- Email: [email protected]
Developing the Advanced Practice Recruitment Strategy at an Academic Medical Center: The APRN Pipeline
Developing the Advanced Practice Recruitment Strategy at an Academic Medical Center: The APRN Pipeline Maria T. Brillant, RN, MA, MSN, Kimberly S. Glassman, RN, PhD, and Robert Press, MD, PhD
T
he
Institute
of
Medicine’s (IOM)
recommendation to remove barriers to practice and enable advanced practice registered nurses (APRNs) and
registered
nurses
(RNs) to practice to the full extent of their education and training1 expanded the use of advanced practice nurses in the country. The more restrictive Accreditation Council for Graduate Medical
Education
(ACGME)
and Residency Review Committee (RRC) requirements on residency training and work hours increased the hiring of APRNs to fill the void created by a reduction in GME trainees.2 Finally, the Affordable Care Act created additional demand for more providers to meet the needs of the newly insured population, particularly in primary care.3
T
he creation of the APRN pipeline is a creative approach to solve the multilayered problems of recruitment, credentialing, on-boarding, and orientation of APRNs, particularly those who are just beginning to practice as an APRN. Our goal was to become proactive in rapidly filling the APRN positions in the clinical services as they become available. The inability to recruit enough APRNs at the pace we want to hire places a burden on our clinical services already impacted by a reduction in GME trainees. The growth in both inpatient and ambulatory services created a mismatch in the number of available, competent www.nurseleader.com
APRNs and the number of vacant positions. The reluctance of clinical sites to take new graduate APRNs because of the time it takes to orient them to the positions compounded the recruitment challenges.
MAJOR CHALLENGES WITH RECRUITMENT, ORIENTATION, AND ON-BOARDING In our experience, the review of more than 20 resumes yields about 3 to 5 viable candidates for 1 nurse practitioner (NP) position. Based on the interview results, the outcome
Nurse Leader
39
could be no candidates, depending on the specialty. The administrative cost significantly increases if the right candidate is not identified. The cost of search firms to fill a vacancy ranges from 20% to 30% of the annual base salary and is typically incurred in hard-to-recruit areas such as oncology, neurosciences, transplant, neonatology, and cardiothoracic surgery. Our average time to fill an APRN position is 62 days from the posting date and approximately 86 days from posting to start date. From start date to full productivity (measured as the time it takes for an NP to take a reasonable patient caseload without supervision) may range from 3 to 6 months for a novice nurse practitioner. This adds up to approximately 6 to 9 months of waiting time from the time an APRN need is identified to full productivity. For a clinical service stressed with reduced provider resources, this waiting period had the potential to negatively impact patient care. The APRN pipeline program was designed to address these challenges and meet the pressing needs of the medical center. By taking advantage of the collaborative relationships between the New York University (NYU) College of Nursing (NYUCN) and NYU Langone Medical Center (NYULMC); the generous tuition benefit provided by NYULMC to all RNs, with the majority of the students in the college of nursing who are already practicing RNs at NYULMC, we believed we could successfully launch an innovative program. The proposed APRN Pipeline program was presented to our university colleagues and hospital senior leadership. The program proposal quickly gained support, especially from the vice dean of clinical affairs as well as the vice dean of human resources. The anticipation that through this pipeline, the APRN positions in ambulatory care and other clinical areas could be filled quickly sent messages of operational adeptness and efficiency.
