The Journal for Nurse Practitioners xxx (xxxx) xxx

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The Journal for Nurse Practitioners

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Brief Report

Establishing Organizational Support for Nurse Practitioner/Physician

Assistant Transition to Practice Programs
Christie Ehle Erickson, Debra Steen, Karla French-Baker, Laurel Ash

a b s t r a c t
Keywords: The benefits of transition to practice programs are well supported in the literature. Despite this support, there
barriers are often numerous organizational barriers to the implementation of such a program. Key strategies to
engagement
establish organizational support include securing leadership buy-in, having a clear advanced practice
finance
onboarding
registered nurse/physician assistant leadership model, and creating a business case to financially support a
recruitment transition to practice program. Essentia Health’s advanced practice registered nurse/physician assistant
retention transition to practice pilot used engagement, turnover, and productivity data, which were presented to
leadership to secure buy-in and ultimately expand the program to all departments within the health system.
© 2020 Elsevier Inc. All rights reserved.

Despite known benefits of a transition to practice (TTP) program,
numerous organizational barriers often impede the implementation
of these programs. Morgan et al1 identified critical organizational
factors for program success including support from organizational
leadership, clear organizational structure for physician assistants
(PAs) and nurse practitioners (NPs), and strong leadership of the
onboarding program. “Without strong support from top leadership,
the business model will trump onboarding every time.”1
The health system described is an integrated health system with
74 clinics and 15 hospitals across a large tristate area. The health
system employs 536 NPs and PAs, comprising 34% of the providers
on staff. A robust TTP program was needed to address low
engagement, significant variability in productivity, and the high
turnover of NPs and PAs.
The benefit of a TTP program for NPs and PAs is well supported
in the literature. Transitioning from student to provider of care can
cause feelings of stress, isolation, self-doubt, frustration, and un-
certainty about clinical knowledge.2-8 In surveying organizations
with NP residency or fellowship programs, Kersten and El-Banna9
found the following benefits: increased competence and skill,
increased confidence, enhanced recruitment and retention of NPs,
improved communication and collaboration, enhanced clinical
judgment, improved socialization to the NP role, increased NP
satisfaction, and improved patient safety. Morgan et al1 inter-
viewed 13 health care organizations regarding their experience of
onboarding new NPs and PAs. They identified 3 “critical organiza-
tional factors” for program success including support from orga-
nizational leadership, clear organizational leadership structure for
PAs and NPs, and strong leadership of the onboarding program.
They also identified costs of onboarding including reduced clinical
productivity of onboarding program leaders, mentors, and pre-
ceptors and low clinical productivity during ramp-up of NPs and
PAs.1 Urbanowicz10 and Alencar et al11 described justifying the cost
of a TTP program and obtaining adequate funding as key factors to
the success of a program.
Despite well-known benefits of TTP programs, there are
numerous organizational barriers to the implementation of such a
program. The health system’s TTP program has been presented at
several NP conferences with the most common questions revolving
around attaining organizational support for time and funding. A
review of the literature validates these concerns.
Program Development
The foundation for the TTP program was developed in 2016 by
the health system’s advanced practice registered nurse (APRN)/PA
council. The initial impetus was a system-wide engagement survey
that was performed by an external national consultant whose focus
is on health care solutions for patient and employee experience.
This survey found that the overall engagement of APRNs and PAs
within the health system was at the 14th percentile nationally.
Turnover at that time was 15% with internal churn bringing turn-
over to 19%. Delving deeper into the data revealed that the APRNs
and PAs within their first 2 years of practice had the lowest
engagement at the 4th percentile compared with peers nationally
and were at highest risk for leaving their current position.
These data, along with a written recommendation for the
development of a formal TTP program, were presented by the
APRN/PA council to senior leadership within the health system. The
proposal included the first formal APRN/PA leadership positions

