PA and NP onboarding in primary care

The participant perspective

Abstract

Objective: 

To describe new graduate physician associate/assistant (PA) and NP perspectives of onboarding programs in their first primary care position.

Methods: 

Thirteen semistructured interviews were conducted with new graduate PAs and NPs who participated in onboarding programs. Interviews were transcribed and then analyzed using an inductive coding methodology.

Results: 

Analyses revealed nine thematic concepts that are described in two frameworks. Structural components are improving competence, training on the electronic health record (EHR), promoting mentorship, orienting to organizational dynamics, tailoring ramp-up of patient scheduling, clarifying expectations, and providing clear organizational support. Psychosocial factors are creating comfort and building self-confidence.

Discussion: 

The results describe and delineate important components for onboarding that administrators can incorporate into existing and future programs.

Conclusion: 

Understanding participants' experiences with onboarding programs is essential for ensuring successful transition to practice for new graduate PAs and NPs.

In 2021, the National Academies of Sciences, Engineering, and Medicine emphasized the importance to the provision of high-quality primary care of an adequate healthcare workforce that includes physician associate/assistants (PAs) and NPs.¹ In 2016, PAs and NPs accounted for more than 35% of the primary care provider workforce, with the remainder made up of physicians.² The presence of PAs and NPs in safety-net clinics is even higher and growing faster compared with physicians. Between 2009 and 2019, the proportion of PAs, NPs, and certified nurse midwives (CNMs) in community health centers (CHCs) increased by 153%.³ With rapid growth of the PA and NP workforces, coupled with increasing complexity of care delivery, organizations that want to ensure a successful transition to practice for PAs and NPs should consider onboarding programs an essential tool.

Many newly hired primary care PAs and NPs are new graduates and have specific transition-to-practice needs. For many clinicians, the transition to a new work role can be stressful and uncertain, and for novice clinicians, this transition often is difficult.^4,5 Difficult transition-to-practice experiences can lead to feelings of anxiety, inadequacy, and role ambiguity, as well as decreased job satisfaction and increased intent to leave.^6-9 These negative workforce outcomes can then affect employment continuity and the decision to remain in the profession.¹⁰ Turnover affects employer costs, disrupts care continuity, and places patients at risk for poor clinical outcomes.^11-13 An understanding of the needs of new-to-practice PAs and NPs is important for informing organizations' onboarding practices and workforce development.

Onboarding has been studied extensively in psychology but is a newer area of research for PAs and NPs in primary care. In the business sector, onboarding has led to positive outcomes, including improved job satisfaction, organizational commitment, performance levels, and career effectiveness, as well as lower turnover and stress.¹⁴ A successful onboarding program also has the potential to help new hires find meaning in their work and improve role clarity, self-efficacy, and perceived fit.¹⁴ Several researchers have found initial positive outcomes from healthcare organizations' implementation of onboarding programs.^15,16 Pittman and colleagues interviewed CHC leaders and found higher productivity among PAs and NPs in CHCs that offered dedicated time for onboarding and structured education programs.¹⁷ Also, Erickson and colleagues published a description of a primary care onboarding program that demonstrated positive outcomes among PAs and NPs, including increased engagement, reduced turnover, and higher clinical productivity.¹⁶ The growing evidence of positive outcomes from onboarding has revealed the paucity of data describing which specific onboarding program strategies have been successful. This study aims to describe these strategies from the participant perspective.

With growing evidence of the benefits to employees and employers of onboarding programs, potential employees are weighing their job opportunities with onboarding support in mind. This is encouraging healthcare organizations to create onboarding programs tailored to new hires' needs. This study describes onboarding program components that new-graduate PAs and NPs felt were strengths or areas for improvement in their orientation to their first primary care position. The study also provides recommendations for employers hoping to create or enhance onboarding programs.

METHODS

The study was approved by the Duke University institutional review board. Electronic informed consent was obtained from all participants and their participation was completely voluntary.

Study population

Between 2020 and 2021, 13 primary care PAs and NPs participated in the study. Inclusion criteria required that participants be newly hired (within the past 1 to 4 years) in a primary care setting, be practicing in their first clinical position, and have attended an onboarding program that existed for at least 1 year before their participation. To determine data saturation, researchers identified the point when little new information was coming from participants. At that point, they could be reasonably confident that they had saturated the interview data to the point of redundancy.¹⁸ The final sample consisted of seven PAs and six NPs. All participants worked in primary care facilities in the United States (Table 1).