GOALS OF THE APRN PIPELINE PROGRAM 1. Shorten the timeline for the recruitment, orientation, and on-boarding processes 2. Provide exposure to the NYULMC work environment and culture through direct placement in clinical areas requiring nurse practitioners 3. Develop prospective APRN hire’s interest in targeted specialty areas 4. Allow easier entry into practice of new grad APRNs 5. Retain employed RNs who completed the NP program 6. Reduce the costs of recruitment and on-boarding
FRAMEWORK APRN students are placed in clinical rotations through the collaborative efforts of the advanced practice nursing program, the nursing education department, and the college of nursing. APRN students in different levels of clinical rotations are strategically placed in clinical settings with certain considerations: readiness of the clinical area or office setting to train
40
Nurse Leader
an APRN; APRN student’s interest in the specialty area; and potential for a future APRN position available. Here, they are exposed to the role of an APRN at NYULMC. The pipeline allows the APRN to orient to the clinical setting with the ability to practice how to use the existing electronic health record. Students on clinical rotations at the medical centers’ sites and physician offices are granted student access to the patient’s electronic record. All their entries are cosigned by the assigned NP or physician preceptor. Upon completion of the program, the APRN students are invited to an open house to learn about all the available APRN positions and express their interests to apply. The new APRNs are then either matched to the vacancy in their previously trained clinical areas, or to other similar areas. The open house is highly attended by our new APRN graduates. They get to ask questions, and clarify credentialing requirements and other pertinent practice information. Multiple APRN positions may be available in some clinical areas as a result of newly added or recently created APRN services. With multiple applicants and potential candidates present at the open house, a special meeting is set up with the chief of clinical service. During this meeting, the physician chief of service gives a brief description of the service, including its structure, the types of patients the NPs will have, the support system provided, and the qualities of the desired APRNs. This has been one of the most enjoyable and widely accepted elements of APRN recruitment. This exploratory process allows APRN candidates to know more about the position and some of the people with whom they will be working. Meeting potential candidates face to face and allowing question and answer sessions yield the most immediate, highly desirable candidates in larger numbers. Open houses often have a higher yield for employers when the right candidates and participants are present in the room. The APRN pipeline facilitates this dynamic approach by identifying in advance the target audiences for the open house. For example, acute care NP students placed in their clinical rotations in the hospital were sent direct invitations to the open house. Inviting those who have the right profile for the job yielded a more successful match of APRNs to available positions.
HOSPITAL, NURSING, FACULTY, AND, PHYSICIAN COLLABORATION It takes a collaborative approach to solve complex problems. The success of the program lies in jointly identifying problems and finding possible solutions. Engagement is crucial to get cooperation. One advantage is the strong collaboration that already exists between our hospital and the college of nursing. Gaining the support of our physician faculty through the leadership of the vice dean of clinical affairs and our senior nursing leaders has been foundational to a well-supported structure. The elements fundamental to a successful pipeline program were established. The program proposal was presented with highlights on the gains and challenges for each supporting participant. The hospital gets to meet the needs of its patients in a timely fashion, reduce
April 2015
the cost of recruitment and on-boarding, and retain already established employees utilizing the tuition benefits program. The college of nursing faculty gets support in student placement for clinical rotations, and increases their student opportunities for employment post-graduation. The physician faculty gets to train APRNs who will potentially fill their positions with shorter recruitment time and on-boarding, making teamwork easier. The challenge for all parties is that not all positions are amenable to employ entry-level practitioners. Some require experienced practitioners. Also, timing may not be ideal; positions cannot wait for APRN students to graduate from the program. Therefore, positions cannot be guaranteed to students in the pipeline program. At the same time, when the new graduate APRN is ready to enter practice, the particular position available may not be of interest to that APRN. The way the APRN pipeline works most effectively is to prepare for job openings that exist at the time of completion of the APRN program and the readiness for available vacancies that exist. There is significant improvement from the previous process of simply posting positions with random matching.
