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William Lindsey, Consultant
Lynn Godkin, Lamar University
This study sought to determine why a very few Texas advanced nurse practitioners are choosing independent practice (Godkin & Godkin, 1997) as allowed by law. Previous studies describing entrepreneurs have characterized typical entrepreneurs as having strong preferences for extroversion, intuition, thinking and perception, with common combinations such as: TNPs, EPs, NPs, and TPs, and having fewer IJs, SJs and FJs. The typical composite type for entrepreneurs has been reported to be ENTJ (Carland & Carland, 1992). This type represented only 6% of this sample of advanced nurse practitioner students. Similarly, ISTJs and ESTJs are under represented in the typical entrepreneur sample. In this study, the opposite was true. Reasons for this circumstance are suggested.
The Texas legislature provided for advanced nurse practice partly in response to a physician shortage in under served areas. Unfortunately, there is evidence that very few in the State actually enter private practice. This study used the Type Indicator® (MBTI®) to determine if nurse practitioners in Texas have the entrepreneurial traits common to successful business owners which might draw them to independent practice. It was determined that MBTI® types associated with entrepreneurs are under represented in this sample. Only the Nurse Anesthetist sub-sample responded otherwise.
Advanced nurse practitioners (ANP) have a higher level of education than other nurses. They have legal authority, in most states, to practice independently with limited physician supervision (Pearson, 1998). Recent changes in Texas law, in response to an apparent physician shortage in areas under served by and unattractive to physicians, allows ANPs such practice (Nurse Practice Act, 1997). Unfortunately, data gathered from a recent survey of ANPs in the greater Houston metropolitan area (Godkin & Godkin, 1997) notes that very few have made the move to independent practice or have sought entrepreneurial endeavor. This raises several questions. Why aren't more nurse practitioners pursuing private practice as allowed under Texas law? "Are our academic, professional, and certification requirements for the teaching and nursing professions denying admission to certain psychological types who might be productive in their chosen fields?" (Schurr, Henriksen, Alcorn, & Dillard,1992, p.38). In this context, the purpose of this study was to determine if nurse practitioners in Texas have the entrepreneurial traits common to successful business owners which might draw them to independent practice.
Each state has specific statutes or rules regulating the practice of nursing in general and advanced nurse practice in particular. Regulations revolve around (a) legal authority (including educational requirements), (b) prescriptive authority, and (c) reimbursement. States handle each category differently (Pearson, 1998).
Concerning legal authority to practice, 26 states have no requirements for physician involvement in or supervision of advanced nurse practice at all. In these states, all authority is given to each state's Board of Nursing. States mandating at least some degree of physician participation typically separate authority between a Board of Nursing and a Board of Medicine. The primary legislative instrument regulating nurse practitioner authority and licensing in Texas is the Nurse Practice Act (Vernon's Texas Civil Statutes, Article 4514-4528). The Act, through the Board of Nurse Examiners, gives nurse practitioners the legal right to practice independently with limited supervision with physicians (Board of Nurse Examiners, 1997a). The State of Texas defines ANP as a:
Registered professional nurse, currently licensed in the State of Texas, who is prepared for advanced nursing practice by virtue of knowledge and skills obtained through a post-baccalaureate or advanced educational program of study acceptable to the board. The advanced nurse practitioner is prepared to practice in an expanded role to provide health care to individuals, families, and/or groups in a variety of settings including but not limited to homes, hospitals, institutions, offices, industry, schools, community agencies, public and private clinics, and private practice. The advanced nurse practitioner acts independently and/or in collaboration with other health care professionals in the delivery of health care services (Board of Nurse Examiners-State of Texas, 1997b).
Most states now allow ANPs some form of prescriptive authority. Some states exclude controlled substances. Illinois and Georgia allow no prescribing authority at all (Pearson, 1998). Prescriptive authority in Texas remains, at least somewhat, tied to physicians and does not include controlled substances. Prescriptive authority is also limited to certain practice sites that serve (a) specifically defined "medically under served populations"; (b) practices in hospitals or long-term care facilities; (c) physician practices; and (d) school clinics. Texas law specifically requires nurse practitioners to have a physician on-site at least once every ten business days in which the nurse practitioner is on-site providing care (Pearson, 1998).
