Good morning. My name is Sarah Wall. I am the Director of Advanced Practice for UT Health Houston Neurosciences. We are fortunate to have our esteemed AANS President as our department chair. Dr. Morkos is very supportive of advanced practice and has been a huge advocate for strengthening our program. One area that we have been particularly interested in is transition to practice. We are often hiring new graduate APPs into our positions and we find that NP and PA school does not fully prepare them for that new graduate experience. If you consider the physician model of residency and fellowship, it makes sense that it wouldn't. There are also certain nuances to transitioning from being a bedside nurse to a nurse practitioner that just can't be taught until you're licensed and at the bedside. We often catch ourselves saying to our new grads, it's time to get out of nurse mode. I have no disclosures. Before we get started, let me lay some groundwork here. This year at our program, with the full support of Dr. Morkos, we implemented a standardized 24-week APP onboarding program. This was a huge step forward for us. Previously, a two-month onboarding process with no real structure was the best we had. I've been in APP for more than a decade, and my very first day also happened to be July 1st. I got to the unit and was introduced to a resident who was tasked with orienting me. After our boss walked away, he informed me that he was the intern, and it was also his first day. Day 1 of year 1 of 7. He wasn't even able to tell me where the bathroom was. Needless to say, I read a lot that year. I always vowed that someday I would make sure that this was not how we did things. It took me some time, but finally we made the change. Our current transition to practice program pairs didactic learning through an online self-paced program with clinical training. We also incorporated certifications such as ENLS and FCCS into this program. We paired it with monthly meetings and check-ins with mentors and preceptors. As my team and I researched and developed this program, I became more and more confident that this was the way our profession needed to go to keep our quality and good name in this rapidly growing environment. Now that we've gotten that out of the way, let's get down to the nuts and bolts. Let's talk about the objectives. First, we'll start by identifying the core problem which centers around APP retention and productivity. Many healthcare organizations are struggling with high turnover rates and low productivity levels among new APPs, especially within the first few years of practice. These issues are often linked to insufficient support during the transition from training to independent practice. Next, we'll describe how transition to practice can impact these problems. A well-structured transition to practice program directly impacts both retention and productivity. By providing APPs with the necessary tools, mentorship, and hands-on experience, these programs help bridge the gap between education and real-world practice. This results in APPs feeling more prepared, confident, and capable, which in turn improves both job satisfaction and performance. We'll discuss what is needed for a successful transition to practice. For a successful transition to practice, several elements are essential. Structured onboarding processes that provide clarity and direction. Ongoing mentorship to guide APPs through complex cases and situations. Continuing education that focuses on the specific clinical skills required for their roles. Feedback and evaluation mechanisms to help APPs grow and improve. We'll discuss how rapid demand and growth have heightened the need for transition to practice programs. The rapid growth in demand for APPs has made these transition programs even more critical. As the number of APPs increases to meet the demand of healthcare systems, many new graduates are entering the workforce at a faster pace. Without a proper transition structure in place, these new APPs may struggle with the expectations placed on them. Potentially leading to burnout, high turnover, and reduced productivity. As we see more healthcare institutions relying on APPs to fill gaps in care, comprehensive transition programs become a crucial factor in ensuring that this growing workforce can effectively handle their responsibilities. Finally, we'll discuss the barriers to transition to practice programs. We'll explore some of these barriers that make it difficult to implement these programs effectively. These barriers include limited resources, such as funding or personnel, which can prevent institutions from developing robust programs. Time constraints on both new APPs and their preceptors, which limit the opportunity for dedicated training. Institutional resistance, where leadership may be hesitant to invest in programs without an immediate return on investment. Lack of standardization across institutions, leading to variability in the quality of transition programs. Overcoming these barriers requires an institutional commitment and long-term view of the benefits of these programs. Why spend time transitioning to practice? One of the primary reasons for investing time in transition to practice is that it significantly mitigates the transition stress. New graduates often experience overwhelming feelings when entering their first professional role. The shift from educational environment to real-world clinical setting can be daunting, leading to anxiety about their abilities to provide patient care effectively. By implementing structured transition programs, organizations can help alleviate these feelings of uncertainty and stress. A supportive environment fosters a smoother transition, allowing new APPs to acclimate more quickly and comfortably. Another critical benefit of structured onboarding is that it improves confidence in new APPs. Transition programs often include mentorship, hands-on training, and continued education tailored to their specific roles. As APPs gain more experience and knowledge through these structured programs, their clinical competence and decision-making abilities increase exponentially. A confident APP is more likely to engage with patients, make sound clinical decisions, and contribute positively to the health care team, which ultimately enhances patient care quality. Research has consistently shown that formalized transition programs lead to reduced turnover rates among APPs. When new hires feel supported and well-prepared, they are more likely to remain in their positions long-term. Studies indicate that organizations with strong transition programs can see turnover reductions of 20-30% in just the first couple of years of practice. This is not only beneficial for the APPs, but also for the organization, as it reduces the cost associated with recruiting and training new staff. Lastly, investing time in a structured transition to practice can increase productivity. Well-prepared APPs are able to reach productivity targets faster, which can significantly improve RVU generation, a key metric in assessing the productivity and effectiveness of health care providers. When APPs transition smoothly into their roles, they can begin contributing to the organization's goals and objectives much sooner, enhancing overall operational efficiency and patient care delivery. In summary, dedicating time and resources to a comprehensive transition to practice program is a wise investment. It not only supports new APPs in navigating their early careers, but also strengthens the health care workforce, enhances patient care, and ultimately contributes to organizational success. The problem