CREATIVE PROCESS—CREATING OPPORTUNITIES FOR NEW GRADUATES THROUGH MENTORSHIP With the pipeline program, the potential of having a significant number of “entry-into-practice” APRNs requires a supportive structure to retain them and provide meaningful experiences. This is where the APRN Clinical Ladder Program becomes a critical element in supporting the APRN pipeline. The NYU Hospitals Center APRN Clinical Ladder Advancement Program is designed to promote clinical excellence. Professional growth and recognition of advanced practice nurses are encouraged through all levels of nursing practice. The required competency requirements under the leadership domain of a Level II NP in the APRN Clinical Ladder that includes mentorship supply the APRN pipeline with the necessary mentors for the novice APRNs. The creation of the APRN mentorship program that was put into place just prior to the implementation of the pipeline program helps support newly hired APRNs. Every new NP hired is assigned a dedicated mentor through a mentor/mentee matching process done by the mentorship committee members. This is a formal mentorship process with a full year commitment by a mentor to remain available for the new mentee. The role of a clinical preceptor is distinct and separate from that of a mentor. Although the clinical preceptor provides orientation and support in learning the specialty-specific competencies, the mentor provides guidance and direction for overall professional development. The mentor encourages, supports, and facilitates the mentee’s independent practice through collaboration, networking, and knowledge exploration. The mentor makes herself/himself available to the mentee for any needs pertinent to the role of an APRN. Opportunities for entrylevel APRNs’ growth, development and advancement in the www.nurseleader.com
next step of the APRN Clinical Ladder program are supported by the mentorship program. Self-exploration is also encouraged. The newly hired APRN learns the role, the organization, and the complex requirements of being an independent licensed practitioner through the guidance and role modeling of a mentor.
PROGRAM EVALUATION AND MEASURES OF SUCCESS The success of the APRN pipeline program is measured by the degree that it attained its goals. As described above, the most important reduction in time is the period to full productivity. In addition, we achieved significant savings because all hires from the pipeline did not incur agency fees. The program also provided a supportive environment to practice safely, especially for APRNs entering into practice for the first time. Below is an exemplar of how the pipeline was customized to respond to the specific needs of a specialty service. Neuroscience nursing is a specialty area that is an increasing recruitment challenge for organizations nationwide. Unlike cardiology, where positions are easier and faster to fill, few advanced practice nurses specialize in neurosciences. The declining interest in neuroscience nursing could be due to many factors that have not been widely studied. At a minimum, we take new NP graduates with critical care and any neuroscience subspecialty nursing experience. Despite this background, it has been increasingly difficult for new graduate NPs to transition to the role of neuroscience NP after full 12 weeks orientation. As a result, of the 12 neurosurgery APRN positions, only 4 were filled. The inability to fill all required positions causes burnout and increased turnover rate because of the heavy workload. As an academic medical center, we are close allies with the NYU College of Nursing and thus have the opportunity to create a future recruitment pipeline. This alliance enabled us to solve our dilemma, through partnership and collaboration in building a student NP learning experience that would trigger interest in neuroscience through positive exposure to the clinical services early. We partnered with the university and created a learning program for existing NP students in acute care and created the “neuroscience immersion program.” The neuroscience immersion program is designed to create a cadre of prepared NP graduates to fill various positions in the neuroscience specialty areas such as neurosurgery, epilepsy, and neurology. In this particular project, we engaged the program coordinator of the acute care NP program at NYUCN to identify students with interest in neurosciences and who are willing to commit to a full semester of clinical rotations in various neuroscience areas—neurology, neurosurgery, and epilepsy, both in the inpatient and outpatient settings. The immersion program is designed to enhance the students’ exposure to various clinical areas of neurosciences, as well as experience and understand the integrative relationships that exist among the various neuroscience sub-specialties and team members.
Nurse Leader
41
Figure 1. APRN Pipeline Impact on Time to Full Productivity
feedback to the student and the university program coordinator
MEASURES OF SUCCESS • Fill all vacant NP positions with at least 3 years retention/ tenure from the date of hire in the neuroscience areas. • Increase the likelihood of newly hired NPs to function independently with a reasonable patient caseload at the end of their 12-week orientation as measured in the NP satisfaction scores. This is an ongoing program and will be enhanced and expanded to other specialty areas as we continue to evolve, explore our workforce challenges, and learn from our experiences. To date, all neuroscience vacancies are filled.
GOALS OF THE PROGRAM • Provide structured and focused neuroscience clinical rotations for a group of acute care nurse practitioner students from NYUCN who are interested in neuroscience specialty areas • Fill vacancies in neurosciences, especially neurosurgery • Increase the likelihood of newly hired NPs to function independently with a reasonable patient caseload at the end of their orientation through advanced learning of required neuroscience competencies. The NP survey done in 2011 suggested majority of the NPs did not feel ready or confident with a reasonable patient load on their own at the end of an 8-week orientation • Shorten the on-boarding process by placing new grads in clinical areas where they have had extensive exposure during their clinical rotations.
