Onboarding Nurse Practitioners: A Healthcare System Approach toInterprofessional Education

October 201232 Nurse Leader

The Future of Nursing report1 underscores the

belief that nurses can play a vital role in

patient care outcomes. Among many things, the

report discusses nurses practicing to the fullest

extent of their education, nurse/physician collabo-

ration, and team approaches. The issues

addressed in the report are relevant at all levels

of nursing but have unique implications for nurse

practitioners (NPs). As the debate continues

about scope-of-practice standards and boundaries

for NPs, one thing is clear: NPs are increasingly

becoming employed in the acute care setting.

Launette Woolforde, EdD(c), DNP, RN-BC

Although NPs can play an important role in helping torealize the objectives of the Affordable Care Act,2 includ-

ing advancing preventive care and increasing access to care,NPs can also make a tremendous impact on quality outcomesfor hospitalized patients. It is incumbent upon nurse leadersto figure out how to maximize NP functioning as licensedindependent practitioners and take full advantage of theirknowledge and skills as healthcare team members.Considering that physician assistants (PAs) also have an inte-gral and expanding role within some acute care facilities, theyare included in the endeavor discussed here. This article willexplore the approach one health system has taken to enhancethe smooth transition of advanced practice nurses and PAsinto its complex care setting.

At the North Shore-Long Island Jewish (NSLIJ) HealthSystem, we believe that the healthcare delivery model of thefuture will feature teams of interprofessional colleagues work-ing together in an environment that is patient centered. Withapproximately 400 NPs already on board, we needed toensure that they had role clarity; an understanding about theorganization—its mission, vision, values, and approach to care;and an idea of how best to work with the other team mem-bers. We needed to ensure that NPs were comfortable andcompetent in the skills they were expected to perform andthat there was a sound process in place for orientation anddocumentation of their clinical competencies. A dauntingissue for organizations employing ever larger numbers of NPsis that many found themselves onboarded in an unstructuredmanner, leaving them feeling lost, delaying productivity, andaffecting retention.

PROCESSOur goal was to construct a plan to address the gaps in theNP onboarding process. It was expected that this would havemajor implications for teamwork, job satisfaction, and mostimportantly, patient care outcomes.

Traditionally, hospitals have an organized orientation pro-gram and process for new staff. In particular, nursing orienta-tion is usually very clearly defined. This was true for NSLIJ.We had a robust registered nurse (RN) orientation programthat had been in existence as a biweekly, centralized, stan-dardized program at the system level for over 5 years. Becauseresources are always a consideration in growth and expansion,we decided that we would use our existing RN orientationprogram as the framework for a new interprofessional orien-tation program. We agreed that the model would allow NPsto enter the health system through a clear and structuredmechanism, including a formal orientation program thatwould expose them to the standards, policies, procedures, andteam members with which they would be working.

Essential partnerships formed in the planning phaseincluded:• Nursing education/leadership to provide insight about the

existing program and address the practice considerationsfor NPs

• NP, PA, and physician leadership to contribute expertiseon role competencies and current processes

• Human resources to help develop a new onboardingprocess and to ensure clear communication to new NPhires

• Medical staff office to incorporate credentialing considera-tions

STARTING WITH THE EXISTING NURSINGORIENTATION PROGRAMThe biweekly RN orientation hosts between 30 to 60 RNorientees in each program, with annualized volumes of 750to 1,500 RN orientees. The program focuses on the core setof competencies for general clinical practice. The centralizedcomponent is followed by a unit/department-based orienta-tion in which nurses engage in preceptorship and focus oncompetencies specific to their patient population.

Although we wanted to establish an organized process forthe NPs, we also recognized that this was an opportunity toenhance our interprofessional collaboration and team trainingpractices. We decided that, in addressing the needs of the NPs,we would not go forward with the silo models used in thepast. Rather, interprofessional collaboration would be evidentin both the development team for the program and withinthe program itself.

INTERPROFESSIONAL PROGRAM DEVELOPMENTTEAMThe program development team consisted of nursing educa-tion leaders, along with NP and PA leaders. We workedtogether and examined the topics and competencies in theexisting RN orientation program and agreed upon theirrelevance in an interprofessional orientation model. Weenhanced information on topics in some areas and workedtogether to change the way we approached teaching so that itwould be more inclusive for nurses and mid-level providers.

THE NEW INTERPROFESSIONAL ORIENTATIONPROGRAMWithin the program itself, interprofessional collaboration isa prevailing theme. NPs learn alongside PAs and RNs, andwork together, sharing their thoughts, experiences, andideas. Team members gain a better understanding of eachother and their respective roles. Additionally, NPs are edu-cated to NSLIJ standards, policies, and procedures. The corecompetencies for which NPs are credentialed are validatedduring this part of the process. The program design teammodified and developed several dimensions of the originalprogram to formulate the new approach. Some of thesecomponents are addressed next.

SimulationThe value of simulation in preparing clinicians for the practiceenvironment is well established. NPs start by engaging in ateam situation in which a patient, who has a family member atthe bedside, begins deteriorating. The primary nurse escalatesthe situation and calls for the help of a secondary nurse and theNP. All roles (except the patient) are played by orientees. TheNP role is played by an NP orientee. In this situation, the NP

www.nurseleader.com Nurse Leader 33

has the opportunity to function in the advanced practice rolein terms of patient assessment and intervention, and gets tointeract with other team members and the patient’s family. NPsalso participate in an individualized simulation scenario inwhich the NP performs a physical assessment on a patient andintervenes based on assessment findings. The scenario isdesigned as an episodic situation that focuses on the need forcardiac and respiratory systems assessment.

