- Email: [email protected]
Onboarding Nurse Practitioners: A Healthcare System Approach to Interprofessional Education
Onboarding Nurse Practitioners: A Healthcare System Approach to Interprofessional Education Launette Woolforde, EdD(c), DNP, RN-BC
he Future of Nursing report1 underscores the
addressed in the report are relevant at all levels
belief that nurses can play a vital role in
of nursing but have unique implications for nurse
patient care outcomes. Among many things, the
practitioners (NPs). As the debate continues
report discusses nurses practicing to the fullest
about scope-of-practice standards and boundaries
extent of their education, nurse/physician collabo-
for NPs, one thing is clear: NPs are increasingly
ration,
becoming employed in the acute care setting.
T
32
and
team
Nurse Leader
approaches.
The
issues
October 2012
A
lthough NPs can play an important role in helping to realize the objectives of the Affordable Care Act,2 including advancing preventive care and increasing access to care, NPs can also make a tremendous impact on quality outcomes for hospitalized patients. It is incumbent upon nurse leaders to figure out how to maximize NP functioning as licensed independent practitioners and take full advantage of their knowledge and skills as healthcare team members. Considering that physician assistants (PAs) also have an integral and expanding role within some acute care facilities, they are included in the endeavor discussed here. This article will explore the approach one health system has taken to enhance the smooth transition of advanced practice nurses and PAs into its complex care setting. At the North Shore-Long Island Jewish (NSLIJ) Health System, we believe that the healthcare delivery model of the future will feature teams of interprofessional colleagues working together in an environment that is patient centered. With approximately 400 NPs already on board, we needed to ensure that they had role clarity; an understanding about the organization—its mission, vision, values, and approach to care; and an idea of how best to work with the other team members. We needed to ensure that NPs were comfortable and competent in the skills they were expected to perform and that there was a sound process in place for orientation and documentation of their clinical competencies. A daunting issue for organizations employing ever larger numbers of NPs is that many found themselves onboarded in an unstructured manner, leaving them feeling lost, delaying productivity, and affecting retention.
PROCESS Our goal was to construct a plan to address the gaps in the NP onboarding process. It was expected that this would have major implications for teamwork, job satisfaction, and most importantly, patient care outcomes. Traditionally, hospitals have an organized orientation program and process for new staff. In particular, nursing orientation is usually very clearly defined. This was true for NSLIJ. We had a robust registered nurse (RN) orientation program that had been in existence as a biweekly, centralized, standardized program at the system level for over 5 years. Because resources are always a consideration in growth and expansion, we decided that we would use our existing RN orientation program as the framework for a new interprofessional orientation program. We agreed that the model would allow NPs to enter the health system through a clear and structured mechanism, including a formal orientation program that would expose them to the standards, policies, procedures, and team members with which they would be working. Essential partnerships formed in the planning phase included: • Nursing education/leadership to provide insight about the existing program and address the practice considerations for NPs • NP, PA, and physician leadership to contribute expertise on role competencies and current processes www.nurseleader.com
• Human resources to help develop a new onboarding process and to ensure clear communication to new NP hires • Medical staff office to incorporate credentialing considerations
STARTING WITH THE EXISTING NURSING ORIENTATION PROGRAM The biweekly RN orientation hosts between 30 to 60 RN orientees in each program, with annualized volumes of 750 to 1,500 RN orientees. The program focuses on the core set of competencies for general clinical practice. The centralized component is followed by a unit/department-based orientation in which nurses engage in preceptorship and focus on competencies specific to their patient population. Although we wanted to establish an organized process for the NPs, we also recognized that this was an opportunity to enhance our interprofessional collaboration and team training practices. We decided that, in addressing the needs of the NPs, we would not go forward with the silo models used in the past. Rather, interprofessional collaboration would be evident in both the development team for the program and within the program itself.
INTERPROFESSIONAL PROGRAM DEVELOPMENT TEAM The program development team consisted of nursing education leaders, along with NP and PA leaders. We worked together and examined the topics and competencies in the existing RN orientation program and agreed upon their relevance in an interprofessional orientation model. We enhanced information on topics in some areas and worked together to change the way we approached teaching so that it would be more inclusive for nurses and mid-level providers.
