Evaluating Onboarding Program for Advanced Practice Clinicians in Specialty Clinics: A Program Evaluation

The transition of Advanced Practice Clinicians (APCs), including Nurse Practitioners (NPs) and Physician Assistants (PAs), into new practice settings poses significant challenges, impacting both the clinicians' well-being and patient care outcomes. Despite the growing role of APCs in healthcare onboarding programs often have large training gaps contributing to burnout and undue financial burden to organizations. It is critical that onboarding processes address the specific transitional needs of novice APCs. Local Problem: Novice APCs within a large academic healthcare organization in the Mountain West region often face challenges such as anxiety, burnout, and role ambiguity during their transition, leading to poor clinical outcomes, job dissatisfaction, and costly turnover. The lack of structured onboarding exacerbates these issues, impacting patient care quality and organizational stability. Furthermore, inadequate support for APCs may increase healthcare costs, compromise patient safety, and decrease clinician morale. Addressing these challenges requires targeted and structured onboarding programs that recognize the unique needs of APCs and provide comprehensive support throughout their transition into clinical practice. It is vital to address these issues to maintain high-quality care within organizations. Methods: Utilizing the Johns Hopkins Evidence-Based Practice Model, a program evaluation was conducted to assess existing onboarding programs for APCs within a large academic healthcare organization in the Mountain West region. Stakeholder interviews, literature review, and a modified Novice Nurse Practitioner Role Transition (NNPRT) survey were employed to evaluate onboarding and identify areas for improvement. Stakeholders were frequently consulted to gain their insight and feedback on the project. Interventions: Stakeholder feedback and recent literature were synthesized to identify areas for improving APC onboarding, including organizational alignment, mentorship, sense of purpose, compensation, perceived competence, and self-confidence. Results: Findings from the modified NNPRT survey and stakeholder interviews highlighted several key areas for improvement in APC onboarding. While satisfaction levels varied, suggestions for enhancing the process included extended shadowing periods, structured training schedules, and clear expectations. Results suggest participants had a large variety of backgrounds and experiences, informing the need for tailored support strategies. Stakeholder interviews emphasized the importance of supportive cultures, effective leadership, and comprehensive documentation in optimizing APC performance and enhancing patient care. These results underscore the importance of evidence-based onboarding practices in supporting APCs' successful transition into clinical practice. Additionally, interview discussions revealed insights into the financial considerations, turnover rates, and recruitment strategies impacting APC management and organizational sustainability. Conclusion: Addressing the unique transitional needs of APCs through structured onboarding programs is crucial for improving patient care outcomes, reducing turnover, and ensuring organizational stability. By aligning onboarding practices with evidence-based strategies, healthcare organizations can better support APCs navigating their professional roles and contributing to high-quality healthcare delivery.

1 Evaluating onboarding programs for advanced practice clinicians in specialty clinics: A program evaluation Amber D. Schmidt, Katherine Doyon College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III March 31, 2024 2 Abstract Background: The transition of Advanced Practice Clinicians (APCs), including Nurse Practitioners (NPs) and Physician Assistants (PAs), into new practice settings poses significant challenges, impacting both the clinicians' well-being and patient care outcomes. Despite the growing role of APCs in healthcare onboarding programs often have large training gaps contributing to burnout and undue financial burden to organizations. It is critical that onboarding processes address the specific transitional needs of novice APCs. Local Problem: Novice APCs within a large academic healthcare organization in the Mountain West region often face challenges such as anxiety, burnout, and role ambiguity during their transition, leading to poor clinical outcomes, job dissatisfaction, and costly turnover. The lack of structured onboarding exacerbates these issues, impacting patient care quality and organizational stability. Furthermore, inadequate support for APCs may increase healthcare costs, compromise patient safety, and decrease clinician morale. Addressing these challenges requires targeted and structured onboarding programs that recognize the unique needs of APCs and provide comprehensive support throughout their transition into clinical practice. It is vital to address these issues to maintain high-quality care within organizations. Methods: Utilizing the Johns Hopkins Evidence-Based Practice Model, a program evaluation was conducted to assess existing onboarding programs for APCs within a large academic healthcare organization in the Mountain West region. Stakeholder interviews, literature review, and a modified Novice Nurse Practitioner Role Transition (NNPRT) survey were employed to evaluate onboarding and identify areas for improvement. Stakeholders were frequently consulted to gain their insight and feedback on the project. 3 Interventions: Stakeholder feedback and recent literature were synthesized to identify areas for improving APC onboarding, including organizational alignment, mentorship, sense of purpose, compensation, perceived competence, and self-confidence. Results: Findings from the modified NNPRT survey and stakeholder interviews highlighted several key areas for improvement in APC onboarding. While satisfaction levels varied, suggestions for enhancing the process included extended shadowing periods, structured training schedules, and clear expectations. Results suggest participants had a large variety of backgrounds and experiences, informing the need for tailored support strategies. Stakeholder interviews emphasized the importance of supportive cultures, effective leadership, and comprehensive documentation in optimizing APC performance and enhancing patient care. These results underscore the importance of evidence-based onboarding practices in supporting APCs' successful transition into clinical practice. Additionally, interview discussions revealed insights into the financial considerations, turnover rates, and recruitment strategies impacting APC management and organizational sustainability. Conclusion: Addressing the unique transitional needs of APCs through structured onboarding programs is crucial for improving patient care outcomes, reducing turnover, and ensuring organizational stability. By aligning onboarding practices with evidence-based strategies, healthcare organizations can better support APCs navigating their professional roles and contributing to high-quality healthcare delivery. Keywords: Advanced Practice Clinicians, Onboarding, Transition, Mentorship, Novice 4 Evaluating onboarding programs for advanced practice clinicians in specialty clinics: A program evaluation Problem Description Advance Practice Clinicians, commonly referred to as APCs, which include Nurse Practitioners (NPs) and Physician Assistants (PAs), play a vital role in the evolving landscape of our U.S. healthcare system. When allowed to practice at their full scope of expertise, Nurse Practitioners and Physician Assistants deliver high-quality and cost-effective health care (Barnett et al., 2022; van den Brink et al., 2021). With approximately 28,000 Nurse Practitioners graduating annually (Salsberg, 2018) and 11,092 Physician Assistants certified for the first time in 2022 (NCCPA, 2023), these numbers emphasize the increasing significance of the APC group within our healthcare system. However, despite their growing importance, the onboarding processes for APCs exhibit a significant lack of uniformity and fail to address their needs. Novice Advanced Practice Clinicians, including those who have recently graduated and APCs with prior experience transitioning to new specialties, often face challenges when transitioning to a new practice setting. These challenges encompass a range of issues faced by APC providers, including but not limited to anxiety, burnout, stress, self-doubt, a lack of worklife balance, and overall dissatisfaction within their clinical position (Barnes et al., 2022; Dyce, 2019). The need for awareness of these challenges and how they impact patient care and APC turnover within the organizations regarding the specific transitional needs of Advanced Practice Clinicians can significantly impact the successful transition of both novice and newly hired APCs. This lack of awareness often increases stress and role ambiguity during this crucial phase of their professional journey (Ortiz Pate, 2023). Such challenges contribute to poor clinical outcomes, job dissatisfaction, and costly turnover (De Milt et al., 2011; Faraz, 2017; Morgan et 5 al., 2023; Ortiz Pate