The question of how to help new graduate physician assistants (PAs) and NPs make the transition from student to practicing clinicians is of interest to employers as well as new PAs and NPs. At a stakeholder summit convened by the Physician Assistant Education Association (PAEA) in 2016, one of the recurrent themes was that employers need information about what to expect from new PAs and how to best support them as they transition into practice.1 PA graduates have reported requiring an average of 6 to 8 months to feel proficient in their first jobs, with one-third of surveyed PAs in primary care not feeling proficient at 1 year.2,3 New NPs report experiencing anxiety, isolation, and a lack of confidence in their new roles, despite often having experience as an RN.4 New graduates increasingly seek employment in settings that provide structured mentoring and other support during the transition period (Jennifer Broderick, managing director of the Center for Healthcare Leadership and Management at the American Academy of PAs in Alexandria, Va. Personal communication with Perri Morgan, June 25, 2019).
Some organizations are addressing the need for support during transition to practice by implementing onboarding programs or fellowships.5-8 Each approach provides structured education and mentoring while the new clinician gradually takes on increasing patient care responsibilities. Fellowships are extended training periods, similar to medical residencies, in which PAs and NPs typically are paid below the market rate. Fellowships may or may not lead to employment with the organization that administers the fellowship. Onboarding programs differ from fellowships in that the participants are formally hired, with full salary and benefits and the expectation of long-term employment.
The need for information about transition to practice is highlighted by changes in the context in which PAs and NPs practice. Members of the millennial generation tend to change jobs more frequently than previous generations, and given a strong job market that offers an array of opportunities, current PAs and NPs may more frequently enter new work settings.9 For PAs, the traditional model in which the supervising physician who made the hire serves as a personal mentor is less viable in large modern healthcare systems, where the physician may not have a personal economic interest in the PA's success and may not consistently work in close proximity to the PA. Expansion of scope-of-practice laws for PAs and NPs and implementation of optimal team practice for PAs also may heighten the need for effective and efficient onboarding, because employers might begin to view PAs and NPs as more autonomous than they were in the past, and hasten to reduce support and increase productivity expectations.10-12
We are particularly interested in onboarding approaches for safety-net settings such as community health centers (CHCs), which are increasingly relying on PAs and NPs. In 2012, 42% of CHC providers were PAs and NPs, an increase from 31% during the last half of the previous decade.13,14 High proportions of economically or socially disadvantaged patients served in these settings might make the transition to practice especially difficult, because new clinicians are required to address multiple social determinants of health in addition to providing medical care. Surveyed clinicians in underserved communities reported a lack of resources for patients along with heavy workloads as their leading contributors to workplace stress.15 Workplace stress and burnout can lead to high clinician turnover, which is costly for all organizations, and may markedly affect CHCs, which typically operate on tight budgets.16
Existing literature from other professions suggests that onboarding can reduce turnover and improve job performance, job satisfaction, and commitment to the organization, but studies of PA and NP onboarding programs have not evaluated these outcomes.17,18 Literature on PA and NP transition to practice describes the need for support for new PAs and NPs, outlines factors associated with successful or unsuccessful transitions, describes the learning experience of new clinicians, and describes programs in specific specialty settings, but published information about how to implement an onboarding program is limited, especially for PAs.3,8,19-23 Our project starts to address this gap through investigation of existing practices in onboarding of PAs and NPs. We conducted an interview study of organizations that have implemented onboarding programs, focusing on primary care settings, especially in underserved settings such as CHCs. Our findings group into three categories:
- administration of onboarding programs
- content delivered in the programs
- strategies used to assist the new clinicians.
This paper, the first in a three-part series, provides an overview of the project and presents our results pertaining to the administration of onboarding programs for newly hired PAs and NPs.