Medicare and Medicaid rules give ANPs the right to be reimbursed at between 70% and 100% of physician fees. State law usually controls the exact rate (Buppert, 1998). Texas allows a reimbursement rate of 85%. Actual reimbursement rates vary greatly among different health care plans (Buppert, 1995; Pearson, 1998). Managed care plans are specifically prohibited from discriminating against nurse practitioners.
Notable research on the psychology of the entrepreneur has been produced by David McClelland (1961) who attempted to determine whether entrepreneurial behavior has any psychological basis. He identified, among other things, the need for achievement as a key entrepreneurial characteristic. Caird (1993) has identified five psychological tests most commonly used to study traits of entrepreneurs: (a) the Thematic Apperception Test (TAT); (b) the Edwards' Personal Preference Schedule (EPPS); (c) the Honey and Mumford Measure of Learning Styles; (d) Jackson's Personality Inventory (JPI); and (e) the Myers-Briggs Type Indicator® (MBTI). The first four, minor instruments, will be discussed in this section. MBTI®, the primary tool available, will be addressed in the next.
The Thematic Apperception Test
The Thematic Apperception Test (TAT) was developed by Henry Murray as a personality test focusing on (a) dominant drives; (b) emotions; (c) sentiments; (d) complexes; (e) attitudes; and (f) conflicts (Sweetland & Keyser, 1985; Murphy, Conoley & Impara, 1994). The TAT is a rather complex exam requiring a trained examiner to administer the test. This may be one reason the TAT is not more widely used. In specific entrepreneur applications, McClelland (1961) used the TAT to quantify needs for achievement, power and affiliation. Similar research reported in Caird (1993) found that the entrepreneurs showed high need for achievement and autonomy. Also, when the TAT was used with different types of entrepreneurs, some differences emerged. For example, when the TAT was administered to technical entrepreneurs, most exhibited only moderate needs for achievement, but higher needs for independence and more toward meeting challenges (Caird, 1993).
The Edwards' Personal Preference Schedule
The Edwards' Personal Preference Schedule (EPPS) was developed by A. L. Edwards to assess personality by identifying specific preferences (Sweetland & Keyser, 1993). The EPPS identifies the importance of certain needs and motives: (a) achievement; (b) deference; (c) order; (d) exhibition; (e) autonomy; (f) affiliation; (g) intraception; (h) succorance; (i) dominance; (j) abasement; (k) nurturance; (l) change; (m) endurance; (n) heterosexuality; and (o) aggression. Studies of entrepreneurs using the EPPS have uncovered high needs of achievement, autonomy, dominance and change among entrepreneurs along with low needs for deference, order, affiliation and abasement (Watkins, 1976; Hornaday & Aboud, 1970; and Begley & Boyd, 1987).
The Honey and Mumford Measure of Learning Styles
The Honey and Mumford Measure of Learning Styles measures general styles and personal preferences for learning (Caird, 1993). The Honey and Mumford test is obscure and not widely used, but some researchers have applied at least some of its components to entrepreneurs. Specific preferences measured are: (a) reflection; (b) theorizing; (c) experimentation; and (d) action. In applying this test to entrepreneurs, research has found that entrepreneurs prefer to learn by action and experimentation and most successful growth-oriented entrepreneurs have activist or pragmatic learning styles (see Thorpe & Dyson, 1988).
Jackson's Personality Inventory (JPI)
Jackson's Personality Inventory (JPI) has also been applied to entrepreneurs (Sexton & Bowman, 1986; Begley & Boyd,1987). The JPI measures personality characteristics using 16 scales: (a) anxiety; (b) breadth of interest; (c) complexity; (d) conformity; (e) energy level; (f) innovation; (g) interpersonal affect; (h) organization; (i) responsibility; (j) risk taking; (k) self-esteem; (l) social adroitness; (m) social participation; (n) tolerance; (o) value orthodoxy; and (p) infrequency (Sweetland & Keyser, 1983; Murphy, Conoley & Impara, 1994).
The Myers-Briggs Type Indicator®
The MBTI®, based on C. J. Jung's (1923) theories about perception and judgment, is one of the oldest and most widely utilized tests for identifying personality characteristics (Myers & McCaulley, 1985). The MBTI® identifies four different indices, reflecting one of four basic individual preferences: (a) Extraversion/Introversion (E/I); (b) Sensing/Intuition (S/N); (c) Thinking/Feeling (T/F); and (d) Judgment/Perception (J/P) (Myers & McCaulley, 1985).
