Although physician assistant (PA) and NP training equips these clinicians with a basic level of core skills and knowledge, onboarding support can facilitate effective adjustment to real-world practice. Many healthcare organizations are interested in creating onboarding programs to help PAs and NPs transition successfully into new practice settings, but creation of these programs can be a challenge for many hiring groups.1-5 This may be especially true in primary care practice, which requires not only medical knowledge, but also a variety of skills to function on teams, coordinate care, and address social determinants of health. Acquiring and applying these skills might be particularly difficult for new PAs and NPs in community health centers (CHCs), where patient care is often confounded by economic and social challenges.6 Although Klein and Heuser provided a framework to help structure onboarding for newcomers in general, onboarding literature in the healthcare field is scant.7 In particular, information is needed on the ideal content and topic areas for clinics to include when bringing on a new PA or NP.
In the summer of 2018, our team interviewed administrators of onboarding programs for PAs and NPs in 13 clinics and healthcare systems to identify common onboarding practices. The first article in this series shared details about administration of onboarding programs and factors that should be considered when developing PA and NP onboarding programs.8 This article, the second in a three-part series, focuses on common content covered during onboarding in these organizations.
Methods were described in detail in the first article in this series.8 Briefly, from May through July 2018, one member of our team conducted semistructured interviews with volunteers from 13 healthcare organizations about their approaches to onboarding new PAs and NPs. Six organizations were multisite CHCs, two were academic medical centers, two were multispecialty integrated health systems, one was a staffing organization, one was a large physician-owned multispecialty organization, and one was a small (five-provider) 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. Most programs were geared toward, though not exclusively for, new graduates, and most organizations that we studied indicated that the majority (65% to 75%) of their new PA and NP hires in recent years have been new graduates.
In part, the framework described by Klein and Heuser guided the coding of the interviews.7 This framework outlined the content areas that need to be covered in onboarding programs. In response to the data we collected, we added and subtracted new codes as necessary.
The 13 interviewees described a variety of content areas that they cover when bringing on a new hire. Most of this content fit into the categories defined by Klein and Heuser. Table 1 shows these categories and their definitions, along with representative quotations from interviewees. We modified the Klein and Heuser framework in five ways. First, since the content described in the task proficiency category was brought up most often by our interviewees and comprised several distinct topics, we created subcategories for this topic. Second, we added a new category for wellness, a topic that was not included in the original framework. Third, we combined Klein and Heuser's categories of navigation and politics because they seemed to include similar content in our settings. Fourth, we subsumed the section on history into culture and values because history was mentioned rarely and only within the context of organizational culture. Finally, we dropped three categories not identified by our interviewees: social relationships, language, and inducements. We presume that human resources departments rather than onboarding administrators discussed inducements with their new employees.
After hiring the right person for the position, most of the organizations we interviewed felt it was important to orient the new hire to the mission, goals, and strategies of the organization. This also included content about relational and communication skills, such as those necessary for difficult conversations with patients as well as cultural competency. Many of those whom we interviewed spoke of these aspects along with organizational culture and values, and separating these two categories was not always possible as we analyzed the interviews.
All of the onboarding programs we investigated addressed task proficiency, or the extent to which the clinician has learned the necessary skills needed to function and perform their job duties and tasks.7 Because the content was broad, we created subcategories for this concept: electronic health record (EHR) use (including documentation and inbox management), medical knowledge, billing and coding, and quality improvement.
Facilities with an EHR deemed it crucial that onboarding include training on how to use the EHR. The rationale for working to ensure that new PAs were proficient with EHRs went beyond efficiency, and included care quality and safety. Within education about the EHR, two subcategories received focus in onboarding programs: documenting patient encounters and inbox management. Most centers provided their new clinicians with the skills to efficiently document patient encounters. Program administrators recognized that the investment in this training could contribute to long-term increased productivity. Providing time for training in inbox management was an additional focus for many of the programs.