From May through July 2018, we conducted semistructured interviews with volunteers from 13 healthcare organizations about their approaches to onboarding new PAs. Because all of these organizations reported that they onboarded PAs and NPs similarly, we generalize the findings to apply to both professions. The sample was purposively selected to include leaders in development of onboarding programs for PAs and to focus on safety-net settings while also including a variety of other settings that might offer insights into effective onboarding. Six organizations were multisite CHCs, two were academic medical centers, two were multispecialty integrated healthcare systems, one was a staffing organization, one was a large physician-owned multispecialty organization, and one was a small (five clinicians) PA-owned private practice. Interviewees were people who had responsibility for the onboarding process in their organizations. In many cases, they had created the onboarding programs. Most were PAs, but one was a physician, and one was a chief talent officer.
We did not include interviews with representatives from PA and NP postgraduate residencies. The onboarding programs that we studied were designed to assist the transition to practice for full-time employees. Although we queried our participants about onboarding for experienced as well as newly graduated PAs and NPs, most programs were geared toward, but not exclusively for, new graduates, and most organizations that we studied indicated that most (65% to 75%) of their new PA and NP hires in recent years had been new graduates.
We constructed an interview guide based on a framework from Klein.24 One investigator (PM) conducted all interviews by telephone, asking interviewees to describe
- how they facilitated the adjustment of new PAs into their organizations (including content and strategies)
- unique aspects of onboarding for PAs and for new graduates
- the goals of their onboarding program.
Interviews were recorded and transcribed. Two investigators (PM and MS) thematically analyzed the transcribed interviews using Nvivo software. Initial codes were based on Klein's framework, and additional codes were developed de novo in response to the data.24 The entire team met frequently during the coding stage to discuss how to best group ideas into thematic codes. We circulated a summary of our initial findings to all interviewees and sought feedback on this summary during conference calls, following a modified Delphi approach. The summary was revised in response to the feedback.25
We present our results descriptively since this qualitative study was not designed to produce numerical estimates.
Administration of onboarding programs
Interviewees repeatedly stressed a theme that we had not directly inquired about—administrative aspects of onboarding programs. We identified five administrative aspects to address before starting an onboarding program for PAs and NPs: goals, critical organization factors, organizational fit, program design, and costs.
Goals of onboarding
We asked interviewees directly about the goals of their onboarding programs, and have grouped their responses into eight goals (Table 1). Retention was the most commonly identified goal. Some interviewees emphasized that they wanted to retain the new PAs and NPs for their entire careers. Many mentioned the high cost of turnover as a strong motivator for investment in onboarding programs. Another goal was to foster provider well-being. Administrators wanted to help new NPs and PAs to thrive and feel comfortable in their work. Ensuring quality of care was a frequent goal of onboarding programs. Interviewees indicated that it was important to ensure the new clinicians' clinical competence before rushing them to see large numbers of patients. They hoped that this approach would contribute to patient safety and decrease medical errors. Onboarding programs strove to inculcate a common understanding of core values of the organization. Some organizations sought to standardize the use and expectations about PAs and NPs, primarily so that clinicians would not be underused. They sought improved transparency in roles and expectations for administrators, new PAs and NPs, and collaborating physicians. The goal of some programs was to improve competence in areas that they saw as inadequately addressed during PA and NP training. These areas included skill with electronic health records, regulations, especially in the areas of coding, billing, and documentation, and, in some organizations, patient care approach to specific conditions. Onboarding program administrators emphasized that maximizing the early phase of a PA's or NP's career can contribute to their long-term success and reduce the time required to reach full expertise or full productivity. This goal focused on pursuing a high scope of practice for the new PAs and NPs. Finally, informants perceived that new graduates are seeking jobs that provide support during the transition to practice, and intended for their onboarding programs to provide a competitive recruitment advantage to attract PA and NP applicants.
