ORIGINAL RESEARCH

Nurse Practitioner Satisfaction:

Identifying Perceived Beliefs and Barriers
Mary E. Ryan, DNP, FNP-BC, and Diane Whitaker Ebbert, PhD, FNP-BC

ABSTRACT
Purpose: The purpose of this study was to identify opinions of nurse practitioners (NPs) regarding job satisfaction and
barriers in a Midwest area encompassing counties in 2 states with dissimilar statutory regulations.
Data Sources: The Misener Nurse Practitioner Job Satisfaction Scale was mailed to 522 family NPs living within
targeted counties.
Conclusions: Job satisfaction scores revealed minimal global satisfaction. Highest scores included time for direct
patient care, autonomy, and challenge. Dissatisfying factors involved reward opportunities, bonus availability, and
research involvement.
Implications for practice: Identifying and addressing satisfaction and barriers to career fulfillment to promote
increased workplace contentment and career longevity

Keywords: job satisfaction, nurse practitioner

Ó 2013 Elsevier, Inc. All rights reserved.

A
s the American College of Physicians
Policy Monograph1 acknowledges nurse
practitioners (NPs) as critical players in
providing primary care, recruiting more nurses into
advanced practice and identifying strengths and ob-
stacles in that environment become critically impor-
tant. Current NP regulations are highly variable by
state law, as well as influences of the nursing, medical,
and pharmacy professions. Bringing advanced prac-
tice nurses (APNs) to the political arena in numbers
large enough to be heard and influence policies on
state and national levels would benefit future NPs as
they negotiate workplace contracts and look at rural
and metropolitan areas for setting up households and
maintaining careers. The incentive to address laws
increasing accessibility and payment for NPs may
impact the ability to secure primary and secondary
care for a broader population base. The goal of this
study was to identify attributes that keep working
NPs motivated and content and to identify barriers to
career satisfaction.
accessibility to NP care. With Washington, DC,
included in this study, Kansas ranked 27th and Mis-
souri 50th among 51 states, with 51 being the most
restrictive and least able to afford NPs the opportu-
nities to provide complete patient access, prescribing
privileges, and autonomy in scope of practice.2
Frederick Herzberg’s theory of “satisfiers” explains
that individuals are not content with incidental tasks,
minimal challenge, or low pay. The 2-factor “moti-
vation-hygiene” theory describes the internal satis-
faction of achieving, feeling competent, and enjoying
personal self-actualization independently of dissat-
isfiers, scripted as simply the absence of satisfiers.3
Herzberg argued that long-term motivators are in-
trinsic to the work of the day, encompassing a full
range of an employee’s abilities and acceptance of
responsibility. Factors influencing caregiving include
the structural design of the workplace, financial re-
sources, environmental characteristics, and collegi-
ality, all of which affect NPs’ ability to pursue and
maintain a satisfactory career position.

THEORETICAL FRAMEWORK LITERATURE REVIEW

In the current health care environment, job satisfac- A large study4 describing satisfaction among NPs in
tion is crucial to understanding NP success and the Veterans Administration identified a number of
identifying attrition factors. In 2006, an expert panel barriers and positive influences. In the late 1990s,
measured the regulatory environment and consumer Boykin and Schoenhofer5 expanded on the inherent