et al., 2023; Sargent & Olmedo, 2013). To mitigate these issues and facilitate smoother role transitions, aligning onboarding programs with the existing literature is essential (Salsberg, 2018). Before the 2020 COVID-19 pandemic, the average voluntary turnover rate for US NPs was 10% (Hartsell et al., 2020). Evidence shows that the voluntary turnover rate for US NPs may have risen to 15% in 2022 (NSI, 2022). As APC turnover continues to increase, it is vital for organizations to proactively adapt, beginning with the onboarding process, to effectively mitigate potentially detrimental effects on both the quality of patient care provided and the financial stability of hospitals and clinics. The literature suggests areas experiencing higher turnover rates among Advanced Practice Clinicians tend to have notably elevated healthcare costs. A single instance of APC turnover in the United States can incur direct costs of up to $114,919 USD (Strobehn et al., 2023). Furthermore, reduced turnover among APC providers has enhanced patient outcomes and decreased healthcare expenses (Strobehn et al., 2023). Recruiting and retaining Advanced Practice Clinicians are dominant objectives and financial priorities for healthcare organizations (Painter et al., 2019). In light of the growing demand for Advanced Practice Clinicians and increasing recognition of the levels of stress and turbulence felt by new providers, as well as the associated costs that accompany the transition to a new practice setting, there is a prevailing sentiment that the solution lies in new APC providers embracing structured onboarding programs tailored to their chosen specialties (Painter et al., 2019; Sciacca & Reville, 2016). In response, the American Association of Nurse Practitioners (AANP) published a position statement to the effect that upon completing an accredited Nurse Practitioner program and obtaining national board certification, NPs are fully prepared to provide 6 safe patient care without the need for additional academic, clinical, or supervisory hours (AANP, 2022). The AANP went on to state that they oppose any mandated post-graduate residency or fellowship for NP licensure (AANP, 2022). Given the conflicting need for APC transition support and the AANP's assertion that NPs are fully prepared for the workforce upon graduation and board certification, a substantial gap exists for new or transitioning providers. Five factors of onboarding have been identified to help bridge the gap for novice APCs to navigate a potentially stressful transition better and to avoid potentially grave consequences in clinical practice. Available Knowledge With NP graduation rates rising over 200% since 2008 (Salsberg, 2018), and a 58.5 % increase in PA graduates since 2014 (NCCPA, 2023), our healthcare environment increasingly relies on APCs to provide high-quality medical care to patients. Several studies have documented the challenges faced by APCs during their role transition, including the increasing medical complexity of patients, expectations to see increased patient volumes, increased patient care demands, and a lack of mentorship support due to the limited time available for established APCs and physician colleagues to provide mentorship (Barnes, 2015; Brown & Olshansky, 1997; Faraz, 2019; Sargent & Olmedo, 2013). The study of onboarding specific to NPs and PAs is relatively new despite being an extensively studied topic in psychology (Ortiz Pate et al., 2023). The earliest transition to practice approaches are APC fellowships or residencies, which consist of 1-2 years of training where APCs are considered trainees rather than employees, are usually paid a lower wage than their employee peers and results in a formal certificate of completion (Morgan et al., 2023). In contrast, onboarding programs are shorter, ranging 3 months to 1 year, where the participants are 7 considered employees rather than trainees and are paid a competitive salary (Morgan et al., 2023). In both circumstances, there is a gradual increase in clinical responsibilities supported by mentoring and didactic training (Morgan et al., 2023). Formal onboarding has financially demonstrated its capacity to yield positive outcomes such as increased clinical productivity, decreased turnover and intent to leave, increased job satisfaction, decreased clinical errors, improved documentation, increased organizational commitment, enhanced career effectiveness, lowered stress levels, and resulted in successful role transition (Bauer, 2021; (Morgan et al., 2023)Ortiz Pate et al., 2023). Additionally, an effective onboarding program can empower new hires to find meaning in their work, enhance their understanding of their roles, boost selfefficacy, and strengthen their perceived fit within the organization (Bauer, 2021). Several studies within healthcare organizations have reported initial positive outcomes following the implementation of onboarding programs (Chaney et al., 2021; Erickson et al., 2021). One study conducted interviews with healthcare leadership and found that clinics that offered structured education and dedicated time for onboarding observed higher productivity among APCs (Pittman et al., 2021). As evidence for the advantages of onboarding programs continues to grow, job seekers increasingly consider the availability of onboarding support when evaluating employment opportunities (Ortiz Pate et al., 2023). The literature indicates five factors that onboarding programs should be evaluating during their onboarding process of APCs. Those factors are organizational alignment, mentorship, sense of purpose, perceived competence, and self-confidence, as well as compassion (Barnes et al., 2022). Organizations that align onboarding programs with these five factors have the potential to deliver safe, high-quality, and cost-efficient patient care in our community as well as throughout the United States ((Barnes et al., 2022) Buerhaus, 2018; Perlo et al., 2017; Sikka et al., 2015; 8 Swan et al., 2015). With more advanced practice clinicians rapidly entering the workforce, it is vital to assess and reflect on on onboarding programs to determine where improvements could be made. Recent studies suggest that as the scope of practice for NPs and PAs expands across the United States, it is essential for hospitals and clinics to bolster support for Advanced Practice Clinicians. A study examining 144 malpractice cases, including 49 involving NPs and 99 involving PAs, revealed various issues such as failure to diagnose, procedural errors, failure to treat, medication errors, communication errors, and failure to supervise (Ghaith & Lindor, 2023). Among these cases, negligence was found in 37 instances, with an average award of $3,216,538, while settlements averaged $1,607,716 (Ghaith & Lindor, 2023). Many of these costs were incurred by the healthcare organizations. Furthermore, the cases resulted in permanent disability, death, or temporary injuries, indicating the critical need for improved support and oversight of APCs in healthcare settings (Ghaith & Lindor, 2023). Adequately preparing advanced practice clinicians is increasingly essential to decrease adverse workforce outcomes such as increased employer costs and to avoid placing patients at risk for poor clinical outcomes (Chanfreau-Coffinier et al., 2019; Katz et al., 2015; Lam et al., 2020). Rationale The Johns Hopkins Evidence Based Practice Model (EBPM) was used to guide this program evaluation to evaluate existing onboarding programs for Advanced Practice Clinicians within a large academic healthcare organization in the Mountain West region. The Johns Hopkins EBPM is a systematic approach to healthcare decision-making that integrates the best available evidence and clinical expertise to guide clinical practice and enhance the quality of 9 patient care delivered by clinicians (Dang et al., 2022). This model was developed to bridge the gap between research and clinical practice in healthcare settings. The application of this model bridges this clinical practice gap by cultivating a spirit of inquiry to address the need for improving the onboarding process for APCs and ensuring evidence-based practices in the transition to practice. Specific clinical questions were formulated, focusing on organizational alignment, mentorship, sense of purpose, perceived competence, self-confidence, and compensation among APCs who completed the onboarding process. An extensive literature review was conducted to identify a validated survey, the Novice Nurse Practitioner Role Transition scale (NNPRT), which was adapted and modified to encompass both Physician Assistants and Nurse Practitioners, ensuring its relevance to the APC population. This modified survey, along with a demographics section, was incorporated into an electronic questionnaire distributed to a sample of APCs. Findings from the questionnaire and interviews were used to assess the effectiveness of the current onboarding programs and identify areas for improvement. The collected data and feedback from stakeholders were used to evaluate the current onboarding procedures and their impact on APCs, ultimately fostering a culture of collaboration and support among various stakeholders. By following the Johns Hopkins EBP Model, this program evaluation aimed to systematically assess the