Content area
Background
This study examines the impact of a quarterly advanced practice provider (APP) onboarding boot camp on the transition to practice for advanced practice RNs and physician assistants within an organization.
Method
The program includes didactic and simulation content covering various topics, with evaluations conducted through pre- and postintervention evaluations.
Results
Statistical analysis of evaluation responses from 78 participants showed significant improvements among APPs in comfort level, ability to differentiate between patients who were and were not sick, and understanding of pediatric emergencies.
Conclusion
The findings underscore the effectiveness of specialized onboarding initiatives in enhancing the knowledge and comfort of APPs. [J Contin Educ Nurs. 2025;56(7):277–282.]
Full text
Transition to practice (TTP) programs are increasingly recognized as essential for supporting advanced practice providers (APPs), including advanced practice RNs (APRNs) and physician assistants (PAs), in navigating the complexities of clinical roles. Historically, our organization provided minimal onboarding tailored to APPs, often integrating them into general hospital orientation without addressing the unique aspects of advanced practice. In addition, APPs were frequently excluded from onboarding programs for physicians and nurses, leading to gaps in support and professional development (Morgan et al., 2023; Penn Medicine, 2023). The absence of specialized support has contributed to difficulties in role transition and professional integration. Although APRNs and PAs are qualified to engage in clinical practice after completing an accredited program, achieving national certification, and meeting state licensure requirements, TTP programs, such as residencies and fellowships, offer opportunities to enhance proficiency and expertise beyond entry-level competence, helping consolidate clinical knowledge (Cosme, 2023; Dover et al., 2019).
A comprehensive literature review was conducted by our medical librarian with a multi-database service. The search used the keywords “advanced practice” AND “transition” OR “onboarding” OR “orientation.” Results were filtered to include peer-reviewed scholarly articles published between 2019 and 2024, written in English, and published in the United States. This search resulted in a selection of articles that were manually appraised for relevance to the study.
Current literature consistently highlights the critical role of structured onboarding programs in supporting APPs, particularly APRNs. Most of the available research focuses on TTP programs for APRNs rather than PAs. These programs significantly assist APRNs by easing the transition into the role through structured education, mentorship, and clinical integration. Robeano et al. (2019) showed that such programs reduce stress, improve confidence, and foster a team-oriented environment. Their evaluation data, collected 30 days, 180 days, and 1 year after hire, showed substantial improvements in retention, job satisfaction, and overall service quality.
Lambert (2020) underscores that the design of these TTP onboarding programs should be tailored to meet the specific needs of APPs in diverse clinical settings. By implementing standardized onboarding procedures and mentorship frameworks, health care organizations can create a more supportive environment for APRNs.
Mentorship has been highlighted as a critical element of TTP programs. Urbanowicz (2019) emphasized the importance of mentorship in supporting new APRNs during their transition, providing practical guidance for designing these programs and stressing that continuous mentorship and professional development foster both role satisfaction and clinical competence.
The positive impact of TTP programs on retention rates is well documented across various studies. Stiesmeyer et al. (2024) found that programs tailored to rural health care settings were particularly effective in helping new APRNs adjust to their roles, especially in underserved areas. Goodwin et al. (2021) similarly reported that a structured curriculum to career program for nurse practitioners in primary care bolstered role confidence and job satisfaction, attributing lower turnover rates and improved patient outcomes to ongoing mentorship and structured learning.
Batchelder et al. (2024) conducted a comprehensive scoping review that emphasized the vital role of TTP programs in supporting the integration of APRNs into the health care workforce. Their findings indicated that well-structured TTP programs not only enhance professional competency but also foster a greater sense of autonomy among new clinicians, which in turn leads to improved job satisfaction and retention rates. However, the review also showed that many programs struggle with challenges such as inadequate training resources and inconsistent access to clinical supervision. To address these issues, the authors advocated for the development of more robust training frameworks and the implementation of peer support networks that could provide ongoing encouragement and guidance. By reinforcing these elements, TTP programs can better prepare APRNs and PAs for the complexities of their roles and ultimately contribute to more stable health care teams.
The literature strongly supports the implementation of structured TTP programs for APPs. These programs are instrumental in reducing role stress, enhancing confidence, and improving retention through a combination of mentorship, education, and clinical integration. As noted by DeGarmo (2020), both ongoing evaluation and refinement of these programs are essential to adapt to the evolving demands of the health care environment. As health care systems evolve, the continued development and optimization of these programs will be critical for supporting the next generation of APPs and improving patient care outcomes.