TABLE 1. - Participant characteristics

	Total N = 13 n (%)	By profession
		NP N = 6 n (%)	PA N = 7 n (%)
Sex
Female	10 (76.92%)	3 (50%)	7 (100%)
Male	3 (23.08%)	3 (50%)	0 (0%)
Mean age in years (SE)	29.38 (0.895)	31.83 (0.749)	27.29 (0.993)
Setting
Non-CHC	9 (69.23%)	4 (66.67%)	5 (71.43%)
CHC	4 (30.77%)	2 (33.33%)	2 (28.57%)
Graduation year
2016	1 (7.69%)	1 (16.67%)	0 (0%)
2017	2 (15.38%)	1 (16.67%)	1 (14.29%)
2018	6 (46.15%)	2 (33.33%)	4 (57.14%)
2019	4 (30.77%)	2 (33.33%)	2 (28.57%)
Clinical site location
Northeast	2 (15.38%)	0 (0%)	2 (28.57%)
Southeast	3 (23.08%)	1 (16.67%)	2 (28.57%)
Midwest	6 (46.15%)	4 (66.67%)	2 (28.57%)
Southwest	2 (15.38%)	1 (16.67%)	1 (14.29%)
Onboarding length of time
≤1 month	2 (15.38%)	0 (0%)	2 (28.57%)
2-6 months	4 (30.77%)	4 (66.67%)	0 (0%)
7-11 months	0 (0%)	0 (0%)	0 (0%)
12+ months	7 (53.85%)	2 (33.33%)	5 (71.43%)

Percentages may not total 100% because of rounding.

Study procedures

Participants were recruited via referrals from content experts, dissemination of study advertisements via organizational electronic mailing lists, and posts to social media sites (for example, the private Facebook group for federally qualified health center family NPs). All participants completed a short eligibility questionnaire and an online survey assessing demographics and information about their education, practice setting, length and general structure of the onboarding program, administrative aspects of the program, and strengths and areas for improvements of the program. Survey results were used by the study team to tailor the semistructured interviews, which allowed for deeper discussion of the participants' experiences with their onboarding programs.

All interviews were conducted via telephone between February 2020 and June 2021 by two authors (LA and MS), both of whom are primary care clinicians. Using a researcher-developed interview guide (Table 2), interviewers asked participants to describe their onboarding program, note any strengths and weaknesses of it, and report whether it supported their transition to practice. The framework for developing the interview guide was based on a widely known strategic planning technique known as a SWOT analysis (Strengths, Weaknesses, Opportunities, and Threats). In addition to using this framework to gather information, researchers added a question specific to the study focus that asked whether participants felt they were able to successfully transition to practice. The interviewer also asked participants to expand on any strengths or areas for improvement cited in the online survey. Participants were compensated $100 for their time.

TABLE 2. - Interview guide

Can you briefly describe your onboarding program? What were the strengths/what worked well? Follow up on issues noted in their survey What were the weaknesses (any challenges you encountered within the onboarding program)? Overall, was your onboarding program adequate? Why or why not? What opportunities for improvement were there in onboarding/what suggestions do you have for improvement? Follow up on issues noted in their survey Do you feel that you have successfully transitioned into this position? Why or why not? Anything I did not ask you about that you want to tell me about your onboarding experience?

Data analysis

Interviews were recorded, transcribed, deidentified, and imported into NVivo 12 Pro. An inductive coding approach was used to identify themes and subthemes in the transcripts and consisted of three phases: initial coding, code refinement, and final coding.¹⁹ To increase intercoder reliability and the credibility of the analysis, a codebook was developed by two authors (NOP and PM) who were not the participant interviewers.²⁰ These authors independently coded three interviews to develop initial codes during the first phase. They then met to discuss and revise their initial codebook and repeated the process until all interviews were coded as is consistent with continuous thematic analysis.¹⁸ A separate coder (HRB), not involved with interviewing or the initial coding, was included in these discussions to help resolve coding differences and develop the initial codebook. During the second phase, NOP and PM reanalyzed transcripts using the initial codebook to ensure consistent usage of codes and, with HRB, revised the codebook as necessary. In the final phase, the codes were discussed and refined by all authors until consensus was reached on code use and definitions. Having three independent qualified researchers collaborate during data coding and thematic development allowed for checking of assumptions, biases, and reactions that might have influenced data interpretation.¹⁸ Also, including three additional researchers in the data analysis process allowed for any parallels that were noted across data sources to be considered dependable and contribute to data trustworthiness.¹⁸

RESULTS

The final sample consisted of seven PAs and six NPs (Table 1). Most participants were female (76.92%). All participants worked in primary care with almost 70% based in non-CHC settings. At the time of data collection (2020-2021), most participants were new graduates, with about 77% having graduated in 2018 or 2019. More than half of participants attended onboarding programs lasting 12 months or longer, and nearly 31% attended programs lasting 2 to 6 months.