FRAMEWORK • NP students in the acute care program with or without neuroscience nursing background but with strong interest and curiosity in neurosciences were selected. • NPs commit to a semester-long clinical rotations for a total of 250 hours divided as follows: • Neurosurgery, inpatient—100 hours • Neurosurgery, outpatient—50 hours • Neurology, inpatient—50 hours • Epilepsy, inpatient and outpatient—50 hours • NP students are assigned 5 senior neuroscience NPs in various subspecialties • A checklist of program activities and learning experiences were provided to both the NP student and the NP preceptors. These learning activities were derived from the neuroscience NP delineation of privileges. • A rotation schedule in the neuroscience subspecialties was provided to the students weeks prior to the beginning of the clinical immersion to enable them to arrange their time to meet the scheduled rotations. Three weeks prior to close of the semester are left open to provide opportunity for students to make up for any lost time during their rotations as a result of unforeseen circumstances • A brief student evaluation tool (in addition to the university’s student evaluation tool) was created to provide
42
Nurse Leader
SUMMARY The 25 new graduates who entered the pipeline submitted their resumes, and we were able to predict who among the applicants could potentially fill a particular position. It is significant to note, however, that the pipeline did not reduce the amount of time it takes to fill the positions, nor did it shorten the time between posting and the start date of the selected applicant. On the contrary, the amount of time from posting to fill and posting to start date increased. These are due to several factors. First and foremost is the fact that the 25 APRNs who entered the pipeline were just completing their final semester in the APRN program. The time for licensure and certification was also a significant factor. Credentialing is held until state registration is obtained. However, there was a remarkable decrease in the amount of time it took to orient to the new role, thereby decreasing the time from start date to full productivity (Figure 1). Our pipeline program continues to be an effective way to mine our own viable resources to fill APRN positions in a timely manner and reduce the cost of recruitment and on-boarding, increase physician satisfaction, increase retention of employees, and enhance the hospital’s return on investment on employees utilizing tuition benefits program. There is much to learn about this program, including its advantages and limitations. So far, it has shown promise in reducing orientation to new roles, which means new NPs can function for full productivity sooner than usual. It reduces and even eliminates the cost of agency fees, resulting in significant savings. Some of the limitations are obvious. The number of applicants in the pipeline far exceeds the total number of available positions to fill. Because all applicants are identified while still completing their APN program, the time from posting the position to actual start time varies and can be extended because of the time required to complete the APRN program and state licensure. Some positions cannot wait for the pipeline applicants to be ready and have to fill with outside viable candidates who responded to the posting. Therefore, there is a potential to lose some of the positions to non-pipeline applicants and lose pipeline applicants to other Continued on page 49
April 2015
Developing the Advanced Practice Continued from page 42
jobs in the market. Some pipeline applicants may not like the positions that are available when they are ready. There is value in utilizing an APRN pipeline program to retain employees and reduce recruitment costs. Having a pool of potential applicants to evaluate for possible fit in to a particular position is an invaluable resource. Further exploration and more studies need to be done to evaluate sustainability and applicability in various situations. NL References 1. Summers L. IOM report contains recommendations to facilitate advanced practice. Am Nurse. 2010;42(6):9. 2. Lundberg S, Wali S, Thomas P, Cope D. Attaining resident duty hours compliance: the acute care nurse practitioners program at Olive View-UCLA Medical Center. Acad Med. 2006;81:1021-1025. 3. Poghosyan L, Lucero R, Rauch L, Berkowitz B. Nurse practitioner workforce: a substantial supply of primary care providers. Nurs Econ. 2012;30:268274, 294.