onboarding process for APCs, identify areas for improvement based on evidence and ensure that the transition to practice aligns with best practices and the needs of APCs. Specific Aims The purpose of this Doctor of Nursing (DNP) program evaluation project is to assess the existing onboarding programs for advanced practice clinicians (APCs) in specialty clinics in a 10 large urban center and assess the feasibility, usability, and satisfaction of the current onboarding practices. Methods Context Two specialty departments within the large urban center of academic healthcare organizations in the Mountain West region were identified for this program evaluation project on Advanced Practice Clinicians (APCs) onboarding process. The specialty departments under evaluation encompassed outpatient Urgent Care Clinics, as well as an inpatient Cancer Intensive Care Unit and Medical Intensive Care Unit. These departments were chosen due to their significant population of Advanced Practice Clinicians, comprising both Nurse Practitioners and Physician Assistants. In these departments, APC leadership and peers play a pivotal role in onboarding new APC providers. An Advanced Practice Clinician leads each department and is directly responsible for assessing the onboarding progress of incoming APC providers. They actively engage with attending physicians and fellow APCs to gather feedback, which is then used to inform the leadership regarding the onboarding progress of these new providers. These Mountain West Urgent Care clinics consist of nine physical locations across the Wasatch Front, along with a virtual care unit that provides healthcare services directly to patients in their homes. The collective Urgent Care clinics currently serve an estimated 227,000 patients annually, with anticipation that this number will grow to 550,000 patients by the year 2028 (B. Kelly, personal communication, September 2023). In 2023, the demographics of this population show that 96.7% of patients are residents of Utah, while 2.7% come from the six states bordering Utah: Idaho, Wyoming, Colorado, Arizona, Nevada, and New Mexico. The remaining 0.6% of patients have permanent residences in various other states across the United States. 11 The staffing levels in the Urgent Care department are subject to fluctuations over time. At the writing of this manuscript, there are a total of 145 APC providers. Among them, 113 employees work various hours, ranging from full-time equivalent (FTE) positions to half-time positions. Additionally, there are 30 providers who work on an as-needed (PRN) basis. The intensive care units at the Mountain West region hospital comprise of two distinct inpatient units: the Cancer Intensive Care Unit (ICU) and the Medical ICU, both of which are supported by the same 21 Critical Care Advanced Practice Clinician staff. The Medical ICU has traditionally operated with a 25-bed capacity, subject to capacity variations based on supportive staffing levels, and in 2023 served approximately 2,000 patients, 75% being Utah residents. Similarly, the Cancer ICU has maintained a 16-bed capacity, serving approximately 1,200 patients in 2023, 62% being residents of Utah. Notably, the patient population served in the Cancer ICU is anticipated to experience a substantial increase, given that the unit is gradually expanding from 16 to 25 beds starting in February 2024. Intervention(s) The first step of this program evaluation was to assess the current onboarding process. Interviews were conducted with onboarding stakeholders in these specialty departments. Based on feedback from the interviews, an evaluation of the degree of organizational alignment, mentorship, sense of purpose, perceived competence and self-confidence, and compensation among APCs who had completed the onboarding process was completed. The second step was to compare the feedback obtained from the stakeholders to the current literature. In the third step, we presented a summary of both stakeholder perspectives and the findings from the literature to the stakeholders themselves and documented their feedback. The fourth step was to create a one- 12 page executive summary combining the feedback from stakeholders and the available literature and distribute this to the stakeholders once again for a final session to collect feedback. Study of the Intervention(s) This program evaluation was conducted through a series of interviews with stakeholders. This descriptive approach empowered the project team to assess not only the existing onboarding procedures but also explore the motivations and experiences of stakeholders involved in APC onboarding. Through a combination of discussions, interviews, questionnaires, and the examination of available evidence, valuable insights emerged concerning the effectiveness and intricacies of the current onboarding programs in practice. Measures A validated survey known as the Novice Nurse Practitioner Role Transition scale (NNPRT), developed by Dr. Hilary Barnes, and published in 2022 was distributed to participants via email and as a poster in the provider rooms with a scannable QR code (Appendix A). This survey was designed to assess the transition of novice nurse practitioners into practice. The survey consists of 40 questions categorized into organizational alignment, mentorship, sense of purpose, perceived competence, self-confidence, and compensation (Appendix C). Respondents rate these questions on a six-point Likert scale, ranging from "very strongly disagree" to "very strongly agree." The survey underwent a slight modification to incorporate broader language applicable to Advanced Practice Clinicians, encompassing both Physician Assistants and Nurse Practitioners, while retaining all other aspects of the original survey. At the beginning of the questionnaire, the respondents indicated if they were a PA or NP. This initial question automatically tailored all subsequent training-specific questions accordingly. 13 This electronic questionnaire incorporated an 18-item demographics section (Appendix B) to complement the modified NNPRT questionnaire. The questionnaire was given to three members of APC leadership to identify and correct any potential errors prior to distributing to the larger group. The one-time electronic questionnaire was then emailed out to 113 Urgent Care APC staff with FTE positions, as well as 21 inpatient Cancer Intensive Care Unit and Medical Intensive Care Unit APCs. Furthermore, a poster containing a scannable QR code was placed in each of the provider rooms. In addition to the questionnaire, interviews and discussions were conducted with a range of stakeholders. These interactions included novice APCs, experienced APCs, APC onboarding educators, APC residency program directors, medical directors, administrators, financial directors, and operations managers. After the data was collected a summary of responses combined with data from the literature (Appendix D) was presented to stakeholders for feedback. An executive summary of stakeholder feedback was generated based on discussions and field notes that were documented during the discussion of summary results. Analysis Data collection involved administering the questionnaire and gathering content and ideas from stakeholders. Information obtained from these discussions and interviews were documented through field notes and analyzed to categorize and describe perspectives and experiences as well as perceived strengths and weaknesses in current onboarding practices. In the demographics section of the questionnaire, open-text box questions allowed previously onboarded APCs to provide feedback and suggestions for improving current onboarding practices. The modified NNPRT questionnaire was assessed using a 6-point Likert scale to understand the factors influencing APC role transition at the large urban center. 14 Descriptive statistics were used to characterize the APC participants, stakeholders, and questionnaire results from the modified Novice Nurse Practitioner Role Transition (NNPRT) questionnaire. Ethical Considerations The University of Utah classified this project as quality improvement and it did not fall under the jurisdiction of the Institutional Review Board's (IRB) oversight. Survey participation was entirely voluntary, and respondents had the freedom to discontinue the survey at their discretion without facing any repercussions. Demographic information was collected to gain a deeper insight into the specific requirements of Advance Practice Clinicians in Utah, but no direct identifying information was obtained. The survey distribution was facilitated through the Research Electronic Data Capture (REDCap) software hosted by the University of Utah. To ensure confidentiality, all data was de-identified to safeguard participant privacy. Results Key findings emerged from the 32 responses out of the 162 Advanced Practice Clinicians, resulting in a response rate of 20%. The findings from part 1, which entailed the demographics section (Table 1), showed that the participants were 46% Nurse Practitioners and 53% Physician Assistants. Among Nurse Practitioners, 53% held Master of Science in Nursing degrees, while 47% held Doctor of Nursing Practice degrees. Additionally, Nurse Practitioners held various certifications, with the most common being Family Nurse Practitioner (67%). In terms of prior experience, nurse practitioners transitioning from registered nursing roles showed a distribution of experience with 20% with 2 to 4 years, 53% with 5 to 8 years, and 27% with 9 or more years of experience prior to becoming an APRN. On the other hand, 100% of physician assistants held a Master of Science in Physician Assistant Studies degree. 