Abstract
Background and Objectives Integrating advanced practice providers (APPs) into neurologic practice can improve access, promote patient education, and reduce health care costs. APPs receive limited formal education in neurology, so on-the-job training is essential. We set out to identify common challenges and best practices for onboarding, training, and integrating APPs into neurologic practice.
Methods We conducted a survey and focus group with 8 APPs currently practicing within an academic neurology department as part of a clinical quality improvement initiative. We explored their roles in multidisciplinary teams, challenges faced during onboarding and training, and strategies for success. Qualitative thematic analysis was performed.
Results Neurology APPs serve diverse roles including caring for hospitalized and ambulatory patients, performing procedures, assisting trainees, and performing research. Participants reported limited formal neurologic education before their job and a need for educational sessions and resources tailored to APPs. Neuroanatomy, neuroimaging, and generating a neurologic differential diagnosis were key knowledge gaps identified. We identified 7 informal strategies for on-the-job training, 7 challenges to on-the-job training, and factors promoting or threatening job satisfaction. Graded responsibility and clinical mentorship were essential for successful onboarding. APPs desired peer-to-peer mentorship and structured educational opportunities.
Discussion Common challenges and success strategies identified can inform the design of a formal curriculum for onboarding neurology APPs. Our findings suggest that an optimal APP training process involves graded responsibility and support for self-directed learning, employs peer mentors, and targets education of the multidisciplinary team including physicians and patients. Our results may inform other institutions recruiting, hiring, and training APPs.
Advanced practice providers (APPs), including nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists, are increasingly being integrated into neurologic practice.1 APPs may improve patient access,2 increase quality of care, and help meet the shortfall of neurologists in the United States, which is expected to reach 19% by 2025.3,4 In 2015, the American Academy of Neurology (AAN) released a position paper recognizing that APPs “are an integral part of multidisciplinary neurology teams” and calling for research to clarify the educational gaps and professional needs of APPs entering practice.1
There are currently no evidence-based guidelines for optimizing the integration of APPs into neurologic practice. Degree programs for PAs and NPs include minimal requirements for classroom experiences in neurology, and neither require a neurology clinical rotation.5,6 In 2018, an AAN survey of practicing APPs found that 87% had some neurology lectures in school, yet only 30% had a course and 25% had a clinical rotation.7 Thus, APPs enter neurologic practice with limited formal exposure to neurology, which may limit their effective integration on clinical teams.1,5,7 Options for postgraduate training are limited.8 Although there are over 700 degree-granting APP programs, only 15 postgraduate programs exist, of which 3 focus on neurology.7,9 Most APPs do not complete postgraduate training before entering practice, so on-the-job learning is typical. Some institutions have developed structured onboarding and education programs for the inpatient setting10 and for neurocritical care.11,12 The average educational period requires 6 months.7 Such programs appear to be feasible and cost-effective,9 although longitudinal studies are lacking.
We sought to understand the needs and experiences of neurology APPs currently practicing in our department to develop a training approach specifically tailored to newly hired APPs in neurology inpatient and outpatient settings. By sharing common challenges and possible solutions, we hope that our findings can inform others seeking to recruit, train, and retain APPs.
Methods
We undertook a mixed quantitative-qualitative study using a brief demographic survey and a semistructured facilitated focus group as part of a clinical quality improvement initiative to improve onboarding and training of newly hired APPs. All APPs within the Department of Neurology at a large, academic medical center were invited to participate.
A brief web-based anonymous survey was sent by email using SurveyMonkey (San Mateo, CA). Subsequently, a 90-minute in-person focus group was held in October 2019. A semistructured focus group facilitator's guide was developed, and 2 facilitators (C.T.D. and G.G.) guided the discussion (full interview guide included in eAppendix 1, links.lww.com/CPJ/A275). The focus group was audio recorded. Observers were present during the session (A.V., J.P., D.P., and M.O.) to take back-up notes. Facilitators and observers were physicians in the department but were not the direct supervisors of the APPs. The audio recording of the session was digitally transcribed via Temi software (Temi.com, San Francisco, CA). One author (G.G.) reviewed the draft transcript and corrected any errors as well as deidentified the transcript to protect participants' confidentiality before analysis. The audio recording was destroyed after the session.