428 The Journal for Nurse Practitioners - JNP Volume 9, Issue 7, July/August 2013
value of using APNs. Benefit packages were identi-
fied as 1 of the most satisfying attributes, while the
lack of opportunity for professional development and
difficult interpractice collegiality were barriers to
satisfaction.
More recently, Schiestel6 illustrated that a
shortage of primary care physicians (MDs) and dearth
of nurses serve as motivators to review assumptions
about job satisfaction among NPs. In a predomi-
nantly middle-aged female population, adult NPs in
Arizona were only minimally satisfied with their jobs,
reporting autonomy as satisfying and interpractice
collegiality as a barrier to job satisfaction. Earlier
studies that reviewed demographic disparities among
rural NPs reported a lack of knowledge about the NP
role and intercollegial role recognition as major
barriers to job satisfaction.7 Weiland8 examined bar-
riers to independent practice, illuminating the prob-
lematic design of autonomous practice in the wake of
political, social, and economic counteragendas.
Over the past decade, widely varying state laws
regarding collaboration and NP practice continue to
confuse professionals, the public, and payers alike.
Authors consistently describe ambiguity regarding
NP supervision and the NP/MD role with resultant
job satisfaction inference.9,10
In 1992, of approximately 27,000 NPs in the
United States, only 492 practiced in Missouri. With
the passage of HB564 in 1993, controversy envel-
oped the state regarding collaborative practice
agreements and prescriptive authority. On-site su-
pervisory guidelines and confusion about NP/MD
roles continue to be described in job satisfaction re-
ports.9,10 Barriers include mileage constraints for NPs
in collaborative practices, constraints on prescribing
pain medications, and mandated chart review re-
quirements.11 Compared with other states’ rankings
in practice environments, Missouri ranked in the “F”
category for severely restricting patient choice for
access to services.2
In contrast, Kansas NPs formed The Kansas
Advanced Practice Nursing Task Force to encourage
changes to legal jargon clarifying the NP role in that
state. Introduced in January 2010, Kansas HB244712
tried to amend statutes to authorize NPs to serve as
the primary care provider of record. The Kansas bill
clarified NPs as independent providers, reflecting
www.npjournal.org
Medicare language regarding provider mix. HB2447
would have changed scope of practice language and
eliminated diagnoses made by NPs as being separate
from medical diagnoses. The bill received an infor-
mational hearing through the House Health & Hu-
man Services Committee, but no action was taken.
Kansas NPs are authorized to make decisions for
nursing needs and may prescribe drugs pursuant to
written protocols authorized by MDs.13
In early 2013, HB2251 was introduced to remove
barriers such as collaborative oversight requirements,
mandatory chart reviews performed by MDs, and
signature restrictions. The Kansas State Board of
Nursing (BON) voted to refuse to support the bill’s
current language; it has not received a hearing.13 The
APRN task force for Kansas describes the aging
workforce, and calls for increased access to care as
major healthcare reform agenda items.14
In 2012, the American Association of Colleges of
Nursing reported 16 states that allow independent
practicing NPs,15 while Iowa was identified as the
only Midwestern state in that category.16 The pri-
mary care workforce shortage in Kansas reflects
354,235 persons underserved, totaling 13% of the
Kansas population, according to the Council of State
Governments.
The consensus report by the Institute of Medicine
and the Robert Woods Johnson Foundation advises
that nurses “should practice to the full extent of
their education and training.to be full partners with
physicians and other health professionals in rede-
signing health care in the United States.”17 Obstacles
to autonomy occur on many fronts, including the
need to acquire and maintain credentials and privi-
leges and frustrations negotiating with facility ad-
ministrators and medical/nursing staff when clear role
identification is not in place.18 Nurses’ invisibility is
seen as a major contributor to the lack of under-
standing about the value of NP services, whether in
billing insurance, having the NP name on the office
stationery, or accessing the NP for office
appointments.
In 2011, Demilt, Fitzpatrick, and McNulty
authored a descriptive study expanding on intent to
leave current NP positions, the nursing profession,
and the relationship between job dissatisfaction and