Critical organization factors
Although we did not inquire about this area directly, our interviewees emphasized the importance of organization factors (Table 2). They stressed that support from organization leadership, including from top leaders, is required in order to ensure support from other departments whose collaboration is critical, such as human resources, legal services, and credentialing. It also helps to protect onboarding clinicians from being asked to forgo planned onboarding activities in order to meet pressing clinical needs. As one interviewee described, without protection from organization leaders, productivity concerns “will trump onboarding every time.” A clear organization leadership structure for PAs and NPs is very helpful in the creation and administration of PA onboarding programs. Having PAs report through PA (or advanced practice provider) reporting lines in the institutional medical hierarchy creates a clear line of authority. Having a Director of PA Services, Director of NP Services, or Director of Advanced Practice Providers provides a powerful advocate for the onboarding venture. Finally, the person or persons responsible for leadership of the onboarding program should be clearly identified within the organization, have adequate training for the role, and be invested in the process. As one interviewee put it, they should have a “passion for developing people.” Program faculty (mentors and others) also should be clearly identified and have training in didactic and clinical teaching.
Issues of organizational fit were important to interviewees (Table 3). Well before pursuing a new NP or PA hire, it is important to evaluate and prepare the work site to ensure that it needs a PA or NP and not another type of worker and to ascertain whether there is resistance toward incorporating a PA or NP. The collaborating physicians as well as the staff and supervisors should understand how to use PAs and NPs at the top of their license. In addition, the support that will be needed for the new hire, the appropriate feedback mechanisms, and schedules for new PAs and NPs should be clearly defined. Finally, site staff need to understand the regulatory and paperwork requirements necessary for the PA to start work. Several of our participants cited a need to tighten up their credentialing process so that start dates could be consistently met. Interviewees pointed out that it is critical to describe the position accurately to potential hires, because without a clear understanding of factors such as hours of work required, complexity of the patient population, the specific role of the PA or NP, income potential, and available support, the scene is set for misunderstandings and disappointment. Interviewees agreed that it is much better to have an applicant decline a job than to accept a job that they later learn they do not want. Most interviewees stressed the importance of hiring the right person for the organization. Safety-net clinics placed importance on hiring people who were motivated to care for their particular patient populations. Some described using behavioral interviews that probed how applicants would respond in specific situations, to assess whether the applicant would be a good fit for the organization. Some informants asserted that onboarding “starts with the interview,” and recommended leveraging all contacts with the new hire to set the tone by demonstrating and reinforcing the organization's values and priorities.
Designing the program
The interviewees identified the need to design the program in advance (Table 4). Written standard operating procedures, including manuals that outline the entire onboarding process, onboarding protocols or outlines, written curricula, checklists for completion of tasks, logs for documenting training or mastery of skills, and forms for providing feedback and evaluation can help ensure that all new PAs and NPs have a similar basic set of experiences. Checklists to help avoid delays in the licensing and credentialing process may be useful. These materials help new PAs and NPs, as well as those assigned to help them, know what to expect during the onboarding process, and to be able to identify who is responsible for each component. A critical design decision is whether to create a single program for all new PAs and NPs, or whether to develop a framework that each worksite adapts to the needs of its unit. Required program components are similar to those for any education program. Many of the organizations we examined used daily goals during the first 1 to 2 weeks of intensive orientation activities, followed by weekly goals during the following few weeks. Learning materials and learning strategies are designed to help the onboarding clinician accomplish these goals, and evaluation materials help to document progress toward the goals. The experience level of the new hire, the expected level of autonomy that they would ultimately assume, and the degree of patient complexity and/or acuity in the practice influenced the timing and duration of onboarding. A critical aspect of timing in onboarding programs is the rate at which a newly hired PA will progress toward full clinical productivity. This topic is discussed further in the next section and in a forthcoming article in the series on strategies used to guide new PAs.
Costs of onboarding Costs associated with onboarding were due primarily to reduced clinical productivity of onboarding program leaders, mentors, and preceptors, and initial low clinical productivity of the new PA or NP (Table 5). The person administering the onboarding program, usually a PA or NP with a leadership position, required protected time to plan and run the program. Most programs reduced the number of patients that preceptors or mentors was expected to see by 50% to 75% during times that they were working with onboarding clinicians, although some organizations offered mentors and preceptors the option of increased pay instead of reduced patient load. At least one organization encouraged mentoring and creation of onboarding programs by counting them positively in the promotion process. Also, new PAs and NPs had light patient schedules in order to allow them time to learn, thereby not bringing in typical clinical income. One organization reported that their onboarding system “cost” 82 clinic hours for the new hire and 67 hours for the mentor/preceptor compared with what both clinicians would produce at full capacity. In larger organizations, an administrative assistant was needed to coordinate the onboarding schedule across departments.