We conducted qualitative thematic analysis,13 using the framework approach using a mixed inductive and deductive approach.14 Two authors (G.G. and C.T.D.) first reviewed the transcript and developed a codebook through iterative review and discussion.15 A third author (A.V.) read the transcript and reviewed the codes, and a final framework was reached by consensus. Codes included those deductively derived from the focus group interview guide as well as those which arose inductively in the data. Two authors (G.G. and C.T.D.) then double coded the transcript by applying the coding framework, and discrepancies were resolved by consensus. No new codes emerged, and thematic saturation was reached.16 Analysis was completed using Dedoose software (SocioCultural Research Consultants, Los Angeles, CA). Illustrative quotes and themes were reviewed and agreed upon by the entire research team.
Standard Protocol Approvals, Registrations, and Patient Consents
The survey and focus group were undertaken as a department level clinical quality improvement initiative at Brigham & Women's Hospital that aimed to improve the onboarding of new APPs based on the experiences of current APPs. As such, this project was not formally supervised by the Institutional Review Board in compliance with our institution's quality improvement initiative policy. Participation was voluntary; participants provided written informed consent to participate and to be audio recorded.
Data Availability
The data generated and analyzed during this study are not publicly available to protect the confidentiality of our focus group participants. The data are primarily qualitative in nature and given the small number of participants have been kept protected. Deidentified and summarized aggregate data may be available from the corresponding author on reasonable request.
Results
Participant Demographics
Eight of 9 APPs completed the survey, and 8 participated in the focus group (1 APP was unable to make the focus group time). Half of participants had been working less than 2 years and the rest between 2 to 10 years. Most participants worked in outpatient settings (Table 1).
Participant Characteristics, From a Study of Perspectives and Experiences of Current Advanced Practice Providers (APPs) Integrating Into a Neurologic Clinical Practice, 2019 (n = 8)
Qualitative Analysis of APP Onboarding, Education, and Integration
We identified 3 phases of APP integration and describe our results accordingly: (1) before the job (prior education in APP degree programs); (2) on the job (onboarding and training); and (3) staying in the job (promotors and threats to job satisfaction).
Before the Job
Limited Experience in Clinical Neurology
Few participants had prior experience in clinical neurology. Only 25% had required neurology rotations in their degree programs. When starting their jobs, APPs were most challenged by neuroanatomy, advanced neurologic physical examination maneuvers, neuroimaging interpretation, and creating a neurologic differential diagnosis. Although APP degree programs taught the basics of a neurologic examination, participants reported challenges translating examination findings to neurologic localization. Participant 1 reported:
I felt great about [the physical exam] coming in. But applying it to the actual disease processes and what it means when you have a certain combination of findings that are abnormal. That is still a work-in-progress. (P1)
Personal Interest in Neurology
Many APPs were drawn to neurology due to long-standing interests in neurosciences or personal connections to the field.
My uncle is a neurologist, so I grew up around him. I liked to go to his clinic and I just loved it. Then I was a neuroscience major in college. (P4)
On the Job
Role of APPs in Practice
APPs held clinical roles in inpatient and outpatient settings and participated in administration, education, and research. APPs identified their role as primarily one of continuity:
I'm kind of the continuity [at hospital]. There's a different person on call every day … my role is to do all the follow-ups and make sure there's continuity of care and that everything that needs to be ordered gets ordered and the plan is followed. … I'll see someone on my own and talk to the consulting physicians, help them initially, and make sure everything's copacetic there. (P1)
Need for Formal Training and APP-Specific Resources
All participants relied on informal training during onboarding. Some were the first APP on their service or in their division. Starting without formal training led them to feel they “just got thrown in” (P8) and had to “fly by the seat of [their] pants” (P6). Knowledge areas and skills that participants identified as necessary for integration included learning the neurologic examination (and recognizing abnormal signs), using the electronic medical record (EMR) efficiently, gaining procedural skills, and recognizing challenging diagnoses (e.g., functional neurologic disorder, FND). Given the lack of formal curricula, participants acquired knowledge and skills through primarily self-directed learning:
I spent a lot of time learning on my own and would ask questions. I'd review charts and look stuff up on my own. I just wish that there was a little bit more teaching. (P8)
Participants used specific resources to facilitate self-directed learning. Online resources included UpToDate and Micromedex. APPs also used institutional handbooks and/or popular textbooks, as well readings recommended by faculty preceptors. However, APPs noted a lack of resources specifically targeted to their level of knowledge and understanding. Resources were directed at medical students, residents, or a general audience and were not specific to APPs.