The E/I scale juxtaposes Extroversion (E) and Introversion (I) to measure attitudes toward the outside world. People who draw energy from the outside world are considered to be extroverted. Extroverts (E) are usually described as outgoing and social. Introverts (I) draw energy from within the inner world of concepts and ideas. Introverts are usually described as shy or withdrawn (Myers & McCaulley, 1985).
The S/N scale distinguishes between Sensing (S) and Intuition (N). Sensing (S) describes someone that achieves perception by way of the senses; focusing on the immediate, realistic and practical. In contrast, persons having a preference for Intuition (N) permit perception to occur beyond what is visible or concrete. Intuitive persons are characterized as imaginative, creative, and insightful (Myers & McCaulley, 1985).
The T/F scale separates Thinking (T) from Feeling (F), two kinds of judgement. Thinking (T) is based on logical effort, a belief in "cause and effect". Thinking (T) persons are usually analytical, objective and critical. Feeling (F) persons are subjective, personal and more attuned to the values of others (Myers & McCaulley, 1985).
J/P isolates Judgment from Perception to understand attitudes and behaviors toward the outside world. It is commonly used with the E/I scale described above. Judging (J) types tend to be concerned with decision making, planning or organizing activities. Perceptives (P) are attuned to what is happening about them. They tend to be curious, adaptable, and open to new events (Myers & McCaulley, 1985).
Interpretation of MBTI®
A subject is identified by having one of each of the four preferences, together identifying the subject's Jungian type. Each subject is classified by the letter associated with each of the four preferences (i.e., E or I, S or N, T or F and J or P). Individuals may also be classified by a combination of one or more preferences (i.e., ST, an IS, a TP or an ENT, etc.). The MBTI® further defines personality types by identifying subjects as having one of 16 dominant characteristics. The individuals preference on each of the four separate indices are used together to form a "composite type".
MBTI®-Based Studies of Entrepreneurs
Carland and Carland (1992) support the view that there are distinctive differences between entrepreneurs and other groups. In general, entrepreneurs are described as more intuitive, more thinking, and more perceptive (Caird,1993).
A sample of 850 managers, small business owners and entrepreneurs, found entrepreneurs to be more strongly extroverted (E) and demonstrate a slightly more intuitive (N) preference (Carland & Carland, 1992). The composite typology for entrepreneurs was ENTJ. A survey of 110 small business owners by Carland, Carland, Hoy and Boulton (1988) showed that entrepreneurs possessed preferences for Thinking (T), Intuition (N) and Perception (P) as opposed to business owners having preferences for Feeling (F), Sensing (S), and Judgement (J).
Two independent samples of 135 and 159 entrepreneurs were compared to small business owners and executives. The findings mirrored similar studies for every comparison. Entrepreneurs had more EPs, NPs, and TPs but fewer bureaucratic IJs, SJs, and Fjs. Generally, Is, Ns, and Ps were significantly under represented in the entrepreneur samples.
Consulting Psychologists Press very recently developed an Entrepreneur Report using a combination of the MBTI® and the Strong-Campbell Interest Inventory. A national sample of adults matched closely to the U.S. census along with samples of small business owners and owner/founders of businesses appearing on Inc. magazine's list of the 500 fastest growing companies in 1987, were used as benchmark measurements. The benchmark personality types associated with associated with entrepreneurs were ISTJ (25.3%), ESTJ (24.2%), ISTP (6.8%) and ESTP (6.8%). The least reported types were INFP (0.2%), INFJ (0.5%), ENFJ (0.7%), and ISFP (1.4%) (Hammer, 1997).
MBTI®-Based Studies Nursing and Health Care
MBTI® has been used in a variety of situations in health care (McCaulley, 1978). The findings are consistent with benchmark studies among nurses in general (Myers & McCaulley, 1985; McCaulley, 1978). None approach the issues of concern to this study. Otherwise, it has been noted that nurses, in general, possess combined preferences described as either Sensing/Feeling (SF), Intuition/Feeling (NF) (Myers & McCaulley, 1985) or have strong frequencies of Sensing/Feeling/Judgement (SFJ) types (Hodges, 1988). Fewer studies have enjoined nurse practitioners in particular. Bruhn, Bunce, & Floyd (1980) have examined the job satisfaction of pediatric nurse practitioners and personality type. Busen & Jones (1995) considered leadership potential by personality type, self-esteem, and learning style.