Recognizing the need for a more unified approach to onboarding at our organization, the Office of Advanced Practice took the lead in 2015 by implementing a 1-day simulation event. In 2016, this program expanded to include 2 simulation days per year, providing further opportunities for hands-on training. In 2017, the Office of Advanced Practice took a significant step forward with the creation of quarterly APP onboarding boot camps for all newly hired APPs as well as those transferring into new roles within the organization. This opportunity aligned with the organizational goals to facilitate collaborative initiatives to improve clinical effectiveness and standardization of evidence-based models of care.
The APP onboarding boot camps are held on a quarterly basis to provide timely and consistent onboarding opportunities throughout the year. They consist of 2 days of didactic content and 1 day of simulation content to prepare APPs for the specific demands of their roles by providing essential knowledge and skills and promoting collaboration with peers and clinical leaders. This article describes the evolution of our organization's APP onboarding boot camp that was designed to ensure consistency, improve knowledge for clinical effectiveness, increase comfort with role transition, and foster interdisciplinary collaboration.
Method
Based on evidence supporting TTP programs for APPs, the following objectives were identified to guide practice change: (a) improve retention of APPs within the organization, (b) facilitate role transition and professional integration, (c) increase knowledge in critical areas of APP practice, and (d) enhance provider confidence and comfort in clinical practice. Evaluation of program content was essential to show the efficacy of the TTP program and outcomes. Evaluation of our APP TTP program outcomes was conducted via pre- and postintervention evaluations for four cohorts of newly hired APPs over a 3-year period. The evaluation process assessed knowledge gained throughout the TTP program through pre- and postintervention evaluations of 29 elements of the program.
Evaluations before and after the APP onboarding boot camp were conducted with an online digital survey platform. The survey was customized to evaluate program content. An evaluation link was sent to members of each cohort before the first day of APP onboarding boot camp and after completion of simulation content on the third day. Based on feedback from evaluations, both didactic and simulation content underwent annual review, with revisions where necessary. Data were collected between 2019 and 2022. Institutional review board approval was sought before data collection, and it was determined that this evaluation was not human subject research. Evaluations were deidentified to ensure confidentiality of employees.
Pre- and postintervention evaluations were developed by the five advanced practice education committee chairs, which included three certified nurse practitioners, one clinical nurse specialist, and one PA, and they were distributed and scored with an online digital survey platform to evaluate content. To enhance the validity of our survey, we had a rigorous review process. A panel of seasoned APPs reviewed the assessment items to establish expert and content validity. Questions were evaluated for clarity, relevance, and alignment with current care guidelines before implementation. This review process ensured that the survey accurately captured key aspects of the TTP while aligning with the program's objectives.
Statistical Analysis
Statistical analysis included summary statistics (mean and SD for evaluation responses and number and percentage for professional demographics), stratified by pre- and postintervention status. The paired t test was used to assess differences from pre- to postintervention evaluation responses, including calculation of mean difference with corresponding 95% confidence intervals. All analyses were conducted with SAS, version 9.4/13.4 (SAS Institute), with results interpreted at a type I error rate of statistical significance of alpha = .05.
Results
A total of 78 participants responded to the preintervention evaluation, and 45 (57.7%) responded to the postintervention evaluation. Analyses were conducted on paired preintervention-postintervention responses only. There were 12 (26.7%) respondents from 2020 and 33 (73.3%) respondents from 2021. Of these, 37 (82.2%) were certified nurse practitioners, one (2.2%) was a certified registered nurse anesthetist, and seven (15.6%) were PAs. There were 21 (46.7%) APPs who were newly licensed but were not new employees of the organization, 10 (22.2%) APPs who were newly licensed and newly employed at the organization, and 13 (28.9%) APPs who were experienced but new to the organization.
There were 29 evaluation questions in all, scored from 0 to 100. The paired samples t test was used to assess pre-intervention-postintervention differences. Of the 29 questions, 28 (96.6%) were significantly different (p ≤ . 01 for all), with an average mean difference of 24.6. The greatest change was seen for the evaluation question “How well do you understand APP patient experience measures?” The result showed a significant mean difference of 53.1 (95% confidence interval of mean difference, 45.1–61.1), indicating increased awareness in the postintervention evaluations. A large improvement was also seen in response to the question “How well do you understand imaging at this time?” The finding showed a significant mean difference of 51.8 (95% CI of mean difference, 42.4–61.3), indicating increased awareness in the postintervention evaluation. The one nonsignificant finding was in response to the question “How proficient are you with talking with a teenager and assuring their confidentiality at this time?” The finding showed a nonsignificant mean difference of 13.6 (95% CI of mean difference, −15.6 to 42.7); however, there were only nine responses to this question. Figures 1–2 show preintervention-postintervention survey outcome measures.