Analyses revealed seven structural and two psychosocial thematic concepts about onboarding components (Figure 1). The structural thematic concepts describe components that participants identified as strengths and areas for improvement of their onboarding programs: improving competence, training on the EHR, promoting mentorship, orienting to organizational dynamics, tailoring the ramp-up of patient scheduling, clarifying role expectations, and demonstrating clear organizational support. The psychosocial thematic concepts focus on the interrelation of onboarding programs' social and structural factors and participants' resulting thoughts and behavior. The two psychosocial thematic concepts describe foundational, nontangible effects of an onboarding program: creating comfort and building self-confidence. The thematic concepts and illustrative quotes are described next and outlined in Table 3.

FIGURE 1.: Onboarding components that lead to a successful transition to practice, according to PA and NP study participants

TABLE 3. - Structural and psychosocial thematic concepts and illustrative quotes

Structural themes
• Improving competence—assisting new PAs and NPs in improving clinical knowledge and skills. “I think what works well in the program is the ability to, the program does a good job of assessing each individual new graduate and having a number of means to fill the gaps. So, as an example, I think about, I think about really, for me, ortho. That was a weak point, both in terms of knowledge. Both in terms of, and in terms of skills and assessment, as well as my own confidence. And so I got to spend some time, we have an orthopedic urgent care.” ID09 “We...had a meeting on the third Wednesday of every month...and we would have different lecture on different topics, we'd have guest speakers come in and it was really beneficial...and it covered topics like [atrial fibrillation], back pain, like surgical admins, basically anything—it was just really helpful.” ID04 • Training on the EHR—assisting new PAs and NPs in becoming efficient users of the clinic's EHR system. “I would say another strength would be, there was, like—there were two half-days where I had formal, you know, [EHR] training with one of their Epic coordinators from the hospital. I would actually have the morning off, it was blocked off on my clinic day; I'd go to the hospital, sit down with her for 4 hours. And, you know, that really helped me get some templates in place, which, you know, helped me have some more efficient charting in those, you know, early days.” ID13 “And I actually did feel very well-supported in our Epic training. I think that having that 4-hour training, and then a month later, having it planned for another 4-hour training. And actually, after I started, so, I thought I was well-prepared, until they made it even better. And instead of, 1 month later, having a 4-hour training, or the proficiency training, they actually had the Epic people come out and spend a day with all providers, after they had been there a month, and figure out where they could improve one-on-one in improving or adding in templates or smart sets or things like that.” ID11 • Promoting mentorship—a more experienced clinician/employee provides guidance about a range of topics, including the onboarding process, professional identity, and clinical care. “Well you're, yeah you're assigned a, specific mentor for that entire year. So, so if you feel like you're struggling with a particular diagnosis or, or whatever you're struggling with, you can go to that mentor and, and talk it over with them and you know kind of come up with a plan together or, or problem solve that together. So you, you feel like you have a little bit of a safety net.” ID22 “So that was I think the biggest thing, but also just really having that one designated PA and I thought it was helpful to be a PA as well. Like I said I had this supervising physician I feel very comfortable with and have, but she, you know she doesn't know the requirements of like our licensure as well as the PA does and how—just even tracking like our continuing ed, going into the portal, and that type of thing. I think it was really important or helpful that it was a PA with a PA, because she kind of knew all of that stuff that I needed to know.” ID19	• Orienting to organizational dynamics—PAs and NPs are given information about the structure of the organization/practice and how things work. “And I feel like [group name] did a great job with our onboarding...Yeah, I think, in the beginning, all the insurance stuff, the risk management, a lot of that, I feel like, was very clear. I didn't feel like I had to worry about anything. If I had a question about getting something set up, the credentialing team was awesome and would answer all my questions. They sent me everything, they sent me links, if I didn't know, things like that, I feel like they were absolutely wonderful with all, like, the credentialing stuff. Because that was stuff that was, you know, I've had other friends who I think have more struggles with that. But they were very straightforward with a giant, giant pile of paperwork, but [laughs], you know, that part was very good.” ID11 “I did think of one more improvement or recommendation I have is...I didn't get a chance to shadow some of the other positions, and I think if I had had the opportunity to shadow like a [medical assistant] working up a patient or shadow the front desk, where we have social workers in our clinic and case workers...had I been able to shadow them, I think like now I have a better understanding of what they do. But had I been given that opportunity when I first started, I think it would have made you know, understanding their roles and why things are done a certain way a little bit easier. So having a better understanding of those roles and other responsibilities.” ID10 “Yeah, I think being clear about like who my collaborating physician was, who my transition-to-practice coordinator was, who my preceptor was and having those point people to go to was really helpful.” ID20 “But we had, basically, certain days, I would go and