What Makes For A Good Orientation
How long is long enough? When will I know I’m ready? How will I learn all this? All valid questions you should be considering when starting your NP job. Especially if this is your first job. The transition to practicing as a nurse practitioner is hugely different than that of becoming a nurse. Not only do you have all the clinical stuff to learn but even the work of learning how to structure your day, how to author notes, how to bill, what needs follow -up. So many facets of just being an NP exist, beyond the medicine piece. This is what many underestimate and these factors just do-pile onto the mountain of overwhelm many feel when becoming a nurse practitioner. So the appropriate question is what will my training be like? In this article I attempt to break down the components I feel lend itself to a good orientation process.
Nurse practitioner orientation is a structured process designed to introduce new nps to the roles and responsibilities within the healthcare organization, the team, and the clinical specialty. It aims to provide them with the knowledge, skills, and tools necessary to excel in their positions. It can range from non-existent (Welcome, here is your census for the day) to highly structured and lengthy (think as many as 4-6 months) depending on the systems values, acuity, support staff, and program development. In general you will find academic centers and large organizations provide more structured support. Outpatient settings tend to offer significantly shorter time frame and less thorough orientation periods.
Factors that impact the robustness of your orientation:
Setting
Academic institutions tend to have previously established and high structured onboarding programs.
Outpatient settings tend to offer significantly shorter orientation phases with fewer resources.
Your experience level
Most teams tailor the approach based on your needs. If you come with experience in the specialty it could be quite brief and focus on workflow, resources, networking, and intro to the EMR. If you are a first time nurse practitioner this will require a broader overview as well as heavy focus on clinical application.
The teams established program
If this is not a team that hires often or has access to resources like educators, sim labs, preceptors you may experience a bit of blind leading the blind syndrome. This is because they do not have direction or anyone to spend the time to develop repeatable systems. They may be quite overworked or inexperienced with onboarding or maybe they just have to do it so rarely they haven’t focused on it.
Go back to bullet point #1 - most large centers or academic settings offer well established resources for training new hires. If you this is a big concern for you, definitely consider applying to these jobs. Or consider a residency or fellowship.
Time and Money
The two most motivating factors in almost any job initiative. When there is no funding you struggle with:
money to pay the non-producing provider
money to pay for training sites, programs, staff
money to pay for ongoing CME for the existing staff so their capability to teach may be limited
Consider why there is a vacancy. In most all cases it is because there is a need for a provider to treat patients. Which means they need help. They may need help really fast. This pushes them to push you. The fine line is knowing when they time is right for pushing you out of the orientation phase. This also could mean there are limited staff who have the appropriate time to teach you.
Things You Will Need To Learn
Organization Policies and Procedures: You will want to know the organization's policies and procedures, including those related to patient care, documentation, safety protocols, and compliance so that you can complete your work more easily. A lot of the time this is the hardest part of starting a new job. Knowing “what we do around here,” who to go to for what, etc often consume a lot of your time in the early days.
Clinical Training: This aspect of orientation involves hands-on training in the clinical setting, where new NPs work alongside experienced practitioners to learn the specific practices and workflows of the organization. This is THE HARDEST PART of becoming an NP. Even though you know it, I’ve told you a thousand times, and everyone says they have gone through it as well - my guess is you still underestimated how hard it would be. Particularly when our schools are heading towards self-taught modules 🙄 😡. You are coming in with less foundational training. You will need to spend a lot of your off time on continued self-education. It just is what it is. Medicine is vast, no matter what your specialty, and in order to become a proficient provider you must spend time furthering your education.
Charting and Documentation: Also could be time consuming. Note writing in and of itself is cumbersome, but throw in a new EMR and you are guaranteed to have quite a learning curve.
Collaborative Team Training: Learning who, how, and when to consult others is a learned skill related to clinical acumen. You also will need to learn how to not revert to being the bedside nurse which is what many uncomfortable new NPs do. Its tough - you feel stupid, you suffer from imposter syndrome, and who are you to tell bedside staff what to do? I get it, been there, done that. It takes a minute to learn how to navigate this.