Many organizations are interested in the question of how long it should take a new PA to reach maximal clinical productivity. Our project did not provide a clear answer, although all sites included some type of gradual ramp-up of productivity expectations. Some organizations we studied are in the process of evaluating the costs associated with the ramp-up. The time at which a PA was expected to see a full daily schedule of patients ranged from 20 to 40 weeks, with most sites offering flexibility depending on individual progress. One CHC allows longer for new PAs to start seeing a full schedule of patients if they are taking over a former clinician's panel of patients than if they are building their own panel, because significant time is required to read the medical records of established patients. Several interviewees agreed that settings in which patients had more complexity and poorly controlled chronic disease required longer ramp-up periods.
Some interviewees pointed out that the costs associated with not providing onboarding support might outweigh the costs of onboarding. The return on onboarding investment might be found in reduced turnover, long-term higher productivity of the clinicians, and/or better care quality. One organization estimated the cost of turnover in the first year at $250,000, but most had not analyzed these potential costs.
The onboarding program experts that we interviewed stressed the importance of careful planning and administration of the programs. Although each institution will need to design its own programs to fit its individual needs, the considerations outlined by our interviewees might serve as a useful guide for others embarking on onboarding projects. Significant planning is required in order to clarify goals of the program, gain institutional support, develop leadership, and plan the program before its implementation.
Many of the goals articulated by onboarding administrators were similar to onboarding goals in other professions, but issues related to the clinician's role are particularly pertinent to PA and NP onboarding. In a study of primary care NPs, role ambiguity on the part of physicians and other colleagues hindered successful onboarding, and low autonomy was associated with turnover intention.20 Further, role clarity is a key indicator of onboarding success and is correlated with positive outcomes such as job satisfaction and commitment to the organization.26 Our informants suggest that both clinicians and their employers gain from maximizing and clarifying the PA or NP role, with benefits that can continue to accrue over the course of a career.
A salient aspect of the administrative factors identified by our informants was the importance of support from top institutional leaders, deemed essential so that uncooperative departments or pressing clinical needs would not undermine the onboarding programs. Future studies clarifying the return on investment from onboarding programs might help garner support from institutional leaders.
Onboarding programs for NPs and PAs have not yet demonstrated improvements in outcomes such as turnover and low productivity, although they strive to do so and most of our interviewees have the impression that the programs are helpful. Estimates of the cost of turnover during the first year of employment range from $120,000 to 250,000 (Jennifer Broderick, managing director of the Center for Healthcare Leadership and Management at the American Academy of PAs in Alexandria, Va. Personal communication with Perri Morgan, June 25, 2019). These estimates are in line with those reported for RNs, estimated to be between 75% and 200% of the nurse's salary.18 However, turnover is not caused exclusively by lack of onboarding support. We are not able to assess accurately the costs of onboarding programs or the potential return on investment of onboarding support. Although many organizations clearly feel that the investment in onboarding is reasonable, widespread uptake of onboarding will require more research on costs and benefits of onboarding programs. And further research is needed to delineate best practices.
Limitations of our study include an absence of NP interviewees. However, the administrators we interviewed indicated that their onboarding approaches are the same for NPs and PAs. Our sample was limited to 13 programs from diverse geographic settings and different types of organizations. The major themes were mentioned by most interviewees, but we might have discovered additional themes if our group were larger. Most of the programs that we examined were relatively large, and it might be difficult for smaller organizations to implement resource-intensive onboarding programs. Hopefully, future work can illuminate ways to scale onboarding programs to fit a variety of settings.
This article outlines key administrative issues pertinent to onboarding programs. The next two articles in the series will outline content to be delivered during onboarding and strategies used to help newly employed PAs and NPs successfully transition into practice. Additional research is needed to identify best practices in onboarding PAs and NPs, and to evaluate costs and benefits of onboarding programs.
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