As mentioned, the purpose of this study was to determine if nurse practitioners in Texas have the entrepreneurial traits common to successful business owners which might draw them to independent practice. The MBTI® Form G was used for this purpose. MBTI® type data were compared to MBTI® data from past research using entrepreneurs to see if nurse practitioners exhibit the same preferences as "typical" entrepreneurs. The following research questions were addressed:
Reliability and Validity of MBTI®
Since its inception over 50 years ago, the MBTI® has become one of the most widely used psychology instruments today. Currently, over three million people a year, in a wide range of settings, complete the MBTI® (Center for Applications of Psychological Type, 1992). Extensive references to the MBTI® research are available (Conoley & Kramer, 1989; Hammer, 1996; Mitchell, 1985; Murphy, Conoley, & Impara, 1994; Myers & McCaulley, 1985). Additional information relating to reliability and validity is presented by Myers-McCaulley (1985) and Hammer (1996). Detailed professional reviews are available (Mitchell, 1985, Coneley & Kramer, 1989, and Murphy, Conoley, & Impara, 1994).
Population and Sample Size
All students enrolled in Texas nurse practitioner programs during the fall semester of 1997 were included in this study. The specific designations of Advanced Nurse Practitioner (ANP) are Pediatric Nurse Practitioner (PNP), Family Nurse Practitioner (FNP), School Nurse Practitioner (SNP), Gerontological Nurse Practitioner (GNP), Neonatal Nurse Practitioner (NNP), Women's Health Care Nurse Practitioner (WNP), Nurse Anesthetist (CRNA) and Certified Nurse Midwife (CNM). All were included in the general category of ANP. There were 1,438 students (244 of these were Nurse Anesthetists and 24 were Nurse Midwives) enrolled at the time in the eighteen university programs across the State (Table 1).
ANP students are grouped into one of three categories (nurse practitioners, nurse anesthetists, or nurse midwives) in the paragraphs that follow. Though not as experienced as practicing ANPs, students enrolled in the various ANP programs are registered nurses. Given changes in the law, it was important to determine the personality type of students currently being enrolled. All but one university program (Parkland School of Midwifery) agreed to participate in the research.
Power analysis (Cohen, 1977) using a significance level of .05, an effect size of .30, and a power value of .95 was used in this study and indicated the required sample size to be 241. Since the MBTI® tests are sold in units of 25, the sample was increased to 250. Each school participating in the study was assigned a relative proportion of the total sample (Table 2).
Usable surveys were returned by 67 ANP students for a total response rate of 26.80% (or 4.66% of the total population). All responses were used. However, some records had incomplete demographic information. The individual MBTI& tests were scored by hand using scoring templates provided by Consulting Psychologists Press. The sample collected was a convenience-based sample in that advisors were asked to randomly distribute the tests among their students. Student participation was strictly voluntary.
Scope and Limitations
While the trait approach has received a great deal of attention in academic literature, the trait or characteristics viewpoint is not without its critics. Gartner (1988), for example, has been very critical of researchers employing trait theories to define the entrepreneur. Because no clear definition of the entrepreneur is accepted, samples are not homogenous. Studies may misappropriate traits to entrepreneurs that could well exist in the general population. Shaver (1995) also suggests that no real personality "profile" exists that differentiates entrepreneurs from the rest of the population. Entrepreneurs may not be born with certain psychological tendencies; necessary entrepreneurial skills can be learned.
The MBTI® has been widely used for a number of years in many different applications. On the negative side, however, some individuals have weaker preference scores than others, mainly due to the two-category type scoring system. Forcing some individuals into a "one or the other" type structure can produce some unreliable results (Hammer, 1996). Hammer (1997) also reminds us "although the theory states that a person's type preferences are stable over time, the reporting of those preferences through taking the MBTI or through taking part in a verification process may be affected by a number of factors, including the expectations by others in the client's environment or developmental changes".