Scope of Practice and Legal Responsibilities: Nurse practitioners need to understand their scope of practice and legal responsibilities within their state, institution, and team. This is tough. Because this varies widely. Can you intubate? IDK, because it’s different everywhere. It definitely starts with your BON designations and ends with your attendings/team culture and systems policies.
Continuing Education: This is, IMO, the most crucial aspect to an orientation period. The time frame is the second most important factor, but, if the program is robust you can significantly speed up your trajectory. So what makes for a well developed program?
Clearly delineated and proficient primary preceptor. Some newbies do better rotating with several providers, others do well with one person and crave consistency. Will it be a fellow NP or PA or a physician? Honestly, who will be the best professional boils down to who is the best teacher for your preferred learning style and who wants to teach.
Copious, and I mean copious layers of educational resources. Books, online programs (an example might be the FCCS offered by SCCM for new critical care providers) paid for or offered by your organization, written material developed by your team, simulation labs, local lectures, morbidity and mortality conferences, lunch and learns, and so forth. The more available to you the better.
Rotations with support services. A day or two in the OR is hugely helpful to quickly get a bunch of intubations and art lines done. Or perhaps some time with a procedural team. Or a few days with complimentary service lines like nephrology, inpatient medicine, etc. That also is a wonderful way to network BTW.
Teams who place priority on your experience. You should be ramping up in the acuity level and amount of patients you are seeing per day. A long training time frame with minimal patient interaction will get you nowhere real fast. When in the interviewing/job negotiation phase ask them how they approach this. How will they ensure that you receive priority.
Timeframe: So this is the big question that most people ask when interviewing. Those who place orientation at the top of their priority list will usually seek the answer to this question. For good reason. Even a super robust/aggressive program requires the tincture of time in order for you to receive proper exposure.
The answer to how much time is enough time is highly individualized, or at least it should be. One person’s learning needs are very different from another’s. To assess your ideal timeframe ask yourself how many patient’s you feel you could successfully treat starting on day one. If a person completed 100 hours of clinicals with the team they will come in the door ready to accept a few patients (depending on the complexity of the service). They may not be able to independently treat, but they can assess, evaluate, make a suggested plan of treatment, and write a note with assistance already. So ask yourself, if you have protected time and a preceptor, how many patients can you see day 1. Then look at the average census of folks on your team. Backtrack how long it takes you (including doing lit reviews, developing dot phrases, and other tasks of care) to care for one patient. Estimate how long you think it will take you to get up to ~ 75% of what the average team member is doing. That would be the suggested timeframe for protected orientation. Don’t forget, once you start taking patients independently you still will require time for growth, you won’t roll off orientation feeling confident but that’s not the goal.
Achievable goals for the end of orientation are :
Can you identify your resources for support
Can you easily access literature/research to help guide decision making
Feeling mostly comfortable with the process of caring for patients in your specialty (work flow, who to call when, etc)
Do you have an established chain of command for problems
This time will be different for all specialties but here are a few generalizations:
Outpatient - you will have less time, it is what it is. I suggest negotiating for dedicated daily or hourly administrative time which you can use for ongoing preceptorship. Sit down with a mentor weekly and review your more challenging cases and ask for their advice.
Outpatient - make sure your ramp up time frame is as long as you are comfortable with. I hear people report anywhere from 2-6 weeks.
Inpatient - for consult services with one main organ system I think a month is a decent time frame, possibly less.
Inpatient - for general services (hospital medicine, critical care or any ICU service) I see a range of 2 months to 6 months with an average of 3.
For both - the key question to ask during the negotiation time frame is “How and when will I be evaluated and what is my recourse if I do not feel I am ready?”
WELCOME, WE ARE SO GLAD YOU'RE HERE
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WELCOME, WE ARE SO GLAD YOU'RE HERE 〰️
Check out this Youtube video where I discuss post graduate NP training programs.
