Newly graduated nurse practitioners (NPs) are ready for entry-level practice. They have been educated, trained, nationally board certified, and licensed to practice in their respective state. Eligibility for national board certification requires education and clinical training be through a nationally accredited program. National accreditation of universities and colleges of nursing is rigorous, and programs must meet designated standards of nursing education. All this is to say that new graduate NPs will arrive to the hospital, clinic, or facility, in which they will be working, with an established set of competencies and skills. However, because each facility is unique and patient populations can be diverse and complex, it is of critical importance that a new graduate NP be onboarded to such degree that the NP is successful in the role, have confidence in the work, and positively impact both the organization and the patients served.
Onboarding programs can vary, and the definition of onboarding can have different meanings based on perspective. For example, a human resources representative may define onboarding as completion of background check, verification of education, and satisfactory professional references, resulting in the NP being established as a new employee. To a leader, onboarding might mean introduction to the mission, culture, policies, and compliance standards of the organization. Onboarding may be ambiguous to some. For example, some clinicians might not expect any onboarding, but rather to show up and be ready to care for patients, leaving any orientation to electronic systems, acquisition of ID badge and parking, standards of care for patients, and the full spectrum to "others," expecting the NP to perform on day 1. All these definitions can be applied, but from the perspective of an NP leader, it has been my experience that an NP needs a comprehensive onboarding program covering organizational, administrative, employment, and clinical aspects, each essential to success. In this column, I outline 6 essential components of an NP-led onboarding program.
The Basics of Employment
Most facilities have basic employment covered. Because of hiring and labor laws, checklists are in place for most employees. Consolidation makes it easier to find the information and have it in 1 location, including for the NP. These basics include information on taxes, payroll/paydays, benefits enrollment, parking, immunization screening, and obtaining a name badge. In addition, there are NP-specific items including dress code. For example, are they expected to wear scrubs? If so, are these issued, or do they need to supply their own? Or are they expected to wear business attire with a lab coat? If they will be expected to wear a lab coat, does the facility issue this, or are there specifics that need to be printed on the lab coat (company name, etc)? Other important basics include office keys, computer/laptop, printer, and general maps and facility wayfinding. Sometimes, the basics can be the most anxiety provoking! Here they are, educated, highly knowledgeable, but feeling lost and unable to focus on patient care.
Credentialing and Privileging
Credentialing and privileging are often misunderstood processes for both the NP entering the practice and nursing leaders. In many smaller clinics and facilities, credentialing and privileging may not be required. However, for larger health systems and affiliates, credentialing and privileging are expected to be completed and approved before an NP can begin delivering patient care. Often the job application process is separate from the credentialing and privileging process; although many of the documents and forms are similar, they are not shared. Most organizations will require identification, licensure, board certification, and transcripts. Most require malpractice insurance enrollment or evidence that the NP has malpractice or professional liability insurance. Many NPs will need to complete applications to enroll with payers or insurers. This will allow the NPs to submit insurance claims for the services they provide. And last, peer references are commonly requested and required.
State Licensure Requirements
Although there are national standards for accredited education, clinical training, and board certification, the individual states regulate the licensure for the NP to practice within the state. Each state can vary on the requirements to obtain and maintain licensure. Some states' requirements are extensive, such as establishment of a contract to work with a supervising physician, or evidence of protocols for practice or retrospective chart reviews. If the facility has a process in place, it is important for their NPs to know what the process is up front, and what their role is, so they can maintain licensure. If the facility requires NPs to maintain requirements on their own, NPs need to know this as well so they can establish a process or method for compliance. More information on state rules and regulations can be found on the government's website or on association websites such as the American Association of Nurse Practitioners (http://aanp.org).
Organizational Enculturation
Nurse practitioner leaders are catalysts for enculturation, onboarding new NPs to organizational, nursing, NP, or other important cultural components. This onboarding includes an overview of the mission, values, and priorities for the facility, including day-to-day cultural norms. This helps the NP assimilate and navigate his/her role within the practice more readily. Knowledge of policies, such as those impacting patient care, reporting, and resolving employee grievances, and clinician bylaws are important but often only discussed when there are issues. Identifying how to access key policies, bylaws, and facility or organizational-specific regulations will empower the NP to seek out these sources proactively.
Administrative Responsibilities
An effective NP leader will provide an overview and instructions on day-to-day administrative responsibilities such as patient care documentation, coding, and submitting insurance claims. The NP will need an overview of common consultative services or an introduction to the facilities' referral network. Other often overlooked but quite essential are details such as the work schedule. How the NP schedules to work (ie, days per week, length of time), how to request time off, how holidays are handled, and expectations for clinical time as well as administrative time are key functions.
Clinical Responsibilities
Finally, an overview of clinical expectations, patient population(s) served, frequent diagnoses, clinical resources, and, where applicable, established standards of care is essential. Although these components are generally understood, details are important. Nurse practitioner leaders should review and develop a progressive plan for the new NP to learn and establish experience. Clinical expectations include quality expectations, benchmarks of quality patient care, quality metrics and visibility into reports and tracking methods for monitoring patient care outcomes, and, finally, the evaluation process. Each NP needs to know how his/her practice will be monitored and evaluated to ensure quality and patient safety. Taking time to teach, evaluate, and achieve clinical competency specific to the organization's patient population can be the single most important component of effective onboarding and ensures the NP's success as an effective practitioner.
Because each of these areas can often be overlooked when onboarding, NP leaders should develop programs for consistent application for each new NP. Spreadsheet trackers, mobile applications, checklists, and online programs for tracking consistency in onboarding have been used, ensuring every new NP engages in a comprehensive and supportive onboarding program and is empowered to be successful.