Discussion
The overarching goal of onboarding and orientation for APPs is role transition and ultimately improved clinical outcomes for the patient population we serve. Data obtained from these survey measures indicate that there are benefits to requiring newly hired APPs to engage in mandatory onboarding and orientation. Statistically significant findings were not only established for notable outcome measures (e.g., “How comfortable do you feel in your APP role at this time, with the transition from novice to expert?” “How well can you differentiate between a sick versus not sick patient and communicate your assessment and plan at this time?” “How well do you understand your response to pediatric emergencies at your primary location at this time?”) but also for all but one of the evaluation questions.
When matched data for the question “How comfortable do you feel in your APP role at this time, with the transition from novice to expert?” were compared, evaluation results showed a mean increase of 15.3 in comfort scores from preintervention evaluation to postintervention evaluation, indicating a statistically significant improvement in this outcome.
When matched data for the question “How well can you differentiate between a sick versus not sick patient and communicate your assessment and plan at this time?” were compared, evaluation results showed a mean increase of 11.5 in perceived ability scores from preintervention evaluation to postintervention evaluation, indicating a statistically significant improvement in this outcome.
When matched data for the question “How well do you understand your response to pediatric emergencies at your primary location at this time?” were compared, evaluation results showed a mean increase of 14.6 in understanding scores from preintervention evaluation to postintervention evaluation, indicating a statistically significant improvement in this outcome.
Our outcomes agree with previous literature that supports the implementation of structured TTP programs for APPs. These programs are instrumental in reducing role stress, enhancing confidence, and improving retention through a combination of mentorship, education, and clinical integration.
Limitations
Unfortunately, we cannot prove role retention because of many factors that influence the decision for an employee to move to a new position, such as work-life balance, compensation, and career advancement.
Although completion of the pre- and postintervention evaluations was mandatory, response rates for the postintervention evaluation were lower than response rates for the preintervention evaluation. If the participants who did not complete the evaluation had evaluated the program negatively, these responses may have significant implications for the results.
Although data collection began in 2017, a flaw was identified in the pre- and postintervention evaluations because matched responses were not obtained. This shortcoming was corrected in 2019. Extrapolation of outcomes based on pre-2019 data is limited because of this flaw, and therefore only data collected between 2019 and 2022 were analyzed.
Additionally, because of the onset of the coronavirus disease 2019 (COVID-19) pandemic in March 2020, starting with the June 2020 cohort of the APP boot camp, content was delivered virtually via a synchronous Microsoft Teams meeting and participants engaged with presenters remotely. Data collected before June 2020 reflected in-person attendance by both the presenters and attendees, whereas data collected from June 2020 through 2022 reflect virtual, synchronous attendance.
For the purposes of this study, we focused solely on preand postintervention survey data using a numerical rating scale from 0 to 100. In the future, we plan to establish a formalized process with Plan-Do-Study-Act cycles to enhance our program evaluation. This process will include not only data from the numerical rating scale from 0 to 100 but also qualitative feedback, which we recently incorporated into our surveys.
Conclusion
The implementation of a structured onboarding and orientation program for APPs resulted in statistically significant improvement in knowledge and comfort in the TTP period. These findings support the value of mandatory onboarding in facilitating the transition from novice to expert roles. Despite some limitations, including incomplete response rates and changes in program delivery because of the COVID-19 pandemic, the results agree with existing literature, highlighting the benefits of structured TTP programs in enhancing provider readiness and potentially improving patient outcomes.
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The authors thank their team of advanced practice education committee members, Advanced Practice Provider Onboarding Boot Camp volunteers, simulation center educators and staff, hospital administration, biostatisticians, and Evidence Based Practice Advisor, Dr. Annette Mitzel, DNP, APRN-CNS, for their support and contributions to the program.
From Akron Children's Hospital (LJA, SMC, JMP, LMR), Rebecca D. Considine Research Institute at Akron Children's Hospital (NLM), and Summa Health System (JVT), Akron, Ohio.
Disclosure: The authors have disclosed no potential conflicts of interest, financial or otherwise.
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