15 Females comprised 65% of participants, with males making up 34%. The racial distribution showed 93% identifying as White, 3% as Hispanic or Latino, and 3% as Asian, with 6% choosing not to answer. Regarding work settings, 25% of participants worked in Critical Care and 74% in Urgent Care. Experience levels varied, with 63% having 6 or more years of experience, followed by 16% with 2 to less than 4 years, 13% with 4 to less than 6 years, and 3% with less than one year of experience. Age distribution revealed 50% falling within the 31-40 age group, followed by 44% in the 41-50 age group, 3% in the 26-30 age group and 3% in the 51-60 age group. Responses regarding satisfaction with orientation/onboarding experiences varied, with 0% strongly dissatisfied, 19% dissatisfied, 37.5% neutral, 31% satisfied, and 12.5% strongly satisfied (Table 1). When APCs were asked to describe their orientation or onboarding process, 25% had structured programs i.e. residency or fellowship, 25% had shadowing-based onboarding with mentorship, 34% minimal shadowing with immediate start, 16% informal onboarding. When asked if they had required benchmarks before being scheduled independently such as procedure checklists, 31% had procedure competency assessment and monitoring, 69% had no benchmark or checklist in place. When asked do you have any suggestions to improve the onboarding process for your department, 28% requested to create a feedback and improvement process, 16% expressed the need for structured onboarding and training, 12% requested and increase in mentorship and support, 19% responded with no feedback or changes suggestions, 25% left the response blank (Table 1). To assess the role transition of the 31 advanced practice clinician participants from urgent care clinics and intensive care units, we modified the Novice Nurse Practitioner Role Transition Scale, initially developed in 2022 by Dr. Hillary Barnes and her team, as revealed in the findings 16 from part 2 of the questionnaire. This assessment aimed to gauge the APC's perception of their onboarding experience and gather feedback to enhance the onboarding practices within their respective departments. The NNPRT has five domains for assessment, which include the APCs: 1) organizational alignment (14 questions); 2) mentorship (4 questions); 3) sense of purpose (12 questions); 4) perceived competence and self-confidence (8 questions); 5) compensation (4 questions). The NNPRT Scale utilizes higher scores to signify a more positive role transition experience, whereas lower scores indicate a less positive transition experience. The ratings were assessed on a 6-point Likert scale with the potential range of scores spanning from 1 to 6. On this scale, 1 represented "very strongly disagree," 2 indicated "strongly disagree," 3 denoted "disagree," 4 signified "agree," 5 represented "strongly agree," and 6 corresponded to "very strongly agree". The scores were then separated into agree and disagree with scores 1, 2, 3 indicating disagreement and scores 4, 5, 6 indicating agreement (Table 6). Higher scores signified a more favorable transition into the role, while lower scores indicated a less favorable transition (Barnes et al., 2022). To compute the total score for each domain, we determined the average score across all items within that domain. When the results of the NNPRT were totaled for the 31 participants, they revealed that the organizational alignment score was a mean 59.87 or 71%, mentorship score was a mean of 16.3 or 69%, sense of purpose score was a mean of 56 or 78%, perceived confidence score was a mean of 25.35 or 70%, and compensation score was a mean of 14 or 57% (Table 2). The findings were categorized into 2 distinct groups for analysis: critical care APCs (Table 3) and urgent care APCs (Table 4). The groups were then analyzed to compare statistical significance. The 8 critical care APC participants achieved the following scores: organizational alignment was a mean of 61 or 73%, mentorship was a mean of 17 or 73%, sense of purpose was 17 a mean of 57.63 or 80%, perceived confidence was a mean of 25.25 or 70%, and compensation was a mean of 12.88 or 54% (Table 3). The 23 urgent care APC participants achieved the following scores: organizational alignment was a mean of 59.48 or 71%, mentorship was a mean of 16.3 or 68%, sense of purpose was a mean of 56 or 78%, perceived competence and selfconfidence was a mean of 25.35 or 70%, and compensation was a mean of 14 or 58% (Table 4). A t-test was conducted to assess the statistical significance of the differences between the means of each domain for the two independent groups. The resulting p-values indicated that there were no statistically significant differences between the two groups (Table 3). A series of interviews were conducted with key stakeholders for this program evaluation of APC onboarding. An interview with a medical director, who recognized the need for APCs within their expanding department and subsequently developed a critical care APC onboarding program, provided insights into several key themes regarding onboarding programs for advanced practice clinicians in the ICU. For context, the development of a new ICU was underway, and the director modeled the setup after an APC-staffed ICU already established in New York City. The onboarding program underwent several phases, initially resembling a traditional residency program where selected staff would be paid at a lower rate until program completion. However, this approach was later revised due to being deemed less desirable, resulting in a streamlined 6month onboarding program with rotations in related specialties and didactic components. The development of this residency-like onboarding program was tailored specifically for APCs, driven by the demand for skilled providers in critical care and supported by funding from the hospital. Prior to implementation, thorough examination of the program's structure, including its duration, training focus, and funding considerations, was conducted. Additionally, discussions revolved around expanding the APC team's role within the ICU, including considerations for 18 shifts and coverage. Another significant theme involved recognizing the distinct skill sets between physician assistants and nurse practitioners in critical care, emphasizing the importance of fostering a diverse team. Mentorship, self-management, and the cultivation of a supportive culture emerged as crucial elements for professional growth within the critical care APC team. Furthermore, the interview highlighted continued educational opportunities such as monthly didactic sessions, journal reviews, and rotations in various specialties to enhance skills and knowledge. Assessment of the APC team's impact on patient care outcomes and collaboration with traditional physician resident staff revealed positive outcomes, empirically elevating the standard of care in the ICU. A study published on this group evaluating the APCs' positive outcomes further supported these findings (Stenehjem et al., 2014). The critical care staff demonstrated capability in collaboration, growth, and leadership, which proved pivotal for effective patient care delivery (Stenehjem et al., 2014). When interviewing the individual who oversees and manages the onboarding education, she stated that to ensure progress in their onboarding program, leadership will meet with the new provider multiple times to give them both positive and negative feedback to help them to progress. Overall, the interview underscored the significance of a tailored onboarding program, the importance of a supportive culture, and effective leadership in optimizing APC performance and enhancing patient care in critical care settings. In an interview with the Program Director over several family practice clinics in Utah, she outlined several crucial themes and highlights from the interview, shedding light on the process of improving onboarding for new APCs. Initially, challenges were highlighted regarding the lack of structured onboarding, with personal proactive efforts required to navigate the transition from student to provider successfully. Recent improvements in the onboarding process, 19 such as longer shadowing periods and structured training schedules, were noted as beneficial advancements. Additionally, the interview touched upon the complexities of the credentialing process, emphasizing the importance of comprehensive documentation and the utilization of electronic health records (EHR). Discussions also ensued regarding the role of residency programs for APCs and the variability in support and attitudes towards APCs across different healthcare divisions. Notable insights included the necessity of clear expectations and structured onboarding processes, as well as the importance of advocacy and collaboration to enhance APC support and recognition within healthcare systems. Overall, the program director