Strategies for On-the-Job Training
APPs described using informal, self-initiated strategies for training. We describe 7 strategies and provide supportive quotations in Table 2. The most common strategies included shadowing (other physicians and/or APPs), immersion (learning by doing), self-directed learning, and joining other trainees (e.g., residents) for educational sessions. Participants felt that all new hires should shadow on inpatient services to improve examination skills and become familiar with diverse neurologic conditions. Only a few APPs shadowed with other APPs rather than physicians during onboarding, but those who did found this particularly helpful.
Seven Strategies for Informal On-the-Job Learning, From a Study of Perspectives and Experiences of Current APPs Integrating Into a Neurologic Clinical Practice, 2019 (n = 8)
Another strategy was self-directed case-based learning:
Something I have done and I still do is keep a list on my phone or notes for the day and then go home and read about all the things that I didn't know. Then I felt I was able to be more part of the team because I could speak up and know more what they know. (P4)
Many APPs learned on the job through a preceptorship model (being supervised by and learning from physicians). Overall, participants described a pattern of graded responsibility whereby they spent the first several months of their job shadowing, observing, and test driving their role under close supervision. Participants steadily took on more responsibility over 3–4 months, on average.
By probably 3 or 4 months, I was off on my own most of the time. Unless there was an issue and I had a question, then I would just pause the visit, go to whoever I was working with—whoever's patient I was seeing—[and] bring up the case and then work through it with the faculty member. (P3)
Clinical Mentorship
In an academic setting, it is not uncommon for APPs to work with multiple attending physicians and physicians-in-training. Participants noted the importance of becoming familiar with multiple preceptor styles early. Effective teaching methods included preceptor-initiated feedback, real-time case-based teaching, availability for questions, and support with difficult or unfamiliar cases.
I would spend most of the day with one of the attendings or varying between different attendings. … We have I think eleven different physicians? Spending time with each one, seeing how they do things, seeing their preferences, what medications they prefer to prescribe in a certain order, how they vary in terms of their procedural technique. (P3)
Participants noted several advantages to being at a teaching hospital, including access to resources and expertise, and a culture of teaching and learning. Clinical mentors were approachable and willing to answer questions. Participants noted that the physicians with prior experience teaching residents and fellows appeared most comfortable with APP onboarding.
We have a fellowship program in our clinic. I think that the physicians, especially [those] I worked with, are very used to bringing on trainees. It was very smooth. …
I think that kind of familiarity with bringing on someone new, I could tell that it was easy for them to bring me on board as well. (P3)
Challenges to On-the-Job Training
Participants noted several barriers to on-the-job training. Seven challenges were identified and are described with supportive quotations in Table 3. Important challenges included being a trailblazer (being the first APP pioneering a new role), assumptions among faculty about APPs' prior education, and logistical challenges.
Seven Challenges to On-the-Job Learning Faced by APPs, From a Study of Perspectives and Experiences of Current APPs Integrating Into a Neurologic Clinical Practice, 2019 (n = 8)
Participants reported that many physicians were unfamiliar with APPs' level of prior clinical education, leading to high expectations for specialty-specific knowledge and clinical experience upon hiring:
We only go to [APP school] for 2 or 3 years and there's no residency and yes, you get a year of a clinical rotation, [but it is] not neurology specific. I only worked one previous job prior to [entering neurology], but it was pediatrics, so it's very different coming here into adult neurology. When I came [attendings] assumed “Oh, she has previous experience, she's got this.” But I had no neurology knowledge. I think they do think that we're at the same level and that we can function in the same capacity. (P8)
Logistical challenges including credentialing delays and a lack of logistic knowledge by supervisors (e.g., how to bill visits) were identified as barriers to efficiency and efficacy.