Maria T. Brillant, RN, MA, MSN, is senior director of Advanced Practice Nurses NYU Langone Medical Center in New York, New York. She can be reached at [email protected]. Kimberly S. Glassman, RN, PhD, is senior vice president and chief nursing officer at NYU Langone Medical Center in New York, New York. Robert Press, MD, PhD, is chief medical officer & patient safety officer at NYU Langone Medical Center in New York, New York. 1541-4612/2014/ $ See front matter Copyright 2015 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2015.01.006
www.nurseleader.com
Nurse Leader
49
T
he
Institute
of
Medicine’s (IOM)
recommendation to remove barriers to practice and enable advanced practice registered nurses (APRNs) and
registered
nurses
(RNs) to practice to the full extent of their education and training1 expanded the use of advanced practice nurses in the country. The more restrictive Accreditation Council for Graduate Medical
Education
(ACGME)
and Residency Review Committee (RRC) requirements on residency training and work hours increased the hiring of APRNs to fill the void created by a reduction in GME trainees.2 Finally, the Affordable Care Act created additional demand for more providers to meet the needs of the newly insured population, particularly in primary care.3
T
he creation of the APRN pipeline is a creative approach to solve the multilayered problems of recruitment, credentialing, on-boarding, and orientation of APRNs, particularly those who are just beginning to practice as an APRN. Our goal was to become proactive in rapidly filling the APRN positions in the clinical services as they become available. The inability to recruit enough APRNs at the pace we want to hire places a burden on our clinical services already impacted by a reduction in GME trainees. The growth in both inpatient and ambulatory services created a mismatch in the number of available, competent www.nurseleader.com
APRNs and the number of vacant positions. The reluctance of clinical sites to take new graduate APRNs because of the time it takes to orient them to the positions compounded the recruitment challenges.
MAJOR CHALLENGES WITH RECRUITMENT, ORIENTATION, AND ON-BOARDING In our experience, the review of more than 20 resumes yields about 3 to 5 viable candidates for 1 nurse practitioner (NP) position. Based on the interview results, the outcome
Nurse Leader
39
could be no candidates, depending on the specialty. The administrative cost significantly increases if the right candidate is not identified. The cost of search firms to fill a vacancy ranges from 20% to 30% of the annual base salary and is typically incurred in hard-to-recruit areas such as oncology, neurosciences, transplant, neonatology, and cardiothoracic surgery. Our average time to fill an APRN position is 62 days from the posting date and approximately 86 days from posting to start date. From start date to full productivity (measured as the time it takes for an NP to take a reasonable patient caseload without supervision) may range from 3 to 6 months for a novice nurse practitioner. This adds up to approximately 6 to 9 months of waiting time from the time an APRN need is identified to full productivity. For a clinical service stressed with reduced provider resources, this waiting period had the potential to negatively impact patient care. The APRN pipeline program was designed to address these challenges and meet the pressing needs of the medical center. By taking advantage of the collaborative relationships between the New York University (NYU) College of Nursing (NYUCN) and NYU Langone Medical Center (NYULMC); the generous tuition benefit provided by NYULMC to all RNs, with the majority of the students in the college of nursing who are already practicing RNs at NYULMC, we believed we could successfully launch an innovative program. The proposed APRN Pipeline program was presented to our university colleagues and hospital senior leadership. The program proposal quickly gained support, especially from the vice dean of clinical affairs as well as the vice dean of human resources. The anticipation that through this pipeline, the APRN positions in ambulatory care and other clinical areas could be filled quickly sent messages of operational adeptness and efficiency.