spend time with our registered nurse doing annual wellness visits or learning about what they see on their end of things with the patient educator. And then other days, I'd spend a couple hours with some of our medical assistants, going over the rooming process, and seeing what they do, just so that you know what's expected of them. And then also, like, with the in basket, stuff you could send lab result-wise, to have the nurse call versus the LPN or the medical assistant, so that was kind of nice.” ID08 • Tailoring the ramp-up of patient scheduling—a strategy in which new hires are assigned few patients initially, and then the number of patients is slowly ramped up to a target level. “Yeah, I think the ramp-up period is, like, number one, probably the most important thing that we were able to kind of create. Like I said, I have those friends who jumped in, like, head-first and just felt like they couldn't keep up, and then they eventually transitioned out of primary care after about a year, because they just couldn't keep up with it. And honestly, I feel like I fully understand that, because jumping in at, like, six felt overwhelming on some days. Because you don't know where everything is in the office, you don't know...referrals to make, and those kinds of things, and they take time to learn. So I definitely think the ramp-up period was probably the most important.” ID04 “Where starting out with four patients it really let me have that time to ask some questions and get my charts done so I didn't feel overwhelmed and that slow ramp-up was really helpful to just kind of get, get your feet underneath you as a new provider without feeling like you're drowning.” ID20 “That was the most important thing for me for sure. Because had I felt pressure to see a certain number of patients or to know a certain number of things or to do a number of procedures, that would have been just devastating.” ID09
• Clarifying role expectations—PAs and NPs were informed about what was expected of them in their new positions/roles. “Expectations I think weren't super well communicated. I mean honestly like most healthcare organizations don't do a super great job of doing that anyways. It's just kind of like, ‘Well here are [sic] what we need you to do.’ And it's like, ‘Well with my salary and what—like what are the expectations?’ And I think that piece wasn't super well communicated from the beginning and it still kind of feels like it's, it's hard to know exactly where, where you're supposed to be even now....I kind of would have liked to know if I was up to par, I guess, you know? If I was meeting those expectations and if I was doing a good job...But I think some feedback would have been helpful, because we're [providing] so much feedback for them on how we feel like we're doing, but not getting it back was hard for me.” ID20 “I have the folder, here, but basically, the first day I came in, [name] gave me this folder of all the things, and kind of the expectations, and it was all nice and printed up, which was very helpful. And then also, obviously, everything is fluid, but just having that timeline of what kind of the goals were as far as how many patients we were seeing, but realizing that that wasn't a hard stop, that we had to have that many.” ID08 • Demonstrating clear organizational support—new PAs and NPs felt that they had the support that they needed to succeed in onboarding and in their new positions. “The things that I found most helpful, both practically and emotionally, was the combination of the time I needed to learn and develop the knowledge and skills, and the understanding that that was normal and the expectation...” ID09 “I also felt I had lots and lots of support, whether it was from the other PAs in my clinic or just the fact that I would get e-mails every so often from my assigned senior PA, and knowing that if any issues did arise, I could reach out to her and she would work with me to fix them. So I did feel very well supported throughout the process.” ID02 “...and even my practice medical director, here, she was very much, you know, encouraging of, like, ‘Let us know what we need to do to help you to be successful, here...’” ID05 “So, I think having the open communication, just expecting the appointments where you can talk about, like, how things are going and how they're not going.” ID08	Psychosocial themes • Creating comfort—the onboarding process promoted a feeling of comfort in the newly hired PA or NP. “I was constantly in contact with the head PA at our practice and she was asking me how I felt, was I comfortable.” ID02 “And by the time I did move up to the full template, I was pretty comfortable to do so.” ID16 “So I, I liked that process of, of feeling like I could build my confidence levels and build my time efficiency and all those things at a pace that I felt comfortable.” ID22 “We said, okay, let's increase by about one patient per session until we're at the full max every couple of weeks, and I would check in at the end of those 2 weeks and see if I felt ready to increase. And if I did, we would go ahead, and if I didn't, we would keep going at my current rate until I felt comfortable and then we would increase.” ID02 • Building self-confidence—the onboarding process helped new PAs and NPs to become more confident in their role and abilities to care for patients. “...And it [the onboarding program] just gave me that sense of confidence, since I was continuing to learn with patients. And I always felt like I had the support that I needed as a new provider, but I never felt like they pushed me or overwhelmed me to do more than what I was comfortable with.” ID10 “I liked the process of like the slow ramp-up with the patients, rather than you know some...I've heard some of my friends that you know start off with maximum capacity and just you know really just like go, go headfirst in. So I, I liked that process of, of feeling like I could build my confidence levels and build my time efficiency and all those things at a pace that I felt comfortable. So I would say that was probably one of my favorite parts of the, of the program.” ID22