Staying in the Job
In the third and final phase, “Staying in the job,” we identified factors that determine APP retention and integration.
Promotors of Job Satisfaction
Factors promoting job satisfaction included opportunities for autonomy, recognition for teaching support, and a supportive and collegial environment:
I think that being the inpatient [APP] and caring for the patients, I feel like I have just as much autonomy as one of the residents. And I feel like what I have to say is actually valued, which is very appreciated. (P4)
Threats to Job Satisfaction
Factors threating job satisfaction included poor communication between other services and providers and negative patient attitudes regarding APPs. Some APPs experienced stigma from providers outside of neurology who questioned their competence. APPs also described how patients might initially mistrust them:
When I first started [patients] were like, “Who are you? What do you do? I don't understand. PA-what?” It took a while for them to trust me, trust the care that I was providing. … I think I experienced a lot more issues with patients than providers. (P8)
Some APPs saw patients who had traveled to the institution for a second opinion or were hoping to see a specific specialist and were disappointed when they met with the APP. One of our participants described how this second-opinion dilemma was addressed in 1 clinic. Patients were introduced explicitly to a shared-visit model to build their trust in working with the APP:
We kind of fixed it. If [patients] come in for a second or third opinion, they typically will select somebody specific that they want to see … and those clinics are usually shared-visits. … I typically start off as, “I'm going to get the visit started … and then [the doctor] will come in. It's never an independent visit where they're referred for a second opinion to a provider and then they are scheduled to meet with me.” (P8)
APP-Specific Networking and Continuing Education
APPs desired a stronger peer network. Participants believed that a peer network could provide peer-to-peer mentoring, promote collegiality, and foster mutual support. All participants were willing to serve as peer mentors for newly hired APPs in the future. Participants also desired access to APP-specific continuing education (CE) opportunities. A minority had attended APP-specific conferences; few knew this opportunity existed. A lack of APP-specific resources and CE was noted by participants as a significant gap.
Discussion
In this study, we drew upon the perspectives and experiences of current APPs in our academic Department of Neurology to understand common challenges, best practices, and remaining gaps for onboarding, training, and long-term integration. Our participants represented both PAs and NPs, been on the job <2–10 years, practiced in both inpatient and outpatient settings, and also held nonclinical roles in administration, education, and research. Despite this diversity of practice, participants identified common challenges, best practices, and remaining gaps. Before the job, few APPs received formal training in clinical neurology, which created specific knowledge gaps. On the job, APPs sought graded responsibility while employing informal training strategies and self-directed learning. Finally, we identified promotors of job satisfaction (e.g., autonomy) and threats to job satisfaction (e.g., need for peer network and CE opportunities), which may affect the long-term sustainability of APP integration after onboarding and training.
We found that few of our participants had formal training in clinical neurology during their degree programs. This is consistent with prior literature, which identified many APPs enter their first job with a limited foundation in neurology.1,5,7 Our participants identified neuroanatomy, neuroimaging interpretation, and creating a neurologic differential diagnosis as challenging topics. Participants identified developing the following skills as necessary for successful integration: learning the advanced neurologic examination (and recognizing abnormal signs), using the EMR, gaining procedural skills, and recognizing challenging diagnoses (e.g., FND). In terms of roles and responsibilities, our participants were similar to APPs providing neurologic services reported in the literature, in that they worked both inpatient and outpatient, performed procedures including lumbar puncture, and also served in research and administrative roles.17
Before this study, there was no formal APP curriculum at our institution. Therefore, participants relied on informal training strategies (e.g., self-directed learning, peer shadowing, and joining teaching for other trainees) and clinical mentorship from preceptors. Participants noted a lack of APP-specific resources and didactics, instead relying on resources and conferences designed for residents. APP-oriented educational materials may be more effective. In the field of neurocritical care for example, programs have developed APP-specific training. One institution implemented an orientation and competency model for advanced registered nurse practitioners (ARNPs).11 The training included baseline testing to evaluate knowledge deficits, targeted classes and clinical rotations designed to teach necessary knowledge and skills, and periodic evaluations to ensure that competency was obtained and maintained.11 Most ARNP trainees were practicing with independence after approximately 3 months. This aligns with the informal model of graded responsibility described by our participants and further formalizes it.