GOALS OF THE APRN PIPELINE PROGRAM 1. Shorten the timeline for the recruitment, orientation, and on-boarding processes 2. Provide exposure to the NYULMC work environment and culture through direct placement in clinical areas requiring nurse practitioners 3. Develop prospective APRN hire’s interest in targeted specialty areas 4. Allow easier entry into practice of new grad APRNs 5. Retain employed RNs who completed the NP program 6. Reduce the costs of recruitment and on-boarding
FRAMEWORK APRN students are placed in clinical rotations through the collaborative efforts of the advanced practice nursing program, the nursing education department, and the college of nursing. APRN students in different levels of clinical rotations are strategically placed in clinical settings with certain considerations: readiness of the clinical area or office setting to train
40
Nurse Leader
an APRN; APRN student’s interest in the specialty area; and potential for a future APRN position available. Here, they are exposed to the role of an APRN at NYULMC. The pipeline allows the APRN to orient to the clinical setting with the ability to practice how to use the existing electronic health record. Students on clinical rotations at the medical centers’ sites and physician offices are granted student access to the patient’s electronic record. All their entries are cosigned by the assigned NP or physician preceptor. Upon completion of the program, the APRN students are invited to an open house to learn about all the available APRN positions and express their interests to apply. The new APRNs are then either matched to the vacancy in their previously trained clinical areas, or to other similar areas. The open house is highly attended by our new APRN graduates. They get to ask questions, and clarify credentialing requirements and other pertinent practice information. Multiple APRN positions may be available in some clinical areas as a result of newly added or recently created APRN services. With multiple applicants and potential candidates present at the open house, a special meeting is set up with the chief of clinical service. During this meeting, the physician chief of service gives a brief description of the service, including its structure, the types of patients the NPs will have, the support system provided, and the qualities of the desired APRNs. This has been one of the most enjoyable and widely accepted elements of APRN recruitment. This exploratory process allows APRN candidates to know more about the position and some of the people with whom they will be working. Meeting potential candidates face to face and allowing question and answer sessions yield the most immediate, highly desirable candidates in larger numbers. Open houses often have a higher yield for employers when the right candidates and participants are present in the room. The APRN pipeline facilitates this dynamic approach by identifying in advance the target audiences for the open house. For example, acute care NP students placed in their clinical rotations in the hospital were sent direct invitations to the open house. Inviting those who have the right profile for the job yielded a more successful match of APRNs to available positions.
HOSPITAL, NURSING, FACULTY, AND, PHYSICIAN COLLABORATION It takes a collaborative approach to solve complex problems. The success of the program lies in jointly identifying problems and finding possible solutions. Engagement is crucial to get cooperation. One advantage is the strong collaboration that already exists between our hospital and the college of nursing. Gaining the support of our physician faculty through the leadership of the vice dean of clinical affairs and our senior nursing leaders has been foundational to a well-supported structure. The elements fundamental to a successful pipeline program were established. The program proposal was presented with highlights on the gains and challenges for each supporting participant. The hospital gets to meet the needs of its patients in a timely fashion, reduce
April 2015
the cost of recruitment and on-boarding, and retain already established employees utilizing the tuition benefits program. The college of nursing faculty gets support in student placement for clinical rotations, and increases their student opportunities for employment post-graduation. The physician faculty gets to train APRNs who will potentially fill their positions with shorter recruitment time and on-boarding, making teamwork easier. The challenge for all parties is that not all positions are amenable to employ entry-level practitioners. Some require experienced practitioners. Also, timing may not be ideal; positions cannot wait for APRN students to graduate from the program. Therefore, positions cannot be guaranteed to students in the pipeline program. At the same time, when the new graduate APRN is ready to enter practice, the particular position available may not be of interest to that APRN. The way the APRN pipeline works most effectively is to prepare for job openings that exist at the time of completion of the APRN program and the readiness for available vacancies that exist. There is significant improvement from the previous process of simply posting positions with random matching.
CREATIVE PROCESS—CREATING OPPORTUNITIES FOR NEW GRADUATES THROUGH MENTORSHIP With the pipeline program, the potential of having a significant number of “entry-into-practice” APRNs requires a supportive structure to retain them and provide meaningful experiences. This is where the APRN Clinical Ladder Program becomes a critical element in supporting the APRN pipeline. The NYU Hospitals Center APRN Clinical Ladder Advancement Program is designed to promote clinical excellence. Professional growth and recognition of advanced practice nurses are encouraged through all levels of nursing practice. The required competency requirements under the leadership domain of a Level II NP in the APRN Clinical Ladder that includes mentorship supply the APRN pipeline with the necessary mentors for the novice APRNs. The creation of the APRN mentorship program that was put into place just prior to the implementation of the pipeline program helps support newly hired APRNs. Every new NP hired is assigned a dedicated mentor through a mentor/mentee matching process done by the mentorship committee members. This is a formal mentorship process with a full year commitment by a mentor to remain available for the new mentee. The role of a clinical preceptor is distinct and separate from that of a mentor. Although the clinical preceptor provides orientation and support in learning the specialty-specific competencies, the mentor provides guidance and direction for overall professional development. The mentor encourages, supports, and facilitates the mentee’s independent practice through collaboration, networking, and knowledge exploration. The mentor makes herself/himself available to the mentee for any needs pertinent to the role of an APRN. Opportunities for entrylevel APRNs’ growth, development and advancement in the www.nurseleader.com
next step of the APRN Clinical Ladder program are supported by the mentorship program. Self-exploration is also encouraged. The newly hired APRN learns the role, the organization, and the complex requirements of being an independent licensed practitioner through the guidance and role modeling of a mentor.