THE NEW INTERPROFESSIONAL ORIENTATION PROGRAM Within the program itself, interprofessional collaboration is a prevailing theme. NPs learn alongside PAs and RNs, and work together, sharing their thoughts, experiences, and ideas. Team members gain a better understanding of each other and their respective roles. Additionally, NPs are educated to NSLIJ standards, policies, and procedures. The core competencies for which NPs are credentialed are validated during this part of the process. The program design team modified and developed several dimensions of the original program to formulate the new approach. Some of these components are addressed next. Simulation The value of simulation in preparing clinicians for the practice environment is well established. NPs start by engaging in a team situation in which a patient, who has a family member at the bedside, begins deteriorating. The primary nurse escalates the situation and calls for the help of a secondary nurse and the NP. All roles (except the patient) are played by orientees. The NP role is played by an NP orientee. In this situation, the NP
Nurse Leader
33
has the opportunity to function in the advanced practice role in terms of patient assessment and intervention, and gets to interact with other team members and the patient’s family. NPs also participate in an individualized simulation scenario in which the NP performs a physical assessment on a patient and intervenes based on assessment findings. The scenario is designed as an episodic situation that focuses on the need for cardiac and respiratory systems assessment. Debriefing Immediately after each simulation scenario is a debriefing session that is facilitated by the educator who observed the scenario. In the team scenario debrief, there is usually expression of feelings of anxiety, sometimes some role confusion, and almost always the issue of communication. Always emerging from the debriefing is reflection on the value of situation, background, assessment, and recommendation communication practices and the need to increase familiarity with the Centers for Medicare and Medicaid Services Core Measure guidelines. During the debriefing, many NPs relive the scenario together with the other orientees and demonstrate how they each could have been more effective with communication. Another interesting note is that NP and RN orientees often share that this was their first time working together in a team situation, as many of the participants are novices in their roles.
NEW TOOLS Organizing and documenting the NP onboarding process was very involved. The following five tools were developed or enhanced to help streamline the process. 1. Welcome packet. The centralized RN orientation already used a welcome packet that was made available to nurses via an online link provided through human resources at the time of hire. Revised to take on an interprofessional perspective, the packet included additional study guides and information so that NPs would know what to expect in terms of their performance in simulation and throughout the orientation. 2. Introduction to simulation video. To help prepare NPs (and other participants) for simulation, a link to a brief video is provided in the welcome packet. The video reviews how the high-fidelity mannequin functions, and provides an overview of the simulation room and other details that are helpful in preparing for this aspect of orientation. Seeing the simulation environment beforehand is critical in reducing the associated anxiety that often accompanies these types of activities. 3. Hands-on practice session. In addition to the online video, which is viewed prior to hire, a brief hands-on session is provided upon arrival at the Patient Safety Institute, the health system’s simulation center. In the hands-on session, NPs have one of their first opportunities to learn alongside RNs and PAs. Small groups of interprofessional teams become oriented to the live set-up, and this is usually where the orientees first begin to realize what a
34
Nurse Leader
team experience will feel like. They often embark upon a discussion about working together and roles and responsibilities during this hands-on session, which meets the objective of this activity! 4. Orientation education team. Not only did the design team include RNs, NPs, and PAs, the education team that facilitates the program is also interprofessional in nature. The educators who facilitate the program include RNs, NPs, and PAs, all with diverse backgrounds and areas of clinical specialty. These individuals are accomplished clinicians and educators for their respective disciplines. Over time, we have expanded our pool of educators in response to increased numbers of participants and to broaden the bench to accommodate educator availability. 5. Performance evaluation instrument for simulation scenario. Assessing performance is a key component of a simulation experience. The Clinical Assessment Evaluation Rubric (CAER) was developed to evaluate performance in the comprehensive patient assessment using a simulated scenario. The need for a rubric arose from the desire to have a single, consistent measurement that could be used by multiple scenario observers. The CAER is a comprehensive instrument comprising three subscales: a physical assessment performance subscale, a clinical judgment subscale, and a reflection subscale. The CAER was introduced several years ago for use with RN orientees. Revised versions of it are now used during the simulation experiences within the interprofessional orientation program. The CAER has completed inter-rater reliability testing and is undergoing psychometric testing.