STRUCTURAL THEMES

Improving competence

Participants discussed the benefit of having a review of primary care topics and skills training through various teaching methods. For example, participants described how the use of chart reviews, dedicated time with specialists, and primary care-based lectures improved competence. One participant noted, “The program does a good job of assessing each individual new graduate and having a number of means to fill the gaps. So, as an example...ortho...was [my] weak point...in terms of knowledge, skills, and assessment...and my own confidence. [Therefore,] I got to spend some time [at] an orthopedic urgent care” (participant ID09). Another participant noted, “It was really beneficial...[to] have lectures on different topics [such as atrial fibrillation], back pain...” (ID04). This same participant also discussed the benefits of rotating through specialty rotations such as “endocrine, cardiology, orthopedics...a memory clinic and a headache clinic.” Participants noted that improving competence, using various teaching strategies, is an important aspect of any onboarding program.

Training on the EHR

Participants underscored the importance of EHR training during their onboarding programs. A participant described how time dedicated to EHR skills training improved their efficiency in performing key job-related tasks: “I would say another strength would be...there were two half-days where I had formal [EHR] training with one of their Epic coordinators from the hospital. I would actually have the morning off; it was blocked off on my clinic day. That really helped me get some templates in place, which helped me have some more efficient charting” (ID13). Another participant reported that the “biggest boon was having a light patient schedule at first” so that the clinician had time to “work through the EHR system and get stuff done, at [their] own pace...to ensure efficiency” (ID16). Although EHR training outcomes were not assessed, participants reported that EHR training during onboarding supported development of their clinical efficiency.

Promoting mentorship

Participants valued onboarding programs that included career mentoring, which promotes professional development and growth in the organization.²¹ One participant noted the importance of having a mentor who had gone through the same clinical training, which allowed for career-specific mentorship: “So that was the biggest thing...having that one designated PA and I thought it was helpful to be a PA as well...I had this supervising physician I feel very comfortable with but she doesn't know the requirements of...our licensure as well as the PA does and...I think it was really important or helpful that it was a PA with a PA, because she kind of knew all of that stuff that I needed to know” (ID19). Another participant described regularly scheduled, dedicated time with their mentor that included “goal setting [and discussions confirming that the participant had] dedicated time for learning [and] shadowing opportunities” (ID09). Overall, participants reported that having formal and informal mentorship relationships helped them navigate the onboarding process, build professional identity, and develop role clarity, and they also served to provide guidance on clinical practice.