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1555-4155/© 2020 Elsevier Inc. All rights reserved.
e2 C.E. Erickson et al. / The Journal for Nurse Practitioners xxx (xxxx) xxx
within the health system as leaders of the program. Support was
given by senior leadership for a pilot TTP program with the goal of
increased engagement, decreased turnover, and increased pro-
ductivity. The ultimate goal was to make the health system the
employer of choice for APRNs and PAs.
Leadership for the program was hired the winter of 2016, and
the next 6 months were used for program development. The pro-
gram was structured using criteria outlined in the American Nurses
Credentialing Center’s Practice Transition Accreditation Program
Application Manual.12 A needs assessment tool was developed in
partnership with a doctor of nursing practice (DNP) student,
surveying 29 primary care new graduates who had started with the
health system in the past 4 years to explore gaps between their
education and practice. These data were used to develop topics for
didactic sessions. Data were gathered on the productivity of new
NPs and PAs in primary care using annual relative value units. A
model for progression of the new NP or PA with support of a mentor
was developed, which increased the goal of productivity from the
25th percentile nationally to the 50th percentile nationally at the
end of 1 year. This increase in new hire productivity was used to
justify either 2 hours a week of dedicated time or a $500 a month
stipend for the mentor for 1 year. A mentor guide was developed
that outlined specific accountabilities of the mentors. Mentor
training specific to having difficult conversations and goal setting
was developed as a DNP project.
The primary care pilot began in August of 2016 with a cohort of 8
newly graduated NPs and PAs. Each new hire had an assigned
mentor selected by leadership. These mentors received training
through the DNP project and with the TTP leadership. Mentor re-
sponsibilities included professional and clinical support of the new
hire (Figure 1).
All new hires completed a self-assessment focused on clinical
skills needed within primary care. The TTP program was custom-
ized based on the learning needs of each new hire. Faraz13 noted
that greater professional autonomy in the workplace is a critical
factor in turnover intention in novice NPs in the primary care
setting. The TTP leads facilitated clinical time with specialty areas
or online learning modules as indicated by the self-assessment. An
onboarding schedule guide was used to facilitate orientation and
gradual progression in clinical visit complexity and volume with
goals set for 3, 6, and 12 months. A slower ramp-up of patient
volume and complexity was prescribed to allow for an increase in
clinical confidence and competence. Peer mentors were selected
and assigned to new hires with 2 hours of time dedicated to
mentoring per week for the first year. Twice a month didactic
sessions were developed that included both clinical and organiza-
tional topics (Figure 2).
The key to the success of the TTP program was weekly meetings
with the 4 leads for ongoing evaluation and to discuss opportunities
for change using the plan, do, study, act model. Challenges included a
lack of mentors at small primary care sites, pushback from managers
on a slower ramp-up of the clinic schedule, and concern over time
spent in the mentor role. Frequent communication with clinic
leadership was the key to successful implementation, but this was
challenging because the clinic sites were spread out over a rural, 3-
state service area. The program was presented to both the health
system and primary care leadership to gain support. Education was
shared with clinic leadership when a new NP or PA was recruited. As
preliminary data came back with our pilot group, these were shared
both virtually and in person at system leadership forums.
Results
Data were gathered in primary care for NPs and PAs during their
first year of practice for both the TTP pilot of 8 new hires in the fiscal
Figure 1. Mentor responsibilities.
year of 2017 and the 10 new hires to primary care the previous year.
Data included engagement survey scores, retention and turnover
data, and productivity data.
During the pilot project, the engagement of APRNs and PAs
increased from the 14th percentile to the 50th percentile na-
tionally through the use of an external consultant engagement
survey. These data, collected after the pilot ended, were limited
due to a shorter survey being sent the second year and data not
able to be extracted specifically to NPs and PAs within their first
2 years of practice. Despite challenges with data collection, the
results regarding improvement in NP and PA engagement were
impressive.
Retention improved as measured by turnover data decreasing
from 14.5% to 9%. This equated to a savings of 24 positions annually.
All 8 of the individuals in the primary care pilot were still with the
health system at the end of year 1. Internal estimates of $70,000 for
recruiting costs of an APRN or PA equals a savings of over $1.68
million for the health system annually. This does not take into ac-
count the additional costs related to the productivity ramp-up of a
new hire, which is estimated to be $84,000 to $200,000 (median ¼
$142,000) in lost revenue due to replacing and hiring a new NP or
PA (Figure 3).14
Productivity data showed a remarkable increase. With a
slower ramp-up of the clinic schedule and allowing new hires to
determine the speed of ramping up their own schedule with
support of their mentor, we were able to continue progression
of the new hires’ schedule, reflecting a 15% increase in pro-
ductivity at 6 months and a 11.5% increase at 12 months
compared with before the TTP program. This increase in new
hire productivity more than offset any decrease in mentor pro-
ductivity and was used to justify the mentors’ monthly stipend
(Figure 4).
The success of a TTP program is dependent on navigating
organizational barriers and gaining organizational support. The
requisite organizational support was gained for this project
through clear, frequent communication highlighting successful
business metrics. The results of the pilot program were commu-
nicated with leadership at multiple levels to foster continued
support. Decreased turnover and costs associated with turnover
were used to support the ongoing time for TTP leadership roles.
Increased productivity was used to support continuing the program
in primary care and expanding over the next 2 years to include
medical and surgical specialties.
 C.E. Erickson et al. / The Journal for Nurse Practitioners xxx (xxxx) xxx e3