expected turnover. Common reasons for attrition
The Journal for Nurse Practitioners - JNP 429
included lack of control over practice and sparse
opportunity for advancement. Collegiality and part-
nership with other health care professionals was
described by study participants as minimally
satisfying.19
METHODS
A descriptive, nonexperimental survey method was
the design used for this study.
The Misener Nurse Practitioner Job Satisfaction
Scale (MNPJSS) tool developed by Misener and
Cox20 was recommended for use in graduate research.
Permission was obtained for the tool (Warner J, per-
sonal communication, 9/12/2011). The instrument
uses a 6-point Likert scale (6—very satisfied, 1—very
dissatisfied) and incorporates a 3-page questionnaire
and 6 subscales for satisfaction: intrapractice partner-
ship, professional, social and community interaction, a
challenge/autonomy section, benefits, and a profes-
sional growth/direct patient care section. The query
includes 44 questions identifying office policy, social
contact, direct care, and opportunity to imple-
ment change.
When first administered to a convenience sample
in 2 Southern states, the estimated Chronbach’s alpha
for Misener’s original sample was 96.4 Demographi-
cally, similar studies have been demonstrated in
Nevada,21 Arizona,6 an unnamed state in the Mid-
west,22 and Maine.23 A demographic inquiry was
included for NP age, gender, number of years’
experience as an APN, ethnicity, income, marital
status, and employment type.
Sampling
Sampling was obtained from lists of the Kansas and
Missouri State BONs. APNs with specialty certifi-
cation as family NPs (FNPs) working full or part time
in 2 targeted counties that share a border across
Kansas and Missouri were included in this study. The
MNPJSS tool, cover letter, and demographic ques-
tionnaire were distributed by first-class mail to a
randomly selected group of 75% (N ¼ 522) of board-
certified FNPs listed with the state BONs as residing
in the targeted counties. At the time of distribution,
the boards did not keep lists of specific types of
practice in which NPs worked (primary vs specialty
430 The Journal for Nurse Practitioners - JNP
care), and NPs were asked to return the survey if they
identified their role as primary care.
Data Collection and Analysis
Return of the completed survey implied consent.
Anonymity was highlighted in the cover letter.
Stamped and addressed return envelopes were
provided. Satisfaction means and standard deviations
were used to determine whether relationships
existed between study variables and job satisfaction
scores. The tool took approximately 10 minutes to
complete, rendering it likely to be quickly and
easily completed by working NPs. Personal anno-
tations written by participants were noted and
transcribed.
RESULTS
Of 522 mailed questionnaires, 120 were returned,
and 112 were deemed usable, yielding a 21% usable
return rate. Five letters were returned by the post-
master. According to the Agency for Health Care
Policy and Research (2012), 52% of all NPs practice
in primary care.24 If the sample population reflects
this larger demographic, 271 NPs would have been
expected to qualify as responders working in primary
care, for a return rate of 41%.
The sample was predominantly female (97%),
Caucasian (91%), and married (77%); 63% of re-
spondents reported 5-20 years of experience, with
31% representing newer NPs with fewer than 5 years.
Only 6% worked in advanced practice for more than
20 years. The mean age of APNs responding was 45
years (SD ¼ 10.26). APNs practicing in Kansas made
up 56% of the total respondents, while 40% of the
NPs practiced in Missouri and 3% reported bi-state
practices. A third of the respondents worked in pri-
vate practice settings, with 31% working in hospital-
affiliated positions and only 5% working in rural
primary care practices. Also, 1% described managed
care employment, and 4% worked for govern-
ment agencies.
Annual incomes ranged from $36,000 to more
than $125,000, with 53% of the salaries falling in the
$61,000-$90,000 range. At the extremes, 7% of
APNs reported wages between $36,000-$45,000;
however, part-time vs full-time work was not
queried. Finally, 4% of the NPs recouped greater
Volume 9, Issue 7, July/August 2013
Table 1. Extrinsic Factor Analysis Table 3. Items With Most Positive Satisfaction Scores
Factor Description Mean SD Question Satisfier Mean
Factor 1 Collegiality 3.893 0.534 #7 Intrinsic 5.120
Factor 3 Interaction 4.399 0.237 #32 Intrinsic 5.063
Factor 5 Time 4.362 0.278 #28 Intrinsic 5.027
Factor 6 Benefits 4.653 0.055 #13 Intrinsic 4.935
#36 Intrinsic 5.063