Peer-to-peer mentoring may be another key success factor of onboarding and integration, and participants called for greater peer-to-peer networking. In our study, only a minority of APPs shadowed other APPs at onboarding, yet those who did noted this to be particularly helpful. In 1 previously reported comprehensive educational program for APPs in neurocritical care, a key feature was peer shadowing, with peer mentors guiding newly hired APPs through 3 stages of learning goals.12 The program initially used physician mentors, but transitioned to peer mentorship as the department grew and APP staff gained experience.
Our participants identified that incorrect assumptions about APP knowledge among faculty may lead to inappropriate expectations and ineffectual teaching. Faculty understanding of APP's roles and knowledge are best addressed through faculty development. In the neurocritical care onboarding program previously described for example, the curriculum was developed by a specific group of physicians who were educational champions for ARNPs and familiar with their needs.11 According to our participants, faculty at academic teaching hospitals with other trainees may be well suited to accommodate APPs, given their experience onboarding and training new residents. However, faculty should recognize and support APP-specific needs distinct from those of physician trainees. This was highlighted in the report of a 12-week training program for new inpatient APPs that included rotations through subspecialties and a curriculum of fundamental topics.10 The curriculum was a series of internally cultivated lectures designed with input from APPs. APPs were also encouraged to attend residency lectures, but the authors noted that these were not a replacement for targeted lectures specifically developed for APPs.10
To help address some gaps identified in an informal training process, postgraduate APP residency programs for subspecialty training have been developed. In a survey of 149 graduates of postgraduate PA programs, 97% felt that their training made them more competitive in the job market and 74% believed that their time from orientation to full productivity was reduced.18 Currently, 3 postgraduate training programs exist in neurology.7 The program at Duke University9 employs APPs through a 1-year curriculum. APP residents are paid at the level of first-year medical residents and are supervised and taught by faculty in a clinical preceptor model. Although such programs are effective in an academic medical center and for APP subspecialty training in particular, the upfront investment may not be feasible for all institutions or for private practices. The program is time, resource, and faculty intensive.19 Furthermore, although an APP residency addresses knowledge gaps, it may not address additional challenges we identified. On completion of the program, EMR training, time and patient volume management, and faculty development locally will still need to be addressed by the hiring institution.
Given these challenges, there is a need to develop teaching programs and resources that could reach a wider number of APPs. Specialty-specific organizations like the AAN may be uniquely poised to address the gap of APP-specific neurology content. The AAN has endorsed the integration of APPs into multidisciplinary neurology teams and called for studies to clarify the educational gaps and professional needs of APPs entering practice.1 The AAN is becoming a hub for peer networking and education among neurology APPs.5,20 In October 2019, the academy hosted its first APP conference (with 175 APPs in attendance),4 and an online 10-week virtual education series was hosted in 2020.21 Two additional opportunities for the AAN to address remaining gaps include sponsoring faculty development and offering APP-specific CE opportunities to ensure ongoing competence.
Drawing on the experiences of APPs at our institution, we offer a summary of recommendations to facilitate a formal onboarding and training process (Table 4). In identifying what worked well for current APPs as well as areas in need of improvement, we hope to further inform efforts to formalize the onboarding and training of APPs. Existing APP training programs described in the literature set a precedent for designing orientation and onboarding curricula for APPs that are feasible, effective, and sustainable. Further research is necessary to evaluate best practices and understand the long-term impact of training interventions. APP satisfaction and retention, cost-effectiveness of training strategies, and patient safety and quality outcomes should be examined to develop a stronger evidence base for APP educational interventions. With the right training and support, neurology can be a satisfying career selection for APPs: the ability to train in multiple different subspecialties, perform procedures, and participate in nonclinical academic activities may promote higher job satisfaction and retention.17,22 Practices hiring APPs would do well to investigate local needs of their APPs and adjust strategies as necessary.