INTERPROFESSIONAL PROGRAM ROLLOUT The pilot phase of the rollout involved trialing the above processes at one site within the health system. This large tertiary facility was ahead of the curve in increasing NP presence within the organization. The pilot phase spanned 2008 to 2010. Formal and informal feedback was received from NP participants, the facilitating educators, and leadership at the pilot site. In 2010, a vetting process ensued in which this model was proposed to nursing and medical executive leadership. All were in favor of this model becoming a system-wide standard for onboarding NPs and PAs. As of January 1, 2011, this model was fully implemented across the 15-hospital system.
CONCLUSION In 2011, the first full year of the program, 84 NPs participated, compared to 31 in 2010. Both the participants and the organization recognize this model as a best practice approach and support its continuation and growth. Feedback is solicited from participants through in-person and online mechanisms. NPs offer overwhelming appreciation for the orientation process, many stating that they “have never experienced an orientation like this” in their careers and that they “feel better prepared for practice.” Still, NPs do share that there is a need to improve the department-based components of the process, as this still varies widely from department to department and from facility to facility.
October 2012
As we continue with NP onboarding expansion activities, NSLIJ has established system- and hospital-level NP councils, hired a corporate director of advanced practice nurses, and increased interprofessional continuing education. Plans are underway to develop an NP/PA critical care residency program. Focused attention on NPs as team members is necessary in today’s healthcare environment. Using an interprofessional orientation program can provide a springboard for a successful NP onboarding process. NL References 1. 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-Related Portions 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 director for nursing education at the North Shore-Long Island Jewish Health System and can be reached at [email protected]. Acknowledgments The author would like to acknowledge Maureen White, MBA, RN, NEA-BC, the North Shore-LIJ Health System Institute for Nursing and the interprofessional orientation development team for their dedication to the development and ongoing execution of this program, and the North Shore-LIJ Health System Patient Safety Institute for their expertise and assistance with simulation. 1541-4612/2012/ $ See front matter Copyright 2012 by Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2012.07.002
www.nurseleader.com
Nurse Leader
35
he Future of Nursing report1 underscores the
addressed in the report are relevant at all levels
belief that nurses can play a vital role in
of nursing but have unique implications for nurse
patient care outcomes. Among many things, the
practitioners (NPs). As the debate continues
report discusses nurses practicing to the fullest
about scope-of-practice standards and boundaries
extent of their education, nurse/physician collabo-
for NPs, one thing is clear: NPs are increasingly
ration,
becoming employed in the acute care setting.
T
32
and
team
Nurse Leader
approaches.
The
issues
October 2012
A
lthough NPs can play an important role in helping to realize the objectives of the Affordable Care Act,2 including advancing preventive care and increasing access to care, NPs can also make a tremendous impact on quality outcomes for hospitalized patients. It is incumbent upon nurse leaders to figure out how to maximize NP functioning as licensed independent practitioners and take full advantage of their knowledge and skills as healthcare team members. Considering that physician assistants (PAs) also have an integral and expanding role within some acute care facilities, they are included in the endeavor discussed here. This article will explore the approach one health system has taken to enhance the smooth transition of advanced practice nurses and PAs into its complex care setting. At the North Shore-Long Island Jewish (NSLIJ) Health System, we believe that the healthcare delivery model of the future will feature teams of interprofessional colleagues working together in an environment that is patient centered. With approximately 400 NPs already on board, we needed to ensure that they had role clarity; an understanding about the organization—its mission, vision, values, and approach to care; and an idea of how best to work with the other team members. We needed to ensure that NPs were comfortable and competent in the skills they were expected to perform and that there was a sound process in place for orientation and documentation of their clinical competencies. A daunting issue for organizations employing ever larger numbers of NPs is that many found themselves onboarded in an unstructured manner, leaving them feeling lost, delaying productivity, and affecting retention.