emphasized the need for tailored support and structured onboarding processes to ensure the success of new APCs in clinical practice. In an interview with the operations manager for Utah urgent care clinics, she shared insights into the onboarding costs for advanced practice clinicians, revealing several key themes and highlights. The discussion delved into the onboarding process, emphasizing shadow shifts or shifts where new providers shadow experienced providers as well as a structure of a probationary periods to ensure provider readiness. Cost structures were outlined, which distinguished between an initial offer for all new APCs as a moonlighter, also known as an as needed (PRN) position which is distinguished between a benefited position. The moonlighter phase of providers serves to mitigate and protect the urgent care group from turnover costs, enabling indefinite onboarding until a full-time equivalent (FTE) position becomes available. Additionally, the pay structure in urgent care reflects the duration since graduation, with APCs in their first two years of practice being compensated at a lower rate. APCs receive an automatic raise as they surpass two years of post-graduate practice. Malpractice costs and risk factors covered by urgent care were discussed. Nurse practitioners have notably lower risk factors when compared to physician assistants 20 resulting in the urgent care clinics paying only 54% of the malpractice costs for nurse practitioners when compared to their physician assistant colleagues. Productivity metrics and compensation plans tied to RVUs were outlined, with an acknowledgment of individual learning curves impacting performance. Post-COVID turnover rates were addressed, prompting the need for effective retention strategies amid increased attrition. Recruitment strategies predominantly relied on word-of-mouth referrals and hiring NP and PA students who rotate through for their education programs. Due to the allure of urgent care positions, compensation, and preferred scheduling, there is no need for advertising of vacant APC urgent care positions outside of the previously mentioned strategies currently. Overall, the financial perspective emphasized the increasing importance of tailored onboarding processes and retention efforts in optimizing APC management and financial sustainability in the urgent care settings. Additionally, the associate director of finance and operations over a group of Utah urgent cares also confirmed that with a large APC group, it is extremely difficulty to assign expenses to onboarding. He highlighted that the profitability criteria for new benefited urgent care providers, indicating that they need to achieve a certain level of wRVUs (work relative value units) around the 73rd percentile to ensure profitability. He also acknowledged the complexity of quantifying the cost of unofficial training new providers receive from their colleagues during shifts. New providers rely on their colleagues to train them and validate treatment plans, which inevitably detracts from patient care for both trainer and trainee. In an interview with an urgent care department manager, he echoed the concerns of the finance department, stating that urgent care is a fast-paced setting with limited time to teach. In this setting new graduates are not ideal candidates. He further emphasized the importance of fostering a team-oriented atmosphere and 21 promoting cohesion during shifts by assigning multiple providers to each location. This ensures that individuals feel supported and valued throughout their shifts. Discussion Summary In summary, our findings underscored the challenges faced by novice Advanced Practice Clinicians (APCs) during their transition into new practice settings, particularly within a large academic healthcare organization in the Mountain West region. These challenges included anxiety, burnout, role ambiguity, and inadequate support, leading to adverse clinical outcomes, job dissatisfaction, and costly turnover. Despite the increasing importance of APCs in healthcare, the lack of structured onboarding exacerbates these issues, impacting patient care quality and organizational stability. Utilizing the Johns Hopkins Evidence Based Practice Model, our program evaluation aimed to assess existing onboarding programs for APCs and identify areas for improvement. We found that while satisfaction levels with onboarding varied among APCs, there were consistent suggestions for enhancing the process, such as extended shadowing periods, structured training schedules, and clear expectations. Our demographic data provided valuable insights into the diverse backgrounds and experiences of APC participants, informing the need for tailored support strategies. Stakeholder interviews emphasized the importance of supportive cultures, effective leadership, and comprehensive documentation in optimizing APC performance and enhancing patient care. Overall, our project highlighted the significance of evidence-based onboarding practices in supporting APCs' successful transition into clinical practice. By aligning onboarding practices with the identified needs and challenges of APCs, healthcare organizations can better support these providers and improve healthcare delivery. 22 Interpretation The primary goal of this program evaluation is to assess the existing onboarding protocols in multiple specialty clinics within a large urban health center in the Intermountain West. Additionally, the aim is to pinpoint any areas for enhancement within these onboarding programs, if necessary. Specifically, we aim to understand how these programs support advanced practice clinicians as they transition to new practice settings. This is crucial given the increasing job opportunities and expanded practice authority for APCs. Additionally, considering the aftermath of the COVID-19 pandemic and the complex nature of the U.S. healthcare system, there is a greater emphasis on facilitating smooth and efficient transitions for both new and transitioning APCs during this critical transition phase of their professional growth (Wolfe, 2020). The overarching objectives of this evaluation are: (1) to identify stakeholders and gather feedback to evaluate the current APC onboarding process in specialty clinics and identify preferred content and elements of APC orientation, (2) synthesize recommendations from the literature with feedback from stakeholders, (3) to distribute this summary to stakeholders, (4) to summarize responses and feedback from presentation and assess project feasibility, usability, and satisfaction. The demographics questionnaire responses regarding orientation and onboarding experiences provided valuable insights into the onboarding processes in the urgent care and critical care departments of a large healthcare organization in the Intermountain West. The varying approaches to onboarding, ranging from structured programs to informal shadowingbased methods, underscore the need for tailored onboarding practices to meet the diverse needs of APCs. Furthermore, the need for standardized benchmarks or checklists for assessing 23 competency before independent scheduling raises questions about the consistency and effectiveness of current onboarding practices. Suggestions for improvement provided by the APCs, such as creating feedback mechanisms and increasing mentorship and support, reflect the desire for enhanced support and resources during the onboarding process. This aligns with the literature's emphasis on structured onboarding to facilitate role transitions and, in turn, optimize patient care outcomes. The assessment of role transition using the Novice Nurse Practitioner Role Transition Scale highlighted both positive and challenging aspects of APC onboarding experiences within the large healthcare organization in the Intermountain West. While overall scores indicated a favorable transition experience, disparities in domain-specific scores between critical care and urgent care APCs underscored the need for targeted interventions to address specific challenges. The absence of statistically significant differences between nurse practitioners and physician assistants in key domains suggests commonalities in their onboarding experiences despite differences in educational backgrounds. These findings underscore the importance of tailored support and mentorship to facilitate successful role transitions for APCs in diverse healthcare settings. In addition to demographic and NNPRT scale onboarding insights, interviews with key stakeholders provided further context and diverse perspectives on APC onboarding processes and financial considerations. The discussions highlighted the complexity of quantifying onboarding costs and the importance of structured support mechanisms in optimizing APC performance and financial sustainability. Challenges related to unofficial training and the need for team-oriented atmospheres underscored the multifaceted aspects of onboarding and the importance of fostering supportive cultures within healthcare organizations. Overall, the findings 24 emphasize the need for ongoing evaluation and refinement of onboarding practices to address the evolving needs of APCs and further evaluate the costs of investing in structured onboarding programs for advanced practice clinicians