Analysis of Data
The "typical" profile of the nurse practitioner student responding was a female (73.10%), 36 years old, Caucasian, (85.10%), and classified either as a nurse practitioner student (47.76%) or nurse anesthetist student (47.76%) (Table 3). The age of each participant ranged from a low of 25 years to a high of 58 years, with an average age of 36.32 years. Demographic data of this sample follows the general patterns for registered nurses in Texas. Specific demographic data for nurse practitioners was not available (Board of Nurse Examiners, 1998).
This study sought to answer four questions, the responses to which follow:
What Are the Personality Types of Nurse Practitioner Students Using the MBTI®?
Frequency distributions were performed on all data variables. The personality type variable of the total sample of 67 students showed that 44.8% were Extroverts and 55.2% were Introverts, 62.7% were Sensing and 37.2% were Intuitive, 62.7% were Thinking and 37.2% Feeling, and 68.7% were Judging while 31.3% were Perceiving. The most common composite type was ISTJ representing over 20% of the sample (Table 4). In contrast, the least reported type was ENFP representing 0 respondents. It simply did not appear in the sample.
Do Personality Types of Nurse Practitioner Students Vary Demographically?
One differential appeared. The male portion of the sample appears to have a remarkably higher preference for Thinking (T) than the nurse practitioners (94.4% male vs. 51.0% female). Males also exhibited a somewhat higher preference for Perception (P) than females (38.9% male vs. 28.6% female).
What Proportion Of Nurse Practitioner Students Possess Entrepreneurial Characteristics? Previous studies describing entrepreneurs have characterized typical entrepreneurs as having strong preferences for extroversion, intuition, thinking and perception, with common combinations such as: TNPs, EPs, NPs, and TPs, and having fewer IJs, SJs and FJs.
The typical composite type for entrepreneurs has been reported to be ENTJ (Carland & Carland, 1992). This type represented only 6% of our total sample. Similarly, ISTJs and ESTJs were under represented in the typical entrepreneur sample. In this study, the opposite was true. The ISTJ type represented 20% of the total sample and the ESTJ type accounted for 9% of the total responses (Table 4).
Do the Entrepreneurial Characteristics Identified in the Sample Differ Between Nurse Practitioners, Nurse Anesthetists, and Nurse Midwives? Sampled nurse anesthetists were the only sub-sample to be slightly different than the total sample when comparing composite types. The typical ENTJ entrepreneur composite type accounted for 9.4% of the sample, while the typical non-entrepreneur ISTJ accounted for only 15.6% of the responses. This would suggest that the nurse anesthetist sub-category might be slightly more entrepreneurial than the total sample in this study (Table 5).
The sample of nurse practitioner students presented in this study differs from prior research describing the preferences of entrepreneurs. The most common MBTI® types within entrepreneur samples are under-represented in this sample. Responding ANP students did not possess entrepreneurial traits common to successful business owners, which might draw them to independent practice (Table 6). They did not seem to have the characteristics that could move them from practice to profit.
Previous studies describing entrepreneurs have characterized typical entrepreneurs as having strong preferences for extroversion, intuition, thinking and perception. They exhibit common combinations such as TNP, EP, NP, and TP. They show fewer IJs, SJs and FJs.
The typical composite type for entrepreneurs has been reported to be ENTJ (Carland & Carland, 1992). This type represented only 6% of our total sample. Similarly, ISTJs and ESTJs were under represented in the typical entrepreneur sample. Only the Nurse Anesthetist sub-sample responded otherwise. The typical ENTJ entrepreneur composite type accounted for 9.4% of the sample, while the typical non-entrepreneur ISTJ accounted for only 15.6% of the responses. This would suggest that the nurse anesthetist sub-category might be slightly more entrepreneurial than the total sample in this study.
Concerning individual preferences identified by the MBTI®, typical entrepreneur samples have shown a clear preference for extroversion while our total sample preferred introversion (55%) (Table 6). Nurse practitioners were slightly more introverted than the total sample and more than the nurse anesthetist portion of the sample. Females showed an even stronger preference for introversion than males.
Typical entrepreneur samples show a high preference for intuitiveness. Intuitiveness was preferred by only 37.3% of our sample. Entrepreneur samples typically show a preference for thinking. Thinking was also preferred by our own sample across most lines. The nurse anesthetist portion showed the highest preference for thinking among ANPs with over 71% of the sample. A preference for judging is almost always under represented in entrepreneur samples. Judging was clearly preferred by 68.7% of the participants.
