Nurse practitioner orientation is a relatively new but progressive topic and is usually found within the context of APRN models of care, APRN fellowship programs, or departmental orientations within hospital-based organizations. Orientating novice NPs into a hospital-based organization involves transition and are created to integrate the employee within the organization (Meleis, 2010; Meleis, Sawyer, Im, Messias, & Schumacher, 2000). Additionally, orientation is a type of experienced transition that involves finding cohesion within the organization while building clinical proficiency (Bahouth, Blum, et al., 2013; Coble, 2014). Transitioning into practice is experienced by all nurse practitioners whether novice or skilled, however it is agreed by several researchers that the transition period of novice NPs tend be more dramatic (Bahouth, Blum, et al., 2013; Brown & Olshansky, 1997; Coble, 2014; Horner, 2017).
In novice nurse practitioners, does a structured nurse practitioner orientation program improve competency outcomes in a 12-month period at the Veteran Affairs North Texas Healthcare System?
Healthcare reform and the Patient Protection and Affordable Care Act (ACA) has led to the evaluation and modifications in health care delivery (Obama, 2016). The objectives of healthcare reform are to provide affordable and quality health care while increasing access to care in the United States (Collins & Saylor, 2018). These objectives have become vastly examined in hospital organizations and nurses will serve as the catalysts to lead in implementing effective solutions (Collins & Saylor, 2018). Nurses are the largest profession within healthcare and because of their adaptability, the nursing profession has the potential to effect a vast amount of necessary changes in the health care system (Institute of Medicine, 2011). There have been numerous studies that have demonstrated the association of nursing and patient outcomes. In 2000, the Institute of Medicine (IOM) reexamined issues of nurse staffing and patient outcomes, thus concluding that health is directly correlated by how well patients are cared for by nurses (Kohn, Corrigan, Donaldson, & Institute of Medicine, 2000). Nurses have the ability to assess strengths and weaknesses within healthcare systems and therefore can provide leadership to improve access, quality, and safety while reducing healthcare costs within organizations (Needleman & Hassmiller, 2009). Furthermore, nurse practitioners (NPs) are the largest advanced practice registered nurses whom are poised to assist with the access to care gaps, coordinating complex care for widespread populations, and serving as primary providers while practicing to their full scope of training and education (Institute of Medicine, 2011). Despite being well matched to serve the needs of Americans, NPs are faced with many challenges (Institute of Medicine, 2011; Kohn et al., 2000). There are more than 248,000 NPs in the U.S., and 49.9% hold hospital privileges (AANP, n.d.). The rapid growth of the hospital-based NP has led to unforeseen challenges, role confusion, inadequate support, and fragmented onboarding processes (Bahouth & Esposito-Herr, 2009). Novice NPs tend to experience more difficulties transitioning within hospital organizations which can subsequently lead to unfavorable competency outcomes (Bahouth, Blum, & Simone, 2013; Bahouth & Esposito-Herr, 2009).
A literature review was conducted on NP orientation and common concepts were encountered throughout the literature review and grouped accordingly. It was discovered that most employing hospitals offer no or limited NP orientation programs with such programs varying from nonexistent to a few weeks in duration (Bahouth, Blum, et al., 2013). In several organizations, NP orientation is often grouped with registered nurse programs, provided with limited guidance, or does not occur (Bahouth, Blum, et al., 2013; Metzger & Rivers, 2014). Additionally, there have been instances when key resources were not made available, contributing to inefficiency start up processes and patient safety (Bahouth, Blum, et al., 2013). As a result, novice NPs experience job dissatisfaction, stagnant professional growth, improper use of skills within their scope of practice, lack of appropriate reporting structures, and dysfunctional colleague collaboration (Bahouth, Blum, et al., 2013; Karen A. & Mona P., 2009). This in turn can lead to high NP turnover rates in a time where the shortage of primary care providers is prevalent.
Acclimating into the organization, establishing rapports with colleagues, absorbing the organizational culture, and the formal or informal rules of the organizational environment are integral to the success of the NP (Bahouth et al., 2013; Brown & Olshansky, 1997; Horner, 2017). Because the NP must adapt to the culture of the organization, the orientee must thoroughly understand how the organization functions. Culture represents the morals, values, and behavior of an organization and can be influential of personnel and healthcare teams which in turn, influences quality (Johnson, Nguyen, Groth, & White, 2018; Rovithis et al., 2017). Furthermore, the attitude towards NPs within an organization can facilitate or disrupt the success of the transition and has been linked to medical errors, accidents, and poor outcomes of the patient and the provider (Marshall, 2011; Poghosyan, Nannini, Finkelstein, Mason, & Shaffer, 2013; Rovithis et al., 2017).
Organizational socialization has been acknowledged as essential for the integration of employees into a hospital-based organization (Ahmadian, Soori, Ghaderi, Hejrat, & Mow, 2016; Bahouth, Blum, et al., 2013). Socialization facilitates the psychological health of the novice NP and enhances developmental skills (Bahouth, Blum, et al., 2013). Additionally, socialization assists with isolation reduction, encourages hospital activity participation, and facilitates networking while providing the NP a sense of belonging (Bahouth, Blum, et al., 2013). Organizational socialization has been found to positively influence role transition, clinical development, knowledge, and engagement, thus improving competency outcomes (Bahouth, Blum, et al., 2013; Korte, 2007; Meleis, 2010; Meleis et al., 2000; Poghosyan et al., 2013).