to ease their transition experience and enhance patient care outcomes in healthcare settings. Limitations The findings of this study warrant careful interpretation due to acknowledged limitations. As with any self-report survey, the potential for sampling error or bias must be acknowledged. Challenges arose in obtaining data exclusively from novice Advanced Practice Clinicians, leading to the decision to expand the sample size to include all APCs within the departments. This adjustment was considered appropriate as it established a baseline across departments. When interviewed, the financial department staff could not provide the specific cost data, hindering the determination of the financial ramifications pertaining to Advanced Practice Clinician turnover and the accompanying training costs within the healthcare organization. Another limitation arose from the fact that while 32 APCs completed part one of the questionnaire, which included demographic information, only 31 APCs completed both part one and part two, encompassing the modified Novice Nurse Practitioner Role Transition Scale. Conclusions There is a need for and interest in creating and improving onboarding programs for advanced practice clinicians in Utah as they navigate new practice environments. There is sufficient evidence to guide onboarding program design focusing on the five domains of the NNPRT scale: organizational alignment, mentorship, sense of purpose, compensation, perceived competence, and self-confidence. Focusing on these aspects of APC onboarding has been found to ease the transition into new practice environments. In addition to creating onboarding 25 programs that reflect the literature, the survey responses collected from APCs who have undergone the onboarding process yield valuable and actionable suggestions. It is crucial for leadership to support the suggested improvements and strive to enhance NNPRT scores. The next step is quantifying the costs associated with onboarding APCs to improve performance and ensure quick and efficient financial sustainability in a new practice environment. This process will determine the expenses involved in enhancing onboarding practices to meet the changing needs of APCs and further evaluate the benefits of structured onboarding programs. Through these next steps, we will further advance our efforts to diminish APC turnover, minimize costs for healthcare organizations, and uphold a culture of excellence that attracts top-tier APC job seekers. 26 Acknowledgments I wish to express my heartfelt gratitude to those who have played pivotal roles in my academic journey, both within the confines of this doctoral program and throughout my scholarly pursuits. To the esteemed faculty of the College of Nursing, I sincerely appreciate their commitment to ensuring my success throughout this rigorous program. To my dear friend and mentor, Dr. Silvia E. Smith, for graciously being part of my educational path for nearly ten years. I am also immensely grateful to my fellow classmates for their support and camaraderie, which have been a source of encouragement and delight. I thank Dr. Katherine Doyon for her unwavering support and advocacy throughout this scholarly endeavor. Her consistent encouragement and invaluable guidance have been instrumental in shaping this work. I am forever indebted to her mentorship, and I am committed to carrying forward the knowledge and wisdom she has imparted to me. Furthermore, I am deeply grateful to my family for their devotion and understanding of my demanding schedule, as well as for their steadfast support throughout this challenging journey. Lastly, I wish to express my deepest gratitude to my remarkable husband, whose unshakable belief in my abilities has been a constant source of strength and inspiration. Thank you. 27 References American Association of Nurse Practitioners. (2022). Mandated residency and fellowship training position statement. https://www.aanp.org/advocacy/advocacy-resource/ positionstatements/ mandated-residency-and-fellowship-training Auffermann, K., O’Keefe, R., Smith, T., & Cohn, T. (2021). Exploring novice nurse practitioner job satisfaction. Journal of the American Association of Nurse Practitioners, 33(10), 802–810. https://doi.org/10.1097/JXX.0000000000000454 Barnes, H. (2015). Nurse practitioner role transition: A concept analysis. Nursing Forum, 50(3), 137–146. https://doi.org/10.1111/nuf.12078 Barnes, H., Faraz Covelli, A., & Rubright, J. D. (2022). Development of the novice nurse practitioner role transition scale: An exploratory factor analysis. Journal of the American Association of Nurse Practitioners, 34(1), 79. https://doi.org/10.1097/JXX.0000000000000566 Barnett, M., Balkissoon, C., & Sandhu, J. (2022). The level of quality care nurse practitioners provide compared with their physician colleagues in the primary care setting: A systematic review. Journal of the American Association of Nurse Practitioners, 34(3), 457–464. https://doi.org/10.1097/JXX.0000000000000660 Brown M & Olshansky EF. (1997). From limbo to legitimacy: A theoretical model of the transition to the primary care nurse practitioner role. Nursing Research, 46(1), 46–51. Chanfreau-Coffinier, C., Washington, D. L., Chuang, E., Brunner, J., Darling, J. E., Canelo, I., & Yano, E. M. (2019). Exploring the association of care fragmentation and patient ratings of care quality: A mediation analysis of women veterans’ experience with VA care. Health Services Research, 54(4), 816–826. https://doi.org/10.1111/1475-6773.13153 28 De Hert, S. (2020). Burnout in healthcare workers: Prevalence, impact and preventative strategies. Local and Regional Anesthesia, Volume 13, 171–183. https://doi.org/10.2147/LRA.S240564 De Milt, D. G., Fitzpatrick, J. J., & McNulty, S. R. (2011). Nurse practitioners’ job satisfaction and intent to leave current positions, the nursing profession, and the nurse practitioner role as a direct care provider. Journal of the American Association of Nurse Practitioners, 23(1), 42. https://doi.org/10.1111/j.1745-7599.2010.00570.x Dyce, E. (2019). It gets better: Reflections on first year of practice. The Journal for Nurse Practitioners, 15(9), 696–697. https://doi.org/10.1016/j.nurpra.2019.05.018 Faraz, A. (2019). Facilitators and barriers to the novice nurse practitioner workforce transition in primary care. Journal of the American Association of Nurse Practitioners, 31(6), 364. https://doi.org/10.1097/JXX.0000000000000158 Faraz, A., & Salsberg, E. (2019). From education to practice: What we can learn about the workforce from a survey of new nurse practitioners. Journal of the American Association of Nurse Practitioners, 31(8), 454. https://doi.org/10.1097/JXX.0000000000000226 Germack, H. D., Harrison, J., Poghosyan, L., & Martsolf, G. R. (2022). Practice patterns, work environments, and job outcomes of rural and urban primary care nurse practitioners. Medical Care Research and Review, 79(1), 161–170. https://doi.org/10.1177/1077558720974537 Hartsell, Z., Noecker, A., & Ed, M. (2020). Quantifying the cost of advanced practice provider turnover. Sulivan Cotter, pg 4. 29 Hoff, T., Carabetta, S., & Collinson, G. E. (2019). Satisfaction, burnout, and turnover among nurse practitioners and physician assistants: A review of the empirical literature. Medical Care Research and Review, 76(1), 3–31. https://doi.org/10.1177/1077558717730157 Katz, D. A., McCoy, K. D., & Vaughan-Sarrazin, M. S. (2015). Does greater continuity of veterans administration primary care reduce emergency department visits and hospitalization in older veterans? Journal of the American Geriatrics Society, 63(12), 2510–2518. https://doi.org/10.1111/jgs.13841 Lam, K., Arnold, C. G., Savage, R. D., Stall, N. M., Zhu, L., Wu, W., Piggott, K., Bronskill, S. E., & Rochon, P. A. (2020). Does physician retirement affect patients? A systematic review. Journal of the American Geriatrics Society, 68(3), 641–649. https://doi.org/10.1111/jgs.16216 Liu, Y., Cherian, J., Ahmad, N., Han, H., De Vicente-Lama, M., & Ariza-Montes, A. (2023). Internal corporate social responsibility and employee burnout: An employee management perspective from the healthcare sector. Psychology Research and Behavior Management, Volume 16, 283–302. https://doi.org/10.2147/PRBM.S388207 Moran, G. M., & Nairn, S. (2018). How does role transition affect the experience of trainee advanced clinical practitioners: Qualitative evidence synthesis. Journal of Advanced Nursing, 74(2), 251–262. https://doi.org/10.1111/jan.13446 Morgan, P., Barnes, H., Batchelder, H. R., Tuttle, B., Faraz Covelli, A., Everett, C., Jackson, G. L., Anglin, L., Ortiz Pate, N., Dieter, P., & Bludorn, J. (2023). Nurse practitioner and physician assistant transition to practice: A scoping review of fellowships and onboarding programs. Journal of the American Association of Nurse Practitioners, 35(12), 776. https://doi.org/10.1097/JXX.0000000000000932 30 Ortiz Pate, N., Barnes, H., Batchelder, H., Anglin, L., Sanchez, M., Everett, C., & Morgan, P. (2023). Physician assistant and nurse practitioner onboarding in primary care: The participant perspective. Journal of the American Association of Nurse Practitioners, 35(2), 122–129. https://doi.org/10.1097/JXX.0000000000000823 Painter, J., Sebach, A. M., & Maxwell, L. (2019). Nurse practitioner transition