Orienting to organizational dynamics

Participants noted the value of having an orientation component in onboarding that outlined credentialing requirements, introduced team member roles, and helped them become integrated in the organization's culture. One participant reported that the organization had a very clear orientation where “they were very straightforward with a giant...pile of paperwork” and “all [the participants'] questions were answered” (ID11). Another participant appreciated a clear introduction to onboarding leadership: “being clear about...who my collaborating physician was, who my transition-to-practice coordinator was, who my preceptor was and having those point people to go to was really helpful”; the participant further noted that continuity and consistency for these positions are “really important as a new provider” (ID20). Alternatively, lack of orientation to other team members' roles was negatively described by interviewees: “if I had had the opportunity to shadow a[n] MA [medical assistant], or [to] shadow the front desk, [or] social workers in our clinic or case workers, [I would have had] a better...understanding of their roles and why things are done a certain way” (ID10). Conversely, participants felt a benefit when role introductions were included as part of the orientation. One participant, who “went around [the clinic] after about a week...to see what nurses did, what the lab staff did and the front [desk staff]” described this as “a really nice gradual introduction” (ID04). Altogether, participants valued the organization dedicating time to introducing them to its culture and team members.

Tailoring the ramp-up of patient scheduling

Participants described the benefit of being assigned few patients initially, and then having a tailored ramp-up or -down of the number of patients scheduled. Participants noted “that slow ramp-up was really helpful to just kind of get your feet underneath you as a new provider without feeling like you're drowning” (ID20). Another participant noted that a tailored ramp-up allowed them to spend time with more complex, “resource-limited populations, such as refugees,” addressing the social determinants of health (ID11), which was important for providing care, especially for this clinician. A tailored ramp-up provided participants with a sense of autonomy over their patient schedules, relief of productivity demands, and the opportunity to provide patient-centered care.

Clarifying role expectations

Participants were grateful to have clear, outlined expectations of their professional roles described during onboarding. However, when such expectations were not definitively outlined, participants described difficulty understanding their own place in the organization. Examples of expectations included outlining productivity goals, calculation of relative value units, goals for number of procedures or referrals, and professionalism expectations. One participant noted “how [it was] really nice to have a formal folder” that outlined “all the expectations” including “a timeline of what kind of goals as far as how many patients [they] were seeing” (ID08). Another participant noted that a lack of clear expectations was frustrating, and they would have preferred to know the expectations and whether they were “up to par” and “doing a good job,” and not getting that information made it “hard to know exactly where you're supposed to be” (ID20). In general, participants valued a clear understanding of their own roles in the organization and felt off-course without this.

Demonstrating clear organizational support

Several participants described how organizational support via effective and open communication, frequent check-ins from leadership (such as the collaborating physician and administrators), and the assurance of protected time for development of knowledge and new skills were integral to their onboarding. As one participant noted, “The things that I found most helpful, both practically and emotionally, was [sic] the combination of the time I needed to learn and develop the knowledge and skills, and the understanding that that was normal and the expectation” (ID09). Overall, participants discussed different strategies for organizational support as positive influences on their onboarding experiences and overall well-being.

PSYCHOSOCIAL THEMES

Creating comfort

Participants described, as a major strength, the effect of the relationship between different onboarding structural components and the emotional well-being element of comfort that it provoked in the participant. This cross-cutting theme was accomplished via a combination of the structural strategies described above, including open communication, frequent check-ins, and a tailored ramp-up. This feeling was apparent when participants discussed whether they could speak to other practitioners about patient care: “I always felt comfortable going to...other practitioners or...anybody in the office really...I felt pretty comfortable” (ID22). Participants also expressed how onboarding helped them feel more at ease with their mentors and administrators when discussing the need to adjust the number of patients scheduled. Another participant noted that their organization was “very, very open in asking ‘If you're not comfortable with that we'll back down. We'll see how it goes.’ They were very willing to let me try things and change my schedule as needed” (ID19). In general, participants commented that several strategies could contribute to creating the feeling of comfort during onboarding.

Building self-confidence

According to participants, the effect of having a combination of several structural components working in tandem was an increase in overall self-confidence. One participant expressed how having protected time to learn and organizational support gave them a “sense of confidence since I was continuing to learn with patients. And I always felt like I had the support that I needed as a new provider” (ID10). Another participant described how the combination of open communication, protected time, and gradual ramp-up allowed them to build confidence in their practice without feeling overwhelmed. For example, “You know in the beginning you really need that reassurance and sometimes it's just like bouncing a case off your doc to see like, ‘Oh is, is this the same thing that you would have done?’ If you're starting at your practice seeing 10-plus patients a day, you really don't get that and I think it takes a lot longer to build up your confidence then” ID20.

