Date of Award
Projects: SPU Access Only
Doctor of Nursing Practice (DNP)
Dr. Elizabeth Perpetua
Dr. Darryl DuVall
Background and Significance: Advanced Practice Providers (APPs) require adequate support to successfully transition into a new role (Auffermann et al., 2020; Barnes, 2015; Twine, 2017). Onboarding may be a process that can ease this transition (Auffermann et al., 2020; Barnes, 2015; Erickson et al., 2021). Onboarding is a welcoming process through which new employees learn the skills, knowledge, and behaviors they need to adjust to a new role's social and performance aspects (Bauer, 2010). When onboarding is inadequate, it may delay productivity or even result in attrition, which is costly to health care systems and negatively impacts patient care (Erickson et al., 2021; Hartsell & Noecker, 2020; Woolforde, 2012). Various challenges with the onboarding process had been reported within the project site. However, the process had not undergone a formal assessment to evaluate the process or identify opportunities for improvement. Due to these factors, this organization needed to evaluate the onboarding process of newly hired APPs.
Purpose: This process-focused program evaluation aimed to define and understand the project site's onboarding process for newly hired APPs to identify existing gaps and opportunities for improvement.
Methods: The evaluation was conducted at a non-profit regional healthcare system in northern Washington. The project was guided by the CDC's Framework for Program Evaluation and Patricia Benner's model, From Novice to Expert. The evaluation took place from January 2022 through April 2022 and utilized stakeholder meetings, a review of the organization's onboardings documents, APP and hiring manager surveys created using Google Forms, and post-survey interviews. Quantitative data were analyzed using descriptive statistics. Qualitative data was compiled and reviewed for themes.
Results: Meetings with stakeholders identified program challenges such as inadequate staffing, communication, and coordination issues among departments. A review of program documents identified that the organization had an established process for organizational onboarding with content consistent with recommendations from the literature (Goldschmidt et al., 2011; Sanchez et al., 2020). However, a standardized process for clinical orientation was not identified. The surveys yielded a 36% response rate for APPs (n=12) and 29% for the managers (n= 6). The compliances category identified that APPs require more follow-up education regarding EPIC, Workday and Dimensions, billing and coding. The category of clarification received the highest percentage (29%) of dissatisfied responses from APPs, with annual evaluations and bonus areas of concern. The competency category highlighted the lack of an established process for clinical orientation identified earlier in the evaluation. The culture category received the highest percentage of satisfied responses but did identify that APPs would like more education regarding benefits. Lastly, the connection category found that manager and leadership check-ins are not routinely occurring and that 42% of APPs surveyed had not been assigned a mentor during onboarding.
Recommendations: Once the evaluation was completed, recommendations were shared with the project site. These recommendations included implementing a program coordinator, developing a standardized clinical orientation process, increasing APP and administrative leadership involvement in the organization's onboarding program, and utilizing metrics to track and evaluate the process.
Sustainability: Following the CDC's (1999) Framework for Program Evaluation, project recommendations were shared with leadership and stakeholders through a final report. Information regarding the evaluation process was shared to allow the evaluation to be replicated in the future as needed. Further, the organization was given recommendations to use metrics to track and evaluate the site's program moving forward.
Limitations: There is little high-quality evidence to support best practices regarding the onboarding of APPs. Therefore, the program was compared against common aspects of APP onboarding programs found in the literature rather than a recognized standard. Further, requested data and metrics regarding onboarding were not received, which limited the evaluation of the program. The survey tool was not studied for reliability or validity. Additionally, sample sizes and response rates for the project surveys and follow-up interviews were small.
Implications for Practice: The number of newly hired APPs increases annually within the project site. Due to this, efforts to evaluate and ensure the adequacy of the organization's onboarding process grow increasingly important. Recommendations made because of this program evaluation will assist the organization in making improvements to the current onboarding process. Improvements made as a result of this project may lead to enhanced APP job satisfaction and increased feelings of support for newly hired providers within the organization (Auffermann et al., 2020; Bush & Lowery, 2016). Subsequent improvements may also have the potential to confer financial benefits to the organization through reduced attrition rates and new providers meeting the anticipated level of productivity more rapidly (Auffermann et al., 2020; Erickson et al., 2021).
Auffermann, K., O'keefe, R., Smith, T., & Cohn, T. (2020). Exploring novice nurse practitioner job satisfaction. Journal of the American Association of Nurse Practitioners. https://doi.org/10.1097/jxx.0000000000000454
Barnes, H. (2015). Exploring the factors that influence nurse practitioner role transition. The Journal for Nurse Practitioners, 11(2), 178–183. https://doi.org/10.1016/j.nurpra.2014.11.004
Bauer, T. B., (2010). Onboarding new employees: Maximizing success. Society for Human Resource Management Foundation. https://www.shrm.org/foundation/ourwork/initiatives/resources-from-past-initiatives/Documents/Onboarding%20New%20Employees.pdf
Bush, C. T., & Lowery, B. (2016). Postgraduate nurse practitioner education: Impact on job satisfaction. The Journal for Nurse Practitioners, 12(4), 226–234. https://doi.org/10.1016/j.nurpra.2015.11.018
Centers for Disease Control and Prevention. (1999). Framework for program evaluation in public health (MMWR 1999;48, No. RR-11). https://www.cdc.gov/mmwr/PDF/rr/rr4811.pdf
Erickson, C. E., Steen, D., French-Baker, K., & Ash, L. (2021). Establishing organizational support for nurse practitioner/physician assistant transition to practice programs. The Journal for Nurse Practitioners, 17(4), 485–488. https://doi.org/10.1016/j.nurpra.2020.11.018
Goldschmidt, K., Rust, D., Torowicz, D., & Kolb, S. (2011). Onboarding advanced practice nurses. JONA: The Journal of Nursing Administration, 41(1), 36–40. https://doi.org/10.1097/nna.0b013e3182002a36
Twine, N. (2017). The first year as a nurse practitioner: An integrative literature review of the transition experience. Journal of Nursing Education and Practice, 8(5), 54. https://doi.org/10.5430/jnep.v8n5p54
Hartsell, Z., Noecker, A., (2020). Quantifying the cost of advanced provider turnover. Sullican Cotter. https://sullivancotter.com/wp-content/uploads/2020/02/Quantifying-the-Cost-of-Advanced-Practice-Provider-Turnover.pdf
Woolforde, L. (2012). Onboarding nurse practitioners: A healthcare system approach to interprofessional education. Nurse Leader, 10(5), 32–35. https://doi.org/10.1016/j.mnl.2012.07.002
Formosa, Rebecca L., "Program Evaluation of an Advanced Practice Provider Onboarding Process" (2022). Doctor of Nursing Practice (DNP) Scholarly Projects. 47.