PROCESS Our goal was to construct a plan to address the gaps in the NP onboarding process. It was expected that this would have major implications for teamwork, job satisfaction, and most importantly, patient care outcomes. Traditionally, hospitals have an organized orientation program and process for new staff. In particular, nursing orientation is usually very clearly defined. This was true for NSLIJ. We had a robust registered nurse (RN) orientation program that had been in existence as a biweekly, centralized, standardized program at the system level for over 5 years. Because resources are always a consideration in growth and expansion, we decided that we would use our existing RN orientation program as the framework for a new interprofessional orientation program. We agreed that the model would allow NPs to enter the health system through a clear and structured mechanism, including a formal orientation program that would expose them to the standards, policies, procedures, and team members with which they would be working. Essential partnerships formed in the planning phase included: • Nursing education/leadership to provide insight about the existing program and address the practice considerations for NPs • NP, PA, and physician leadership to contribute expertise on role competencies and current processes www.nurseleader.com
• Human resources to help develop a new onboarding process and to ensure clear communication to new NP hires • Medical staff office to incorporate credentialing considerations
STARTING WITH THE EXISTING NURSING ORIENTATION PROGRAM The biweekly RN orientation hosts between 30 to 60 RN orientees in each program, with annualized volumes of 750 to 1,500 RN orientees. The program focuses on the core set of competencies for general clinical practice. The centralized component is followed by a unit/department-based orientation in which nurses engage in preceptorship and focus on competencies specific to their patient population. Although we wanted to establish an organized process for the NPs, we also recognized that this was an opportunity to enhance our interprofessional collaboration and team training practices. We decided that, in addressing the needs of the NPs, we would not go forward with the silo models used in the past. Rather, interprofessional collaboration would be evident in both the development team for the program and within the program itself.
INTERPROFESSIONAL PROGRAM DEVELOPMENT TEAM The program development team consisted of nursing education leaders, along with NP and PA leaders. We worked together and examined the topics and competencies in the existing RN orientation program and agreed upon their relevance in an interprofessional orientation model. We enhanced information on topics in some areas and worked together to change the way we approached teaching so that it would be more inclusive for nurses and mid-level providers.
THE NEW INTERPROFESSIONAL ORIENTATION PROGRAM Within the program itself, interprofessional collaboration is a prevailing theme. NPs learn alongside PAs and RNs, and work together, sharing their thoughts, experiences, and ideas. Team members gain a better understanding of each other and their respective roles. Additionally, NPs are educated to NSLIJ standards, policies, and procedures. The core competencies for which NPs are credentialed are validated during this part of the process. The program design team modified and developed several dimensions of the original program to formulate the new approach. Some of these components are addressed next. Simulation The value of simulation in preparing clinicians for the practice environment is well established. NPs start by engaging in a team situation in which a patient, who has a family member at the bedside, begins deteriorating. The primary nurse escalates the situation and calls for the help of a secondary nurse and the NP. All roles (except the patient) are played by orientees. The NP role is played by an NP orientee. In this situation, the NP
Nurse Leader
33
has the opportunity to function in the advanced practice role in terms of patient assessment and intervention, and gets to interact with other team members and the patient’s family. NPs also participate in an individualized simulation scenario in which the NP performs a physical assessment on a patient and intervenes based on assessment findings. The scenario is designed as an episodic situation that focuses on the need for cardiac and respiratory systems assessment. Debriefing Immediately after each simulation scenario is a debriefing session that is facilitated by the educator who observed the scenario. In the team scenario debrief, there is usually expression of feelings of anxiety, sometimes some role confusion, and almost always the issue of communication. Always emerging from the debriefing is reflection on the value of situation, background, assessment, and recommendation communication practices and the need to increase familiarity with the Centers for Medicare and Medicaid Services Core Measure guidelines. During the debriefing, many NPs relive the scenario together with the other orientees and demonstrate how they each could have been more effective with communication. Another interesting note is that NP and RN orientees often share that this was their first time working together in a team situation, as many of the participants are novices in their roles.