than $125,000 in annual salary as primary

care providers.
The level of job satisfaction using the Likert
scale measured from very satisfied (6) to very
dissatisfied (1). No questions were reverse-marked.
The degrees of satisfaction with extrinsic and
intrinsic factors are described in Tables 1 and 2.
The MNPJSS also groups the questions into clusters
named factors. These areas are described as factor 1
(intrapractice partnership/collegiality), factor 2
(challenge/autonomy), factor 3 (professional, social,
and community interaction), factor 4 (professional
growth), factor 5 (time), and factor 6 (benefits).
Extrinsic factors describe job influences such as peer
recognition and opportunities to develop ideas, re-
view lab work, time for seeing patients, and benefit
packages; these are included in factors 1, 3, 5, and
6. The intrinsic factors of levels of autonomy, sense
of accomplishment, finding value in the job, and
opportunity for professional growth are included in
factors 2 and 4. These clusters enable the reader to
identify questions posing barriers to professional
growth and also fuel the desire to continue in the
NP profession.
The 44 individual questions were evaluated, and
the 5 items receiving the highest (most satisfying)
scores are listed in Table 3, with the lowest scores
(dissatisfiers) listed in Table 4. Of note, the highest
satisfaction scores were all intrinsic factors, relating
to time allowed for direct patient care, level of au-
tonomy, ability to deliver quality care, sense of
accomplishment, and finding challenge in the work
performed.
In contrast, the most dissatisfying scores were a
mix of intrinsic/extrinsic factors, including compen-
sation for services performed outside normal duties
(extrinsic factor), monetary bonus availability
(extrinsic), involvement in research (intrinsic), time
off to serve on professional committees (intrinsic),
and reward distribution (extrinsic).
The most satisfied FNPs were also those with the
longest tenure, reporting a mean satisfaction level of
5.386 (satisfied to very satisfied, SD ¼ 0.642).
Interestingly, the newest APNs reported a satisfaction
level (mean 4.292, SD ¼ 0.812) higher than those in
practice for 5-10 years (mean 4.139, SD ¼ 4.139), as
did all NP groups with more than 10 years’ experi-
ence (Table 5). Figure 1 illustrates years of experi-
ence, and Figure 2 outlines income distribution.
Comparing the Kansas county to the Missouri
county, overall satisfaction levels were nearly iden-
tical (the former’s mean 4.293, SD ¼ 0.847; the
latter’s mean 4.300, SD ¼ 0.828).
DISCUSSION
Most NPs were minimally satisfied to satisfied with
their current NP positions, consistent with the
Table 4. Items With the Lowest Satisfaction Scores
Question Satisfier Mean
#42 Extrinsic 2.663

Table 2. Intrinsic Factor Analysis #41 Extrinsic 2.809

Factor Description Mean SD #21 Intrinsic 3.515

Factor 2 Autonomy 4.707 0.386F #20 Intrinsic 3.635
Factor 4 Growth 3.965 0.360 #34 Extrinsic 3.660

www.npjournal.org The Journal for Nurse Practitioners - JNP 431

Table 5. Years of Experience vs Job Satisfaction Figure 2. NP Income Distribution

Years of Experience Mean SD

0-5 4.292 0.812
5-10 4.139 0.871
11-20 4.344 0.772
21-30 4.878 0.970
31-40 5.386 0.642

findings of several previous studies over the past 2

decades.6,22,25 In comparison, a study by Priebe26
reported minimal global job satisfaction from NPs in
primary care clinics in southeast Michigan. Tri27
found NPs employed less than 2 years had the least
job satisfaction. The Kansas/Missouri counties study
found lowest satisfaction scores globally among NPs
LIMITATIONS
employed 5-10 years and that NPs with extensive
This study focused on certified FNPs working in
experience (30 years or more) had a marked increase
primary care; therefore adult, geriatric, pediatric, and
in general satisfaction.
psychiatric NPs were not invited to participate,
The Missouri/Kansas study found, as have other
though many of those NPs provide primary care.
studies,18,26 that most NPs responding are older than
Other than the study of adult NPs in Arizona,4 the
41 years. Job satisfaction increased with experience
studies reviewed included APNs in general and were
after 10 years. This has important implications as the
not subclassified into specialties. Small numbers,
nursing workforce ages, making plans for social and
especially of those working in both states, could affect
personal household decisions and considering work
the description of satisfaction levels pertaining to
outside of nursing. Herzberg’s motivators identify
those subsets of the population. Though a significant
areas of strength in satisfaction and reiterate that being
percentage of all FNPs in the counties were sent
satisfied is a separate and unique quality from being
questionnaires, a very small percentage of question-
simply not dissatisfied. Having “information, support,
naires identified NPs working in rural practices,
resources, and opportunities to learn and grow” in-
which may underestimate that demographic. The
crease self-confidence and self-determination and
characteristics of NPs choosing to return a mailed
impact performance outcomes.28
questionnaire may be different from the general
population of NPs. There may have been a difference
Figure 1. NP Years of Experience
if questionnaires had been sent electronically. At the
time of mailing, no inclusive electronic database was
in place for either state. That is an area being
addressed by both Kansas and Missouri State BONs.
The questionnaire did not query whether NP satis-
faction was specifically related to state restrictions
on practice.