to practice: Development of a residency program. The Journal for Nurse Practitioners, 15(9), 688– 691. https://doi.org/10.1016/j.nurpra.2019.05.003 Robeano, K., Delong, D., & Taylor, H. A. (2019). Optimizing transitional support for novice nurse practitioners. Nurse Leader, 17(4), 303–307. https://doi.org/10.1016/j.mnl.2019.03.020 Salsberg, E. S. (n.d.). Changes in the pipeline of new NPs and RNs: Implications for health care delivery and educational capacity. Health Affairs Forefront. https://doi.org/10.1377/forefront.20180524.993081 Sciacca, K., & Reville, B. (2016). Evaluation of nurse practitioners enrolled in fellowship and residency programs: Methods and trends. The Journal for Nurse Practitioners, 12(6), e275–e280. https://doi.org/10.1016/j.nurpra.2016.02.011 Stenehjem, D. D., Bannon, M., & Boltax, J. (2014). Outcomes in cancer patients (pts) admitted to a surgical (SICU) or medical ICU (MICU) compared to a newly opened cancer specific ICU (HICU). Journal of Clinical Oncology, 32(30_suppl), 279–279. https://doi.org/10.1200/jco.2014.32.30_suppl.279 Strobehn, P. K., Barnes, H., Bellury, L. M., & Randolph, J. J. (2023). US nurse practitioner voluntary turnover: Development of a framework for analysis. Journal of the American 31 Association of Nurse Practitioners, 10.1097/JXX.0000000000000960. https://doi.org/10.1097/JXX.0000000000000960 van den Brink, G. T. W. J., Hooker, R. S., Van Vught, A. J., Vermeulen, H., & Laurant, M. G. H. (2021). The cost-effectiveness of physician assistants/associates: A systematic review of international evidence. PloS One, 16(11), e0259183. https://doi.org/10.1371/journal.pone.0259183 Wolfe, B. (2020). Postgraduate inpatient training in the time COVID. Journal for Nurse Practitioners, 16, 478. 32 Tables and Figures Table 1 Demographics for APCs in Utah Specialty Clinics ________________________________________________________________ Advanced Practice Clinicians N=32 (%) APC Certification NP 15 (47%) PA 17 (53%) Years of APC Experience <1 1 (3%) ≥ 2 to < 4 5 (16%) ≥ 4 to < 6 4 (12%) 6+ 21 (66%) Missing 1 (3%) Years in Current APC Position <1 3 (9%) ≥ 1 to < 2 3 (9%) ≥ 2 to < 4 9 (28%) ≥ 4 to < 6 2 (6%) 6+ 15 (47%) National NP Certification (N=15) Primary Care 9 (60%) Acute Care 4 (27%) Adult-Gerontology 1 (7%) Other or Multiple 1 (7%) Education Doctor of Nursing Practice 7 (22%) Master of Science in Nursing 8 (25%) Master of Science in PA Studies 17 (53%) Years of Prior RN Experience (N=15) 2-4 3 (20%) 5-8 8 (53%) 9+ 4 (27%) Age 26-30 1 (3%) 31-40 16 (32%) 41-50 14 (44%) 51-60 1 (3%) 33 Table 1 Demographics for APCs in Utah Specialty Clinics, continued ________________________________________________________________ Advanced Practice Clinicians N=32 (%) Gender Male Female Race White or Caucasian Multiple Races Prefer Not to Answer 11 (34%) 21 (66%) 30 (94%) 1 (3%) 1 (3%) Ethnicity Non-Hispanic or Latino Hispanic or Latino Other Prefer not to answer 28 (88%) 1 (3%) 1 (3%) 2 (6%) Current APC Practice Urgent Care Critical Care Family Practice Multiple or Other 21 (66%) 8 (25%) 2 (6%) 1 (3%) Satisfaction with onboarding/orientation experience Strongly Dissatisfied 0 (0%) Dissatisfied 6 (19%) Neutral 12 (37.5%) Satisfied 10 (31%) Strongly Satisfied 4 (12.5%) Current FTE ≥ 0.5 to < 0.75 ≥ 0.75 to ≤ 1.0 5 (16%) 27 (84%) APC residency Yes No 5 (16%) 27 (84%) 34 Table 1 Demographics for APCs in Utah Specialty Clinics, continued ________________________________________________________________ Advanced Practice Clinicians N=32 (%) Please describe your orientation/onboarding process: Structured programs i.e. residency or fellowship Shadowing-based onboarding with mentorship Minimal shadowing with immediate start Informal onboarding 8 (25%) 8 (25%) 11 (34%) 5 (16%) How satisfied are you with your orientation/onboarding experience? Strongly Dissatisfied Dissatisfied Neutral Satisfied Strongly Satisfied 0 (0%) 6 (18.75%) 12 (37.5%) 10 (31.25%) 4 (12.5%) Did you have required benchmarks before being scheduled independently (i.e. number of intubations, central line placements, procedures checklist)? Yes, procedure competency assessment and monitoring No benchmark or checklist in place 10 (31%) 22 (69%) Do you have any suggestions to improve the onboarding process for your department? Need for structured onboarding and training Increase mentorship and support Create a feedback and improvement process No feedback or changes suggested Response left blank 5 (16%) 4 (12%) 9 (28%) 6 (19%) 8 (25%) 35 Table 2 NNPRT Total Score Factor 1: Organizational Alignment (14 Questions, Total Score Possible 84) N=31 % Agree * 2 3 There is a lack of respect for APCs in my practice setting. Administration has negative attitudes toward APCs. I feel support by administration. 26 (84%) 4 I have a voice in the organization. 18 (58%) 5 My suggestions for improving practice are respected. Administration understands the APC role. 1 6 Factor 3: Sense of Purpose, continued N=31 % Agree * Patient satisfaction is important to me. 28 (90%) 2 (6%) 4 5 (16%) 5 6 I enjoy working with my patient population I feel accepted by my patients. 7 I am excited by the work I am doing. 28 (90%) 19 (61%) 8 I make a difference in the community I serve. 27 (87%) 24 (77%) 9 I belong in the APC role. 31 (100%) 31 (100%) 10 I have good relationships with physicians. 31 (100%) 30 (97%) 11 I have a sense of purpose. 29 (94%) 27 (87%) 12 I am pleased with my APC education. 28 (90%) 31 (100%) 29 (94%) 9 I am treated as a professional by my colleagues. I am given independence to manage my patients. My physician colleagues understand the APC role. 10 I understand what is expected of me in my role as an APC. 31 (100%) Total Average Score (SD), % 56.42 (8.27), 78% APC role expectations were clearly communicated to me when I started. 27 (87%) Factor 4: Perceived Competence and Self-Confidence (6 Questions, Total Score Possible 36) N=31 % Agree * I belong in my practice setting. 31 (100%) I am satisfied with my benefits. I am able to schedule time off when needed. 31 (100%) 7 8 11 12 13 14 30 (97%) 1 2 3 Total Average Score (SD), % 59.87 (5.95), 71% 4 Factor 2: Mentorship (4 Questions, Total Score Possible 24) N=31 % Agree * 5 My mentor is invested in my professional growth A mentor is available to me. 19 (61%) 1 2 3 4 19 (61%) 23 (74%) My mentor is a good role model. My mentor understands my needs as a new APC. Total Average Score (SD), % Factor 3: Sense of Purpose (12 Questions, Total Score Possible 72) 20 (65%) 16.65 (4.5), 69% N=31 % Agree * 1 I feel that I am appreciated by my patients. 28 (90%) 2 3 I enjoy helping patients. 31 (100%) The work I do is important. 30 (97%) *See table 6 for Likert 6-point scale scoring 6 I feel comfortable managing my patient load. I am comfortable in my role. 31 (100%) I feel overwhelmed in my role. 8 (26%) I am able to meet the demands of my APC position. I am able to meet my patients’ clinical care needs. I need more time than I am scheduled to complete my responsibilities. Total Average Score (SD), % Factor 5: Compensation (4 Questions, Total Score Possible 24) 1 2 3 4 I feel that my compensation is fair for the work I do. I feel underpaid for the work I do. 28 (90%) 30 (97%) 29 (94%) 13 (42%) 25.32 (3.26), 70% N=31 % Agree * 20 (65%) 18 (58%) I am satisfied with my compensation. 16 (52%) I am pleased with the pay raise structure in my practice setting. 11 (35%) Total Average Score (SD), % 13.71 (1.79), 57% 36 Table 3 Critical Care NNPRT Scale Factor 1: Organizational Alignment (14 Questions, Total Score Possible 84) 1 2 3 4 5 6 7 8 9 10 N=8 % Agree* There is a lack of respect for APCs in my practice setting. Administration has negative attitudes toward APCs. I feel support by administration. I have a voice in the organization. My suggestions for improving practice are respected. Administration understands the APC role. I am treated as a professional by my colleagues. I am given independence to manage my patients. My physician colleagues understand the APC role. I understand what is expected of me in my role as an APC. Factor 3: Sense of Purpose, continued N=8 % Agree* 0 (0%) 4 Patient satisfaction is important to me. 7 (88%) 1 (13%) 5 6 7 I enjoy working with my patient population 8 (100%) I feel accepted by my patients. I am excited by the work I am doing. I make a difference in the community I serve. I belong in the APC role. 7 (88%) 8 (100%) 8 (100%) 5 (63%) 5 (63%) 8 9 8 (100%) 10 I have good relationships with physicians. 8 (100%) 7 (88%) 11 I have a sense of purpose. 8 (100%) 8 (100%) 12 I am pleased with my APC education. 7 (88%) Total Average Score (SD), % 57.63 (8.58), 80% N=8 % Agree* 7 (88%) 8 (100%) 8 (100%) I belong in my practice setting. I am satisfied with my benefits. I am able to schedule time off when needed. 8 (100%) 8 (100%) Factor 4: Perceived Competence and SelfConfidence (6 Questions, Total Score Possible 36) 1 I feel comfortable managing my patient load. 2 I am comfortable in my role. 8 (100%) 3 Total Average Score (SD), % 61 (5.58), 73% 4 Factor 2: Mentorship (4 Questions, Total Score Possible 24) N=8 % Agree* 5 6 (75%) 6 11 12 13 14 1 2 3 4 APC role expectations were clearly communicated to me when I started. 7 (88%) My mentor is invested in my professional growth A mentor is available to me. 6 (75%) Total Average Score (SD), % Factor 3: Sense of Purpose (12 Questions, Total Score Possible 72) 6 (75%) 17.63 (4.24), 73% N=8 % Agree* 1 2 I feel that I am appreciated by my patients. 