PROGRAM EVALUATION AND MEASURES OF SUCCESS The success of the APRN pipeline program is measured by the degree that it attained its goals. As described above, the most important reduction in time is the period to full productivity. In addition, we achieved significant savings because all hires from the pipeline did not incur agency fees. The program also provided a supportive environment to practice safely, especially for APRNs entering into practice for the first time. Below is an exemplar of how the pipeline was customized to respond to the specific needs of a specialty service. Neuroscience nursing is a specialty area that is an increasing recruitment challenge for organizations nationwide. Unlike cardiology, where positions are easier and faster to fill, few advanced practice nurses specialize in neurosciences. The declining interest in neuroscience nursing could be due to many factors that have not been widely studied. At a minimum, we take new NP graduates with critical care and any neuroscience subspecialty nursing experience. Despite this background, it has been increasingly difficult for new graduate NPs to transition to the role of neuroscience NP after full 12 weeks orientation. As a result, of the 12 neurosurgery APRN positions, only 4 were filled. The inability to fill all required positions causes burnout and increased turnover rate because of the heavy workload. As an academic medical center, we are close allies with the NYU College of Nursing and thus have the opportunity to create a future recruitment pipeline. This alliance enabled us to solve our dilemma, through partnership and collaboration in building a student NP learning experience that would trigger interest in neuroscience through positive exposure to the clinical services early. We partnered with the university and created a learning program for existing NP students in acute care and created the “neuroscience immersion program.” The neuroscience immersion program is designed to create a cadre of prepared NP graduates to fill various positions in the neuroscience specialty areas such as neurosurgery, epilepsy, and neurology. In this particular project, we engaged the program coordinator of the acute care NP program at NYUCN to identify students with interest in neurosciences and who are willing to commit to a full semester of clinical rotations in various neuroscience areas—neurology, neurosurgery, and epilepsy, both in the inpatient and outpatient settings. The immersion program is designed to enhance the students’ exposure to various clinical areas of neurosciences, as well as experience and understand the integrative relationships that exist among the various neuroscience sub-specialties and team members.
Nurse Leader
41
Figure 1. APRN Pipeline Impact on Time to Full Productivity
feedback to the student and the university program coordinator
MEASURES OF SUCCESS • Fill all vacant NP positions with at least 3 years retention/ tenure from the date of hire in the neuroscience areas. • Increase the likelihood of newly hired NPs to function independently with a reasonable patient caseload at the end of their 12-week orientation as measured in the NP satisfaction scores. This is an ongoing program and will be enhanced and expanded to other specialty areas as we continue to evolve, explore our workforce challenges, and learn from our experiences. To date, all neuroscience vacancies are filled.
GOALS OF THE PROGRAM • Provide structured and focused neuroscience clinical rotations for a group of acute care nurse practitioner students from NYUCN who are interested in neuroscience specialty areas • Fill vacancies in neurosciences, especially neurosurgery • Increase the likelihood of newly hired NPs to function independently with a reasonable patient caseload at the end of their orientation through advanced learning of required neuroscience competencies. The NP survey done in 2011 suggested majority of the NPs did not feel ready or confident with a reasonable patient load on their own at the end of an 8-week orientation • Shorten the on-boarding process by placing new grads in clinical areas where they have had extensive exposure during their clinical rotations.