Suggestions for Streamlining Onboarding and Training, From a Study of Perspectives and Experiences of Current APPs Integrating Into a Neurologic Clinical Practice, 2019 (n = 8)
This study was conducted at a single academic institution; our findings may not generalize to the community setting and to the experiences of APPs in other departments. Most participants were PAs not NPs; however, the roles held by both provider types are similar in our institution. We only sought the perspectives of APPs and not of the patients and clinicians working with them.
Clinical neurology practices are integrating APPs to promote access and meet the increasing demand for neurologic services. Despite the rise in hiring, few guidelines exist for optimizing onboarding, on-the-job training, and sustainable integration of APPs. We performed a needs assessment of current APPs in an academic medical center, learning from their perspectives and experiences. Our findings suggest that an optimal APP training process involves graded responsibility, enables self-directed learning, employs peer mentors, and targets the multidisciplinary team including physicians and patients. Future research is needed to evaluate the efficacy of these suggested strategies. We hope that our work can inform academic centers and private practices integrating APPs to improve access and optimize patient outcomes.
TAKE-HOME POINTS
→ Integrating advanced practice providers (APPs) into neurologic practice can improve access, promote patient education, and reduce health care costs; however, APPs receive limited formal education in neurology, so on-the-job training and education is essential.
→ APPs report common knowledge gaps and challenges when integrating into clinical neurology practices. Specific knowledge gaps identified include neuroanatomy, neuroimaging, and generating a neurologic differential diagnosis.
→ APPs use informal training strategies and self-directed learning to integrate into clinical practice. Graded clinical responsibility and clinical mentorship are essential for successful APP onboarding; this may require dedicated compensation of physicians' time in the academic setting.
→ APPs desire opportunities for peer-to-peer mentorship and structured educational opportunities specifically geared to APP trainees. These threats to job satisfaction as well as promotors of job satisfaction (e.g., autonomy) may affect the long-term sustainability of APP integration after onboarding and training.
→ Our findings suggest that an optimal APP training process involves graded clinical responsibility and support for self-directed learning, employs peer and physician mentors, and targets education of the multidisciplinary team including physicians and patients.
Acknowledgment
The authors thank their focus group participants for sharing their perspectives and experiences. They also thank the Department of Neurology for funding the focus group dinner.
Study Funding
No targeted funding reported.
Disclosure
G. Gheihman and A. Vgontzas report no financial or other disclosures relevant to the manuscript. J. Paulson discloses serving on an advisory board for Amneal Therapeutics. D. Pilgrim reports no financial or other disclosures relevant to the manuscript. T. Batchelor discloses receiving royalties from UpToDate, Inc., serving on the Scientific Advisory Board for GenomiCare. M.A. O'Neal discloses receiving publishing royalties from Springer and Oxford Press, consulting for Best Doctors, and serving as an expert consultant for CRICO. C.T. Doughty discloses serving on an advisory board for Argenx and serving on an advisory board for the Dysimmune Diseases Foundation. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.
Appendix Authors
Footnotes
Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.
Previous Presentations: Galina Gheihman, Angeliki Vgontzas, Jordan Paulson, David Pilgrim, Tracy Batchelor, Mary A. O'Neal, Christopher T. Doughty. Integrating Advanced Practice Providers (APPs) in an academic Department of Neurology: perspectives and experiences of current APPs (Abstract 4443). American Association of Neurology Annual Meeting 2020. Neurology Apr 2020, 94 (15 Supplement). Galina Gheihman, Angeliki Vgontzas, Jordan Paulson, David Pilgrim, Tracy Batchelor, Mary A. O'Neal, Christopher T. Doughty. Integrating Advanced Practice Providers (APPs) in an academic Department of Neurology: perspectives and experiences of current APPs. Abstract at the Women in Medicine and Science Symposium, Brigham & Women's Hospital, Sept 2020.
- Received November 23, 2020.
- Accepted March 5, 2021.
- © 2021 American Academy of Neurology
References
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