Preceptors should serve as clinical educators, role models, facilitators, and evaluators (Bahouth, Blum, et al., 2013). As clinical educators, preceptors assist with the developmental transition of the NP. Preceptors support the expansion of critical thinking and technical skills, time management, and communications with clients and staff (Bahouth, Blum, et al., 2013). The preceptor is an important evaluator by measuring the NPs strengths, weakness, progression, and competency measurements (Bahouth, Blum, et al., 2013; Bahouth & Esposito-Herr, 2009).
Didactic education consists of courses, conferences, presentations, journal clubs, and ground rounds (Bahouth, Blum, et al., 2013). Some hospital-based organizations already offer lunch and learn with a wide range of topics depending on the medical specialty. Didactic education is continuing education for NP and will enhance the developmental transition and facilitate expert providers (Horner, 2017).
Mentorship links the gap between education and reality and is important to the success of the NPs transition and job satisfaction (Bahouth, Blum, et al., 2013; Horner, 2017). Mentors are not clinical preceptors. Mentors enhance the professional and personal growth of the NP through navigating their career path and facilitating advancement of the practice. A mentor is nurturing, supportive, and influences development of the role (Bahouth, Blum, et al., 2013; Horner, 2017).
Collaboration is an essential relationship among hospital-based NPs. Collaboration not only encompasses physician communication, it includes nursing, hospital administration, and other departmental relationships. Collaboration involves teaching and learning from others on the healthcare team and results in positive team relations (Bahouth, Blum, et al., 2013).
The overall fiscal health of an organization is primarily measured by employee retention and job satisfaction (Kurnat-Thoma, Ganger, Peterson, & Channell, 2017). Epidemiologic evidence was not located specifically to NPs for the Veterans Affairs North Texas Healthcare System and the oversight of recruitment and retention initiatives for nurses within all Veteran’s Hospital Administration (VHA) is limited. Training resources and the efficacy of nurse recruitment and retention goals have not been evaluated or monitored regularly (GAO, 2015). The government accountability office (GAO) found that VHA lacked adequate training support within medical centers and were unable to determine whether nurses were effectively meeting the health care needs of the veteran (GAO. 2015). In 2015, the GAO selected four medical centers to evaluate their nurse recruitment and training programs. One medical center had experienced high levels of nurse dissatisfaction with leadership and subsequently experienced a twelve percent turnover rate for NPs in 2014 (GAO, 2015). This left the medical center inadequately staffed and consequently affected access and quality of care for veterans (GAO, 2015). In 2011, the VHA began requiring medical centers to provide a Transition to Practice initiative, however the Office of Nursing Services (ONS) informed that funding was not provided to the medical centers thus the medical centers were left with their own funding determinations (GAO, 2015). Consequently, most medical centers recruited and hired only experienced nurses (GAO, 2015).
There is a high probability that a novice NP will leave an organization within the first year if dissatisfied with the organizational orientation (Ziegler, 2018). Essentially, any professional workforce was found to be dependent on the satisfaction of employees (Faraz, 2017; Scruth, Garcia, & Buchner, 2018). However, there are few research studies on the concept of job satisfaction related to novice NPs experience within the first year of employment. No data existed specific to novice NPs and job satisfaction within the Veteran Affairs North Texas Health Care System. According to Faraz (2017), NPs specifically demonstrated critical factors in the workplace linked to retention: professional autonomy, professional and interpersonal relationships, job benefits, and time allotted to complete work. Other studies indicated support of the NP role from colleagues and hospital administration, mentorship, and a thorough orientation were the most significant influences of job satisfaction (Duke, 2010).
NPs are a diverse group of providers with unique concerns that do not fit exclusively into the categorizations of nursing or medicine (Metzger & Rivers, 2014). For hospitals to meet the healthcare needs of their communities, novice NPs will require a properly structured orientation program to successfully transition within the hospital setting (Bahouth et al., 2013; Bahouth & Esposito-Herr, 2009; Metzger & Rivers, 2014). The general orientation plan should encompass several components directed towards clinical knowledge, development and growth, thus improving competency outcomes (Bahouth, Ackerman, et al., 2013; Bahouth, Blum, & Simone, 2012; Metzger & Rivers, 2014; Yeager S, 2010). Orientation programs should include preceptorship, mentorship, didactic education content, and effective collaboration (Bahouth et al., 2013). These key components will ensure accountability for tracking and affirming clinical decisions while assisting NPs to master intricate concepts. (Bahouth et al., 2013). Another example of building clinical proficiency involve credentialing NPs for invasive procedures and clarifying the methods of how an NP will be credentialed to independently perform the procedure (Bahouth et al., 2013; Yeager S, 2010). Any NP orientation program should enhance the psychological development of NPs by building relationships through mentoring, collaboration, socialization, and networking, hence producing behavioral competence (Bahouth et al., 2013). According to Brown and Olshansky (1997), the organization should provide time beyond the graduate program in order to allow for optimal professional development.
The goals of healthcare reform are to provide affordable and quality health care while increasing access to care in the United States. Nurse practitioners are the largest advanced practice nurses whom are poised to assist with access to care gaps, improving quality and patient safety, coordinating complex care for widespread populations, and serving as primary providers. The accelerated utilization of hospital-based NPs combined with inadequate transition and orientation programs can hinder the mastery and competency of NPs. Improper transition into the organizational culture can result in role confusion, job dissatisfaction, stagnant professional growth, improper use of skills, and dysfunctional colleague collaboration. The implementation of a hospital-based NP orientation program will support the transition and professional development needs of NPs. NPs need to feel supported and empowered in their hospital roles to continue providing quality patient care while meeting the future needs of healthcare delivery.
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