Figure 2. Program model.

Discussion/Future Recommendations
The TTP program was initially approved as a pilot project for
ambulatory primary care settings. After the successful pilot year, the
program was expanded to include medical and surgical specialties in the
ambulatory and hospital settings. With this expansion, self-assessments
and onboarding schedule templates were developed for each area.
Upon expansion of the TTP program, several organizational
opportunities became apparent. Opportunities included devel-
oping NP/PA leadership roles, addressing scope of practice issues,
and the potential for a residency program. The health system lacked
designated NP/PA leadership roles, which hindered addressing the
identified issues. In 2019, director of NP/PA services positions were
developed in each of the 3 market areas.
With program expansion to acute care and specialty areas, it
became clear that there was a gap in local resources for mentoring
in these areas. Many of the NPs practicing in acute care areas are
certified as family NPs, creating potential discrepancies between
skill and role expectations. To address the scope of practice gap, the
health system partnered with a local educational facility to develop
a postgraduate adult-geriatric acute care certification program.
Limitations of this study include being done in primary care only.
More research is planned to determine if the program will have a
similar impact on engagement, retention, and productivity in other
ambulatory and acute care areas.
In July 2019, the health system was awarded a collaborative 4-
year Health Resources and Services Administration grant along
with a local university to develop an NP residency program to

Figure 3. TTP financial impact. TTP, transition to practice. Figure 4. TTP productivity impact. TTP, transition to practice.
e4 C.E. Erickson et al. / The Journal for Nurse Practitioners xxx (xxxx) xxx
interface with our existing TTP program. This grant benefits 4
newly graduated NPs each year. The long-term plan is to evaluate
the NP residency program and use the most valuable components
to modify and expand the programming of the TTP program.
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Christie Ehle Erickson, DNP, FNP, FAANP, is director of Transition to Practice Program,
Essentia Health in Duluth, MN, and can be contacted at Christiee.eickson@
essentiahealth.org. Debra Steen, MSN, FNP, is lead of Transition to Practice Program,
Essentia Health in Brainerd, MN. Karla French-Baker, MSN, AGACNP, is lead of Tran-
sition to Practice Program, Essentia Health in Fargo, ND. Laurel Ash, DNP, FNP, is chair
of the Graduate Nursing College of St. Scholastica in Duluth, MN.
In compliance with standard guidelines, the authors report no relationships with
business or industry that would pose a conflict of interest.