CONCLUSIONS
Identifying environments that hinder intrinsic satis-
faction, whether state regulations affecting auton-
omy, intercollegial misunderstanding of roles, or
extrinsic influencers (eg, cramped office space, lack of

432 The Journal for Nurse Practitioners - JNP Volume 9, Issue 7, July/August 2013
administrative support, or capped salaries) is para-
mount in reframing the role of the APN to increase
retention, encourage tenure, and support an influx
of newer professionals. Across most studies, intrinsic
satisfiers showed APNs enjoyed the challenge and
autonomy of their careers. Improving monetary
compensation, inviting research into the work-
place, and emphasizing reimbursement for efforts
beyond negotiated standard duties may increase
satisfaction.
This study showed that APNs practicing after 10
years enjoyed continued increases in job satisfaction.
There was a decrease in satisfaction in NPs during
the 5- to 10-year career span. This may relate to the
“newness” of advanced practice diminishing or fewer
benefits, including salary adjustments as nurses age
and take on greater responsibilities. Preparing new
NPs for a variety of role settings may keep interest in
urban/rural/specialty/primary care alive. Adding
courses in business, economics, and political role
integration would nurture novices and allow net-
working across diverse areas of practice, incorpo-
rating business strategy and work design theory into
the caregiving role.
Creating an atmosphere of collegiality continues
to be a loud and clear call from APNs across multiple
settings. Misunderstanding role identification, with
many states having different and sometimes adversa-
rial statutes from each other, as well as medical and
nursing organizations lends to an air of confusion and
professional disharmony. Employers need to increase
awareness of why APNs leave their practices; exit
interviews should be the last effort to identify and
solve problems, not the first.
Targeted research toward specific groups of nurse
practitioners, and detailed focus on state laws’ impact
on intent to leave the NP positions would pave a
course for health care facilitators as well as legislators.
“Minimally satisfied” should not describe the career
of well- educated professionals ready to care for the
next generation of our nation’s ill, promoting
evidence-based health designs for our population.
Identifying nuances that keep NPs in the workforce,
engagement of nurses considering the advanced
practice trajectory and improvement in cultural sur-
roundings may act as a catalyst for change in work-
place collaboration, reward adjustments and career
www.npjournal.org
satisfaction scores, inviting a challenge for our na-
tion’s NPs to answer.
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The Journal for Nurse Practitioners - JNP 433
Mary E. Ryan, DNP, APRN, FNP-C, works in family
practice with Kansas City Family Medical Care in Kansas City,
MO, and can be reached at Maryryan1019@gmail.com.
Diane Whitaker Ebbert, PhD, APRN, FNP-C, is an assistant
professor and director of advanced practice programs at the
University of Kansas School of Nursing and a family nurse
practitioner at the University of Kansas Department of Family
434 The Journal for Nurse Practitioners - JNP
Medicine. In compliance with national ethical guidelines, the
authors report no relationships with business or industry that
would pose a conflict of interest.
1555-4155/13/$ see front matter
© 2013 Elsevier, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.nurpra.2013.05.014
Volume 9, Issue 7, July/August 2013
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.