice collegiality as a specific form of dissatisfaction amongst a group of senior practitioners in the USA (Faris et al., 2010). The nature of intra-practice relationships (particularly with medical colleagues) has been reported as a major source of dissatisfaction (Jones, 2005;O'Keeffe et al., 2015). Our data concur with this evidence, suggesting that isolation from one's established nursing networks may account for dissatisfaction amongst APNs, diminishing workplace well-being and that newly transitioned APNs are more likely to indicate work-related stress (Brom et al., 2016).
A feature of these data relates to role definition and clarity, which is recognized as being absent at times. This is not new, and not peculiar to the UK. The Swedish study by Jangland et al. (2016) highlighted a feeling of being 'between two roles', neither nurse nor medic. Positive role perception correlates with high levels of job satisfaction among APNs (Brom et al., 2016) Participants noted that maintaining continuity with patients led to enhanced outcomes, as is the case for ambulatory care , transitional care  and gerontological nursing (Morilla-Herrera et al., 2016). The particular mechanisms that contribute to improved outcomes are not always articulated. Jangland et al. (2016), however, point to the preservation of a core set of nursing competencies, alongside the elevation to APN as important in facilitating improved outcomes. Nurse presence and greater knowledge of care environments are reported as contributing factors in improved outcomes (Woo et al., 2017). It is noted here that increased status within the multi-disciplinary team, resulted in APNs advocating on behalf of patients in a more effective way. Evidence would suggest that the APN role brings with it a range of features that might explain improved outcomes, including those already noted, as well as enhanced collaboration, opportunities for patient advocacy, leadership, expert clinical judgement and care management (Sastre-Fullana et al., 2014).

| LIMITATIONS
The sample within this study is relatively homogeneous. All were aged 40 years or over and identified as White British. Despite our best efforts, there are only three male participants within the study.
There remains considerable dissatisfaction among APNs with role identity, concerns relating to isolation and frustration at the absence of a national regulatory framework. Nonetheless, we also identified significant satisfaction with the role, particularly when APNs were well supported and able to recognize the unique contribution that they made to the lives of patients and to their organisations. Support and satisfaction subsequently enhances APN well-being.

| IMPLICATIONS FOR NURSE MANAGEMENT
This study has highlighted a number of areas of dissatisfaction among APNs, with potential impact on nurse retention. We recommend managers seek to reduce isolation, particularly for primary care APNs, promote role clarity (through clear and consistent job descriptions) and generate opportunities for inter-professional development. APNs should be supported, through clinical supervision (with a suitably qualified supervisor), to enable them to flourish within clear role boundaries. Health care providers should seek to utilize the skills and experiences of APNs in order to maximize impact.

ACKNOWLEDGMENTS
We would like to thank Dr Bethany Taylor for reviewing the manuscript prior to submission.

CONFLICT OF INTEREST
The authors have no conflicts to declare.

AUTHOR CONTRIBUTIONS
EW drafted the protocol and the paper, collected and analysed the data. TR collected data, contributed to the protocol and paper and analysed the data. RK, SR, MS, AT and TR contributed to the analysis and protocol development. All authors read and approved the final manuscript.

ETHICAL APPROVAL
This research was reviewed by the Institutional ethics committee and given approval on 3 September 2018 (ref number 022736).
Informed consent was gained from all participants. This research was carried out in accordance with the principles of the Helsinki Declaration.

DATA AVAIL ABILIT Y STATEMENT
Research data are not shared.