DebriefingImmediately after each simulation scenario is a debriefingsession that is facilitated by the educator who observed thescenario. In the team scenario debrief, there is usuallyexpression of feelings of anxiety, sometimes some role con-fusion, and almost always the issue of communication.Always emerging from the debriefing is reflection on thevalue of situation, background, assessment, and recommen-dation communication practices and the need to increasefamiliarity with the Centers for Medicare and MedicaidServices Core Measure guidelines.

During the debriefing, many NPs relive the scenariotogether with the other orientees and demonstrate howthey each could have been more effective with communi-cation. Another interesting note is that NP and RN orien-tees often share that this was their first time workingtogether in a team situation, as many of the participants arenovices in their roles.

NEW TOOLSOrganizing and documenting the NP onboarding process wasvery involved. The following five tools were developed orenhanced to help streamline the process. 1. Welcome packet. The centralized RN orientation

already used a welcome packet that was made available tonurses via an online link provided through humanresources at the time of hire. Revised to take on an inter-professional perspective, the packet included additionalstudy guides and information so that NPs would knowwhat to expect in terms of their performance in simulationand throughout the orientation.

2. Introduction to simulation video. To help prepare NPs(and other participants) for simulation, a link to a briefvideo is provided in the welcome packet. The videoreviews how the high-fidelity mannequin functions, andprovides an overview of the simulation room and otherdetails that are helpful in preparing for this aspect of orien-tation. Seeing the simulation environment beforehand iscritical in reducing the associated anxiety that oftenaccompanies these types of activities.

3. Hands-on practice session. In addition to the onlinevideo, which is viewed prior to hire, a brief hands-onsession is provided upon arrival at the Patient SafetyInstitute, the health system’s simulation center. In thehands-on session, NPs have one of their first opportunitiesto learn alongside RNs and PAs. Small groups of interpro-fessional teams become oriented to the live set-up, and thisis usually where the orientees first begin to realize what a

team experience will feel like. They often embark upon adiscussion about working together and roles and responsi-bilities during this hands-on session, which meets theobjective of this activity!

4. Orientation education team. Not only did the designteam include RNs, NPs, and PAs, the education team thatfacilitates the program is also interprofessional in nature.The educators who facilitate the program include RNs,NPs, and PAs, all with diverse backgrounds and areas ofclinical specialty. These individuals are accomplished clini-cians and educators for their respective disciplines. Overtime, we have expanded our pool of educators in responseto increased numbers of participants and to broaden thebench to accommodate educator availability.

5. Performance evaluation instrument for simulationscenario. Assessing performance is a key component of asimulation experience. The Clinical Assessment EvaluationRubric (CAER) was developed to evaluate performancein the comprehensive patient assessment using a simulatedscenario. The need for a rubric arose from the desire tohave a single, consistent measurement that could be usedby multiple scenario observers. The CAER is a compre-hensive instrument comprising three subscales: a physicalassessment performance subscale, a clinical judgment sub-scale, and a reflection subscale. The CAER was introducedseveral years ago for use with RN orientees. Revised ver-sions of it are now used during the simulation experienceswithin the interprofessional orientation program. TheCAER has completed inter-rater reliability testing and isundergoing psychometric testing.

INTERPROFESSIONAL PROGRAM ROLLOUTThe pilot phase of the rollout involved trialing the aboveprocesses at one site within the health system. This large tertiaryfacility was ahead of the curve in increasing NP presence with-in the organization. The pilot phase spanned 2008 to 2010.Formal and informal feedback was received from NP partici-pants, the facilitating educators, and leadership at the pilot site.

In 2010, a vetting process ensued in which this model wasproposed to nursing and medical executive leadership. Allwere in favor of this model becoming a system-wide standardfor onboarding NPs and PAs. As of January 1, 2011, thismodel was fully implemented across the 15-hospital system.

CONCLUSIONIn 2011, the first full year of the program, 84 NPs participat-ed, compared to 31 in 2010. Both the participants and theorganization recognize this model as a best practice approachand support its continuation and growth. Feedback is solicit-ed from participants through in-person and online mecha-nisms. NPs offer overwhelming appreciation for theorientation process, many stating that they “have never expe-rienced an orientation like this” in their careers and that they“feel better prepared for practice.” Still, NPs do share thatthere is a need to improve the department-based componentsof the process, as this still varies widely from department todepartment and from facility to facility.

October 201234 Nurse Leader

www.nurseleader.com Nurse Leader 35

As we continue with NP onboarding expansion activi-ties, NSLIJ has established system- and hospital-level NPcouncils, hired a corporate director of advanced practicenurses, and increased interprofessional continuing educa-tion. Plans are underway to develop an NP/PA criticalcare residency program.

Focused attention on NPs as team members is necessaryin today’s healthcare environment. Using an interprofessionalorientation program can provide a springboard for a success-ful NP onboarding process. NL

References1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing

Health. Washington, DC: National Academies Press; 2011.2. Office of the Legislative Counsel for the use of the U.S. House of

Representatives. Patient Protection and Affordable Care Act: Health-RelatedPortions of the Health Care and Education Reconciliation Act of 2010.http://www.healthcare.gov/law/full/index.html. Accessed June 17, 2012.

Launette Woolforde, EdD(c), DNP, RN-BC, is the corporate directorfor nursing education at the North Shore-Long Island Jewish HealthSystem and can be reached at LWoolfor@nshs.edu.

Acknowledgments

The author would like to acknowledge Maureen White, MBA, RN,NEA-BC, the North Shore-LIJ Health System Institute forNursing and the interprofessional orientation development team fortheir dedication to the development and ongoing execution of thisprogram, and the North Shore-LIJ Health System Patient SafetyInstitute for their expertise and assistance with simulation.

1541-4612/2012/ $ See front matterCopyright 2012 by Mosby Inc.All rights reserved.http://dx.doi.org/10.1016/j.mnl.2012.07.002