Most of the organizations sought to develop and expand the medical care knowledge among newly hired PAs and NPs. This type of training focused on medical problems seen frequently in these clinics. One site mentioned how the physician would identify readings for different diagnoses and then discuss the readings with the new hire, including circumstances that would necessitate varying from typical management. Some topics were necessitated by current epidemics, such as one clinic's addition of training that addressed opioid use disorder and available resources. Other clinics noticed common knowledge deficits among new hires, and designed experiences to overcome these areas. In particular, two CHCs mentioned assigning some new hires to a short preceptorship in a pediatrics clinic to improve their ability to care for children. Quality measures and quality improvement (QI) also were addressed by some of the sites we interviewed. This type of QI training would occur at the site and focus on initiatives designed to improve patient care and outcomes.
Rules and policies are addressed by most sites when the formal workplace rules, policies, and procedures are reviewed with new hires.7 Several informants indicated that much of this was addressed by their human resources departments, and others listed components that were included in the onboarding programs. PA regulations vary by state and by organization, and are an important and unique topic that must be addressed during PA onboarding. Most organizations addressed the structure of the organization, including the structure of the larger healthcare system, and whether it was physician-owned, run by a corporation, or a CHC. Other structural aspects addressed in onboarding related to the organization of patient care, including team approaches to care and how the new PA should function in patient-centered medical homes.
Most organizations devoted onboarding time and resources to the content category of working relationships. Most interviewees agreed that establishing the relationship with collaborating physicians is the most unique aspect of onboarding PAs and NPs, as opposed to other healthcare professionals. These interpersonal negotiations may be especially challenging if the collaborating physician is inexperienced with working with PAs and NPs.
Several organizations address wellness and burnout prevention with their new hires and ensure that the newcomers know where and how to obtain help with workplace or personal problems if they arise. We combined the categories of navigation and politics because they both dealt with implicit factors and seemed similar in the settings we examined. This was another category in which our interviewees often discussed issues related to the new employees' relationships with physicians in the organization.
This study identified content that clinical sites with established onboarding programs addressed with their new PA and NP hires. Many of these content areas were congruent with those identified in a framework described by Klein and Heuser for other professions.7
The topic of task proficiency was especially prominent in our interviews. Some tasks specific to the clinical site, such as skills related to using the EHR efficiently, were a major focus. In addition, many of the sites provided review of medical knowledge and treatment of diseases prevalent in their patient population, and some reviewed medical content in areas they have found frequently to be underdeveloped in new hires.
Although the Klein and Heuser framework identifies working relationships as a core content area in most professions, our interviews found that this topic was especially relevant to PA and NP onboarding.7 In particular, the relationship with a collaborating physician presents a challenge unique to PA and NP practice. The onboarding administrators we interviewed recognized this challenge and devoted significant attention to it in their onboarding programs.
Because several organizations addressed wellness and burnout, we added this topic to those in the Klein and Heuser framework.7 Burnout is increasingly recognized as a major contributor to clinician turnover.9-11 As discussed in our previous article, employers hope that by taking the time to onboard clinicians slowly and purposefully, they can improve overall satisfaction among new hires and perhaps reduce costly burnout and turnover.4,8 Some of the content areas discussed above might be included as part of efforts to reduce burnout. For example, training in efficient EHR use may be aimed not just at improving efficiency of new clinicians, but also at reducing burnout because time spent working in the EHR has been shown to contribute to clinician burnout.12 Likewise, focusing on working relationships might foster team culture, which is associated with less burnout.13
The limitations to this study are similar to those of our previous article and include the possibility that we may have identified additional content areas if we had interviewed onboarding leaders from more than 13 sites. Another limitation is that none of the onboarding administrators who we interviewed were NPs. However, all of the administrators that we interviewed indicated that they addressed the same content areas for onboarding NPs as for PAs.
Offering an established onboarding program for PAs and NPs, especially new graduates, could be a way to attract and retain clinicians. This could be especially important in areas of healthcare workforce shortages, including primary care clinics and CHCs. Although administrators of the onboarding programs we studied each had unique approaches to orienting new hires, topics emerged that were commonly addressed in most of the institutions. This common content may be a starting point for organizations to consider as they tailor their onboarding training to meet the needs of new hires in their settings. Our final article in this three-part series will review common strategies used to onboard PAs and NPs. Future work should evaluate the effectiveness of onboarding programs and identify best practices.
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