NEW TOOLS Organizing and documenting the NP onboarding process was very involved. The following five tools were developed or enhanced to help streamline the process. 1. Welcome packet. The centralized RN orientation already used a welcome packet that was made available to nurses via an online link provided through human resources at the time of hire. Revised to take on an interprofessional perspective, the packet included additional study guides and information so that NPs would know what to expect in terms of their performance in simulation and throughout the orientation. 2. Introduction to simulation video. To help prepare NPs (and other participants) for simulation, a link to a brief video is provided in the welcome packet. The video reviews how the high-fidelity mannequin functions, and provides an overview of the simulation room and other details that are helpful in preparing for this aspect of orientation. Seeing the simulation environment beforehand is critical in reducing the associated anxiety that often accompanies these types of activities. 3. Hands-on practice session. In addition to the online video, which is viewed prior to hire, a brief hands-on session is provided upon arrival at the Patient Safety Institute, the health system’s simulation center. In the hands-on session, NPs have one of their first opportunities to learn alongside RNs and PAs. Small groups of interprofessional teams become oriented to the live set-up, and this is usually where the orientees first begin to realize what a
34
Nurse Leader
team experience will feel like. They often embark upon a discussion about working together and roles and responsibilities during this hands-on session, which meets the objective of this activity! 4. Orientation education team. Not only did the design team include RNs, NPs, and PAs, the education team that facilitates the program is also interprofessional in nature. The educators who facilitate the program include RNs, NPs, and PAs, all with diverse backgrounds and areas of clinical specialty. These individuals are accomplished clinicians and educators for their respective disciplines. Over time, we have expanded our pool of educators in response to increased numbers of participants and to broaden the bench to accommodate educator availability. 5. Performance evaluation instrument for simulation scenario. Assessing performance is a key component of a simulation experience. The Clinical Assessment Evaluation Rubric (CAER) was developed to evaluate performance in the comprehensive patient assessment using a simulated scenario. The need for a rubric arose from the desire to have a single, consistent measurement that could be used by multiple scenario observers. The CAER is a comprehensive instrument comprising three subscales: a physical assessment performance subscale, a clinical judgment subscale, and a reflection subscale. The CAER was introduced several years ago for use with RN orientees. Revised versions of it are now used during the simulation experiences within the interprofessional orientation program. The CAER has completed inter-rater reliability testing and is undergoing psychometric testing.
INTERPROFESSIONAL PROGRAM ROLLOUT The pilot phase of the rollout involved trialing the above processes at one site within the health system. This large tertiary facility was ahead of the curve in increasing NP presence within the organization. The pilot phase spanned 2008 to 2010. Formal and informal feedback was received from NP participants, the facilitating educators, and leadership at the pilot site. In 2010, a vetting process ensued in which this model was proposed to nursing and medical executive leadership. All were in favor of this model becoming a system-wide standard for onboarding NPs and PAs. As of January 1, 2011, this model was fully implemented across the 15-hospital system.
CONCLUSION In 2011, the first full year of the program, 84 NPs participated, compared to 31 in 2010. Both the participants and the organization recognize this model as a best practice approach and support its continuation and growth. Feedback is solicited from participants through in-person and online mechanisms. NPs offer overwhelming appreciation for the orientation process, many stating that they “have never experienced an orientation like this” in their careers and that they “feel better prepared for practice.” Still, NPs do share that there is a need to improve the department-based components of the process, as this still varies widely from department to department and from facility to facility.
October 2012
As we continue with NP onboarding expansion activities, NSLIJ has established system- and hospital-level NP councils, hired a corporate director of advanced practice nurses, and increased interprofessional continuing education. Plans are underway to develop an NP/PA critical care residency program. Focused attention on NPs as team members is necessary in today’s healthcare environment. Using an interprofessional orientation program can provide a springboard for a successful NP onboarding process. NL References 1. 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-Related Portions 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 director for nursing education at the North Shore-Long Island Jewish Health System and can be reached at [email protected]. Acknowledgments The author would like to acknowledge Maureen White, MBA, RN, NEA-BC, the North Shore-LIJ Health System Institute for Nursing and the interprofessional orientation development team for their dedication to the development and ongoing execution of this program, and the North Shore-LIJ Health System Patient Safety Institute for their expertise and assistance with simulation. 1541-4612/2012/ $ See front matter Copyright 2012 by Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2012.07.002
www.nurseleader.com
Nurse Leader
35