FRAMEWORK • NP students in the acute care program with or without neuroscience nursing background but with strong interest and curiosity in neurosciences were selected. • NPs commit to a semester-long clinical rotations for a total of 250 hours divided as follows: • Neurosurgery, inpatient—100 hours • Neurosurgery, outpatient—50 hours • Neurology, inpatient—50 hours • Epilepsy, inpatient and outpatient—50 hours • NP students are assigned 5 senior neuroscience NPs in various subspecialties • A checklist of program activities and learning experiences were provided to both the NP student and the NP preceptors. These learning activities were derived from the neuroscience NP delineation of privileges. • A rotation schedule in the neuroscience subspecialties was provided to the students weeks prior to the beginning of the clinical immersion to enable them to arrange their time to meet the scheduled rotations. Three weeks prior to close of the semester are left open to provide opportunity for students to make up for any lost time during their rotations as a result of unforeseen circumstances • A brief student evaluation tool (in addition to the university’s student evaluation tool) was created to provide
42
Nurse Leader
SUMMARY The 25 new graduates who entered the pipeline submitted their resumes, and we were able to predict who among the applicants could potentially fill a particular position. It is significant to note, however, that the pipeline did not reduce the amount of time it takes to fill the positions, nor did it shorten the time between posting and the start date of the selected applicant. On the contrary, the amount of time from posting to fill and posting to start date increased. These are due to several factors. First and foremost is the fact that the 25 APRNs who entered the pipeline were just completing their final semester in the APRN program. The time for licensure and certification was also a significant factor. Credentialing is held until state registration is obtained. However, there was a remarkable decrease in the amount of time it took to orient to the new role, thereby decreasing the time from start date to full productivity (Figure 1). Our pipeline program continues to be an effective way to mine our own viable resources to fill APRN positions in a timely manner and reduce the cost of recruitment and on-boarding, increase physician satisfaction, increase retention of employees, and enhance the hospital’s return on investment on employees utilizing tuition benefits program. There is much to learn about this program, including its advantages and limitations. So far, it has shown promise in reducing orientation to new roles, which means new NPs can function for full productivity sooner than usual. It reduces and even eliminates the cost of agency fees, resulting in significant savings. Some of the limitations are obvious. The number of applicants in the pipeline far exceeds the total number of available positions to fill. Because all applicants are identified while still completing their APN program, the time from posting the position to actual start time varies and can be extended because of the time required to complete the APRN program and state licensure. Some positions cannot wait for the pipeline applicants to be ready and have to fill with outside viable candidates who responded to the posting. Therefore, there is a potential to lose some of the positions to non-pipeline applicants and lose pipeline applicants to other Continued on page 49
April 2015
Developing the Advanced Practice Continued from page 42
jobs in the market. Some pipeline applicants may not like the positions that are available when they are ready. There is value in utilizing an APRN pipeline program to retain employees and reduce recruitment costs. Having a pool of potential applicants to evaluate for possible fit in to a particular position is an invaluable resource. Further exploration and more studies need to be done to evaluate sustainability and applicability in various situations. NL References 1. Summers L. IOM report contains recommendations to facilitate advanced practice. Am Nurse. 2010;42(6):9. 2. Lundberg S, Wali S, Thomas P, Cope D. Attaining resident duty hours compliance: the acute care nurse practitioners program at Olive View-UCLA Medical Center. Acad Med. 2006;81:1021-1025. 3. Poghosyan L, Lucero R, Rauch L, Berkowitz B. Nurse practitioner workforce: a substantial supply of primary care providers. Nurs Econ. 2012;30:268274, 294.
Maria T. Brillant, RN, MA, MSN, is senior director of Advanced Practice Nurses NYU Langone Medical Center in New York, New York. She can be reached at [email protected]. Kimberly S. Glassman, RN, PhD, is senior vice president and chief nursing officer at NYU Langone Medical Center in New York, New York. Robert Press, MD, PhD, is chief medical officer & patient safety officer at NYU Langone Medical Center in New York, New York. 1541-4612/2014/ $ See front matter Copyright 2015 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2015.01.006
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