The purpose of this study was to determine if nurse practitioners in Texas have the entrepreneurial traits common to successful business owners which might draw them to independent practice. Why aren't more nurse practitioners pursuing private practice as allowed under Texas law? What is hindering their movement from practice to profit?
"Are our academic, professional, and certification requirements for the teaching and nursing professions denying admission to certain psychological types who might be productive in their chosen fields?" (Schurr, Henriksen, Alcorn, & Dillard,1992, p.38). This question, per se, cannot be answered at this juncture. It is clear, however, that the current group of ANP students do not have characteristics typically found in the entrepreneurial community. It might be well to look at schools with MSN/MBA-like programs to determine if their students are more likely to enter independent practice than others. Can the climate in some schools produce more independent practitioners than others? Such may depend upon the relative emphasis on entrepreneurship as opposed to "big business" in the curriculum.
We suspect that if advanced nurse practitioners are to be self-employed, many issues may need to be addressed such as reimbursement, licensing, and changing educational requirements. Working capital is not a minor factor in business startup. If nurse practitioners do not practice, why continue to institute ineffective legislation?
Caution should be exercised when applying type concepts to advanced nurse practice. This study suggests that psychological type as measured by the MBTI® can be useful in understanding why nurse practitioners fail to choose an entrepreneurial role. However, the MBTI® is only one measure and cannot completely identify entrepreneurial choice. Additional study is needed to develop a clear picture.
|Texas University (Certification)||Enrollment|
|Abilene School of Nursing (ANP)||9|
|Baylor University (CNM)||2|
|Baylor University (CRNA)||36|
|Houston Baptist University (ANP)||17|
|Parkland School of Midwifery (CNM)||6|
|Texas A&M Corpus Christi (ANP)||100|
|Texas Tech University (ANP)||50|
|Texas Wesleyan University (CRNA)||177|
|Texas Women's University (ANP)||315|
|University of Texas at Arlington (ANP)||226|
|University of Texas at Austin (ANP)||46|
|University of Texas at El Paso (ANP)||45|
|University of Texas at El Paso (CNM)||16|
|University of Texas Medical Branch at Galveston (ANP)||120|
|University of Houston (ANP)||87|
|University of Texas at Houston (CRNA)||31|
|University of Texas Health Science Center at San Antonio (ANP)||65|
|West Texas A&M University (ANP)||15|
|University of Texas at Dallas (ANP)||75|
|University||Tests Mailed||Tests Returned|
|Abilene School of Nursing||2||0|
|Houston Baptist University||3||0|
|Parkland School of Midwifery||2||0|
|Texas A&M Corpus Christi||17||3|
|Texas Tech University||9||4|
|Texas Wesleyan University||31||21|
|Texas Women's University||55||0|
|University of Texas at Arlington||39||0|
|University of Texas at Austin||8||0|
|University of Texas at El Paso||11||3|
|University of Texas Medical Branch at Galveston||20||10|
|University of Houston||15||0|
|University of Texas at Houston||5||5|
|University of Texas Health Science Center at San Antonio||11||10|
|West Texas A&M University||3||0|
|University of Texas at Dallas||13||5|
|Average Age||Gender||Ethnicity||ANP Category|
No response 7.50%
Nurse Practitioner 47.76%
Nurse Anesthetist 47.76%
Nurse Midwife 4.47%
|MBTI® Composite Type||Percent in Sample|
|Gender by Percent||ANP Category by Percent|
|Male||Female||Nurse Practitioner||Nurse Anesthetist|
|Entrepreneurs||Nurse Practitioner Students|
More extroverted (E)
More intuititive (N)
More thinking (T)
More perceptive (P)
More introverted (I)
More sensing (S)
More thinking (T)
More judging (J)
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William Lindsey earned a M.B.A. from Lamar University, Beaumont, Texas. He is a computer systems consultant serving governmental and not-for-profit agencies.
Lynn Godkin is Professor of Management and Chair of the Department of Management and Marketing at Lamar University, Beaumont, Texas. He has published in such journals as Health Care Management Review, Academy of Strategic and Organizational Leadership Journal, International Journal of Management, International Journal of Organizational Analysis , The Learning Organisation: An International Journal, British Journal of Management, and the Journal of Business Strategies.