DISCUSSION

This is the first study to describe new-graduate PA and NP perspectives on their onboarding programs in primary care. Participants identified important components of their onboarding programs that contributed to enhanced professional development by letting them acclimate to their new organization and role. The participants reported that, when present, the structural components contributed to a sense of comfort and an increase in self-confidence. Several of the themes that emerged echoed previous research identifying elements of a successful transition to practice (for example, perceived competence, self-confidence, and social support).⁸ Additional structural elements, such as mentorship, orientation to organizational dynamics, and clear role expectations, have been linked to two concepts that are critical for ensuring a successful transition to practice: role clarity and self-efficacy.^8,14

Although studies of NP role transition report that role clarity is an important facilitator of a successful transition, most of the research on role clarity in the context of onboarding has been conducted in the fields of psychology and human resource management.^8,22 For example, the Society for Human Resource Management (SRHM) asserts that “role clarity, or how well a new employee understands his or her role and expectations, is among the most consistent predictors of job satisfaction and organizational commitment during the onboarding process.”¹⁴ Among team-based disciplines, such as sports psychology, and managerial teams, role clarity has been shown to be a significant predictor of role performance effectiveness.²³ Organizations aiming to support new PAs' and NPs' organizational commitment, role performance effectiveness, and successful transition to practice would be wise to consider embedding into their onboarding programs the structural elements that contribute to role clarity. In onboarding primary care PAs and NPs, organizations may consider including components targeted at enhancing role clarity, such as providing new graduates with mentors from their own profession, clearly communicating role expectations during orientation (for example, delineating productivity requirements), and supporting interprofessional relationships to enhance role clarity among team members.²³

Every participant described how their onboarding program made them feel, overall, more comfortable in their role and confident in treating patients. Self-confidence is frequently related to the concept of self-efficacy, and positive emotions, such as feelings of comfort and self-confidence, play a major role in developing self-efficacy.²⁴ Research has found that self-efficacy can have positive effects on employees' commitment to the organization, employee satisfaction, and turnover.¹⁴ Also, greater self-efficacy has been linked to improved clinical performance among PA students, higher workplace satisfaction among nurses, and positive transitions to practice among NPs.^8,25,26 Moreover, studies of comfort theory, which have been applied to successful transition to practice in nursing, have found that social support often facilitates a successful transition to practice.^11,27-29 Our findings suggest that several of the structural components described by participants contributed to their feeling more comfortable and confident.²⁴ Organizations that, during onboarding, prioritize PAs' and NPs' development of comfort and self-confidence over initial productivity can reap rewards in the form of committed and productive employees. Organizations that aim to enhance new graduate self-efficacy may consider including onboarding components that improve self-confidence, such as competence-building efforts (such as inclusion of primary care skills training) and dedicated time for open communication and feedback between new graduates and mentors.⁸

LIMITATIONS

Although the interviewers were trained similarly to conduct the semistructured interviews, each interviewer explored concepts with varying depths, which may have resulted in missing details about aspects of participants' experiences. In addition, given recruiting challenges due to COVID-19, we enrolled five participants from different sites in the same organization; however, we were able to ensure that participants represented a wide geographical area. Finally, our study focuses on primary care practices, limiting the transferability of study results to other settings or specialties.

CONCLUSIONS

This study identifies the structural components of onboarding programs described as strengths and areas for improvement by new graduate PAs and NPs. Onboarding programs for PAs and NPs hold promise for increasing clinician confidence, competence, and productivity, which can lead to improved care continuity and quality of care. A clearer understanding of what PAs and NPs deem important during onboarding has implications for both new-graduate PAs and NPs and the organizations that hire them. Implementing participant-informed onboarding programs may help organizations support positive clinician experiences, an aspect of the Quintuple Aim.³⁰ Based on our study findings, small changes, such as providing PA or NP role-specific EHR training over generalized EHR training, including an introduction to organizational culture, ensuring open communication, and offering frequent check-ins should be implemented in onboarding programs to improve new graduates' experiences. Further, our findings can inform the development and enhancement of primary care onboarding programs aimed at improving recruitment, retention, professional development, and performance of new-graduate PAs and NPs. Because new-graduate PAs and NPs searching for their first jobs often seek a supportive culture, organizations that actively support new employees' transition to practice may have a hiring advantage. For new-graduate PAs and NPs applying for their first position, negotiating the incorporation of structural components of onboarding that others have found helpful can increase the chances of a successful transition-to-practice experience. Future research is needed to examine how incorporating the identified structural components of onboarding programs can improve workforce and healthcare system outcomes.