6 (75%) I enjoy helping patients. 3 The work I do is important. 8 (100%) 8 (100%) *See table 6 for Likert 6-point scale scoring I feel overwhelmed in my role. I am able to meet the demands of my APC position. I am able to meet my patients’ clinical care needs. I need more time than I am scheduled to complete my responsibilities. Total Average Score (SD), % Factor 5: Compensation (4 Questions, Total Score Possible 24) 7 (88%) My mentor is a good role model. My mentor understands my needs as a new APC. 6 (75%) 6 (75%) 1 2 3 4 I feel that my compensation is fair for the work I do. I feel underpaid for the work I do. I am satisfied with my compensation. I am pleased with the pay raise structure in my practice setting. Total Average Score (SD), % 8 (100%) 2 (25%) 8 (100%) 8 (100%) 2 (25%) 25.25 (3.54), 70% N=8 % Agree* 4 (50%) 4 (50%) 4 (50%) 3 (38%) 12.88 (2.42), 54% 37 Table 3 Urgent Care NNPRT Scale Factor 1: Organizational Alignment (14 Questions, Total Score Possible 84) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 2 3 4 1 2 3 There is a lack of respect for APCs in my practice setting. Administration has negative attitudes toward APCs. I feel support by administration. I have a voice in the organization. My suggestions for improving practice are respected. Administration understands the APC role. I am treated as a professional by my colleagues. I am given independence to manage my patients. My physician colleagues understand the APC role. I understand what is expected of me in my role as an APC. N=23 % Agree* 2 (9%) 4 (17%) 18 (78%) 13 (57%) 14 (61%) 18 (78%) 4 5 6 7 8 9 21 (91%) I enjoy working with my patient population 23 (100%) I feel accepted by my patients. I am excited by the work I am doing. I make a difference in the community I serve. I belong in the APC role. 22 (96%) 20 (87%) 23 (100%) 23 (100%) 21 (91%) 10 23 (100%) 11 I have a sense of purpose. 21 (91%) 19 (83%) 12 I am pleased with my APC education. 21 (91%) Total Average Score (SD), % 56 (8.31), 78% Factor 4: perceived competence and selfconfidence (6 Questions, Total Score Possible 36) 1 I feel comfortable managing my patient load. 2 I am comfortable in my role. 3 I feel overwhelmed in my role. N=23 % Agree* 21 (91%) 23 (100%) 7 (30%) 23 (100%) I belong in my practice setting. I am satisfied with my benefits. I am able to schedule time off when needed. 23 (100%) 23 (100%) 22 (96%) Total Average Score (SD), % 59.48 (6.14), 71% 4 Factor 2: Mentorship (4 Questions, Total Score Possible 24) N=23 % Agree* 5 13 (57%) 6 13 (57%) 14 (61%) 16.3 (4.53), 68% N=23 % Agree* I feel that I am appreciated by my patients. 22 (96%) I enjoy helping patients. The work I do is important. 23 (100%) 22 (96%) I am able to meet the demands of my APC position. I am able to meet my patients’ clinical care needs. I need more time than I am scheduled to complete my responsibilities. Total Average Score (SD), % Factor 5: compensation (4 Questions, Total Score Possible 24) 16 (70%) Total Average Score (SD), % Factor 3: Sense of Purpose (12 Questions, Total Score Possible 72) *See table 6 for Likert 6-point scale scoring Patient satisfaction is important to me. I have good relationships with physicians. 20 (87%) My mentor is a good role model. My mentor understands my needs as a new APC. N=23 % Agree* 23 (100%) APC role expectations were clearly communicated to me when I started. My mentor is invested in my professional growth A mentor is available to me. Factor 3: Sense of Purpose, continued 1 2 3 4 I feel that my compensation is fair for the work I do. I feel underpaid for the work I do. 22 (96%) 21 (91%) 11 (48%) 25.35 (3.24), 70% N=23 % Agree* 16 (70%) 14 (61%) I am satisfied with my compensation. 12 (52%) I am pleased with the pay raise structure in my practice setting. 8 (35%) Total Average Score (SD), % 14 (1.48), 58% 38 Table 5 NNPRT Scale Means and Standard Deviations NNPRT Total N=31 Mean Likert Score SD 59.87 4.28 5.95 Mean Likert Score SD 16.65 4.16 4.5 Mean Likert Score SD 56.42 4.70 8.27 Mean Likert Score SD 25.32 4.22 3.26 Mean Likert Score SD 13.71 3.43 1.79 Critical Urgent Critical Care Care Care vs Urgent Care NP PA N=8 N=23 p-value N=14 N=17 Organizational Alignment (14 Questions) P= 0.54 61 59.48 57.93 61.47 4.36 4.25 4.14 4.39 5.58 6.14 6.28 5.32 Mentorship (4 Questions) 17.63 16.3 P= 0.49 15.71 17.41 4.41 4.08 3.93 4.35 4.24 4.53 4.01 4.73 Sense of Purpose (12 Questions) 57.63 56 P= 0.64 56.57 56.29 4.80 4.67 4.71 4.69 8.58 8.31 8.38 8.43 Perceived Confidence (6 Questions) P= 0.94 25.25 25.35 25.93 24.82 4.21 4.23 4.32 4.14 3.54 3.24 3.32 3.23 Compensation (4 Questions) 12.88 14 P= 0.13 13.65 13.76 3.22 3.50 3.41 3.44 2.42 1.48 2.02 1.64 Nurse Practitioner vs Physician Assistant p-value P= 0.10 P= 0.31 P= 0.93 P= 0.36 P= 0.85 39 Table 6 Likert 6-Point Scale Scoring NNPRT Key Likert 6-point Scale Very Strongly Disagree Strongly Disagree Disagree Agree Strongly Agree Very Strongly Agree Score 1 2 3 4 5 6 Agree/ Disagree Disagree Disagree Disagree Agree Agree Agree 40 Appendix A 41 Appendix B 42 Appendix B, continued 43 Appendix C 44 Appendix C, continued 45 Appendix C, continued 46 Appendix C, continued 47 Appendix D Executive Summary Evaluating Onboarding Programs for Advanced Practice Clinicians in Specialty Clinics: A Program Evaluation Situation: Novice APCs in a large academic healthcare organization in the Mountain West region often face challenges including anxiety, burnout, and role ambiguity leading to poor clinical outcomes, job dissatisfaction, and costly turnover. The lack of structured onboarding exacerbates these issues, impacting patient care quality and organizational stability, necessitating targeted interventions to ensure comprehensive support throughout their transition into clinical practice. Background: With a notable increase in NPs and PAs in the healthcare workforce, the reliance on APCs to deliver high-quality healthcare has surged. The literature suggests transition challenges, such as heightened patient care demands and limited mentorship pose challenges to new APCs. The literature reveals two primary approaches to APC transition: traditional fellowships/residencies and shorter onboarding programs. Both entail a gradual increase in responsibilities. Formal onboarding has demonstrated financial benefits and fosters positive outcomes like increased productivity and job satisfaction. Notably, onboarding support correlates with improved productivity and is increasingly valued by job seekers. Additionally, malpractice cases highlight the need for enhanced APC support and emphasize the importance of robust onboarding programs in an effort to mitigate adverse outcomes. Evaluation: The Program Evaluation was conducted in Mountain West urgent care clinics, medical ICU, and an oncology ICU and included: 1. SWOT Analysis: to determine strengths, weaknesses, opportunities, and threats of current onboarding practices through formal and informal interviews conducted with stakeholders and participants. 2. Surveying participants: using a modified NNPRT survey with a demographics section distributed to 164 APCs in specialty clinics post-onboarding with a 20% (n=32) response rate. 3. Analyzed survey data using descriptive statistics to identify areas for improving current onboarding practices. 4. Shared survey results with stakeholders and gathered feedback. Novice APC Role Transition Scores Total Average Critical Care Urgent NNPRT Domains Care Organizational Alignment: APC’s “fit” in their workplace 71% 73% 71% Mentorship: availability and perceived quality of mentorship 69% 73% 68% Sense of Purpose: internal feelings about patient care and job satisfaction 78% 80% 78% Perceived Competence & Self-Confidence: confidence in meeting job demands 70% 70% 70% Compensation: satisfaction with financial compensation, fair salaries 57% 54% 58% Recommendation: Surveying APCs who have undergone the onboarding process yields valuable and actionable suggestions. It is crucial for leadership to support the suggested improvements and strive to enhance NNPRT scores. APC Suggestions for Onboarding Improvements Critical Care • More structured and regimented didactic training • Establish benchmarks and milestones with consideration for experienced providers • More formal evaluation process throughout onboarding • Designated preceptor during onboarding • Full APC credentialing before clinical responsibilities initiated Urgent Care • Create a formal onboarding program • Assigned mentor for support and questions during the onboarding process and beyond • Designated contact for questions during the onboarding process • Initiate a skills day to review key procedures and policies for consistent treatment • List of common procedures that preceptors are aware of and invite you to participate in on shift • Increase 4-hour clinic familiarization shift to 6-hours • Remove expectation to see patients during shadow shifts for preceptor to instruct on EPIC and efficiency tips • APCs with less than 3 years of experience assigned a mentor to review charts as needed • Increased residency length for new graduates or those without prior urgent care experience • New graduates assigned as an extra person on shifts for the first month