that transition to practice attempts to solve is APP retention and productivity. One of the key issues affecting APP retention is high turnover, particularly within the first one to two years of practice. Studies show that APPs experience some of the highest turnover rates in the earliest years of their careers. This can be attributed to a number of factors, such as inadequate support during the transition from training to practice, overwhelming workloads, and lack of mentorship or structured onboarding. For many organizations, replacing an APP can be costly, not only financially, but also in terms of continuity of care and loss of productivity. In some cases, turnover can exceed 10 to 20%, creating a significant challenge for health care systems that are already strained by workforce shortage. Burnout is another major contributor to turnover. APPs often face high levels of job related stress due to increased patient loads, administrative tasks, and pressure to meet productivity benchmarks. In 2022, a survey showed that approximately 40% of APPs reported symptoms of burnout, emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment being the most common. Job dissatisfaction often arises when APPs feel unsupported in their roles or lack opportunities for professional growth and development. Many APPs report that insufficient autonomy or a mismatch between expectations and reality contributes to their frustration, pushing them to leave their positions early on. This is why effective retention strategies, including better transition programs, mentorship, and ongoing support are essential to help mitigate burnout and improve job satisfaction. By addressing the factors that contribute to early career exits and dissatisfaction, organizations can improve retention rates, increase job satisfaction, and ensure long- term success for APPs within the workforce. Then there's the productivity challenges. One of the most significant challenges for APPs is meeting the productivity expectations early in their careers. Many new APPs come into their role with a strong foundational knowledge, but lack the clinical experience needed to immediately handle the complex and fast-paced environments in which they practice. This can be particularly evident in specialties like critical care or surgery, or say, neurosurgery or neurocritical care, where APPs are expected to make quick decisions and manage a high volume of patients. Without proper support and sufficient hands-on training during the transition period, new APPs may find it difficult to meet patient volume expectations or productivity targets set by their institutions. As a result, this can lead to frustration for both the APP and the healthcare organization, impacting overall performance in patient care. Another key productivity challenge is lack of decision-making confidence, especially for new grad APPs. Despite their extensive training, many APPs struggle with feeling fully confident when they make clinical decisions independently. This hesitation often stems from the transition between the structured environment of education and the more autonomous role they must play in practice, where the responsibility for a patient is much greater. When APPs are uncertain about their decisions, they take longer to complete patient assessments or consult with supervising physicians more frequently than expected. This slows down workflow and reduces overall efficiency in patient care. Additionally, without a strong mentor or support system in place, APPs may continue to lack the confidence needed to take on more challenging cases, ultimately impacting their ability to meet clinical and productivity benchmarks. The combination of insufficient clinical experience and lack of decision-making confidence are significant barriers to productivity for APPs. To address these issues, healthcare organizations must provide structured training programs, mentorship, and ongoing education to help APPs build their skills and confidence. This support is essential for ensuring that APPs can meet productivity expectations and thrive in their roles. Based on Sullivan Cotter's survey, Research and Industry Insights, the total direct turnover cost for a single APP ranges somewhere between $85,000 and $115,000. This estimate is consistent with the data from both physician and nursing turnover research. Like research on physician and nursing turnover costs, the indirect costs associated with APP turnover are likely significantly higher than the direct costs. These indirect costs are often difficult to calculate given the different variables within each calculation. Indirect costs such as provider dissatisfaction, burnout, and lost patient revenue can vary widely by organization and are difficult to capture and calculate. But let's just put this slide into perspective. If you have an APP staff of 50 and you have a 10% turnover rate, that's 5 APPs per year. That would cost you between $429,000 and $575,000 a year. But let's think about it on a bigger scale. Let's talk about an institution that employs 400 APPs. If they had a 10% turnover rate, which by the way, the average turnover rate for an APP program nationwide is somewhere between 10% and 20%, so I'm being conservative, that would be 40 APPs per year. Now we're talking about somewhere around $3.5 million a year, and that is certainly not something to be ignored. Now that we've established that APP retention and productivity are a huge problem for all of our organizations, let's discuss how transition to practice can help impact them. One of the key ways to improve retention is through structured support during the transition period. When APPs are given clear guidance, mentorship, and resources from day one, it significantly enhances their job satisfaction. Feeling supported is critical. APPs who feel well-prepared and confident in their roles are more likely to stay long-term. This helps to create a stable workforce, reducing the need for continuous recruitment and ongoing onboarding efforts. Studies show that when APPs have structured support, they feel more engaged and satisfied with their jobs, making them more likely to stay in the workforce. A smooth transition into practice allows APPs to reach productivity benchmarks faster. When onboarding is consistent and thorough, APPs can focus more on patient care and efficiency rather than trying to figure out their roles or navigate unclear processes. Programs that include standardized procedures to help reduce the risk of COVID-19 and increase efficiency enable APPs to provide higher-quality care. This not only boosts individual productivity, but also contributes to the overall success of the health care team and organization. Effective onboarding that provides clear support during the transition is a win-win. It keeps APPs engaged in the workforce and allows them to focus more on patient care and efficiency. Effective onboarding that provides clear support during the transition is a win-win. It keeps APPs engaged and loyal to the organization while ensuring they can quickly become productive contributors, enhancing overall health care delivery. There are four key components to any successful transition to practice program. The first is mentorship. Pairing a novice APP with an experienced mentor is a critical element for professional growth and retention. Mentors provide guidance, share their expertise, and offer support as new APPs navigate the complexities of their roles. This relationship fosters confidence in novice APPs and helps build a strong foundation for clinical decision-making and practice management. Mentorship also enhances job satisfaction and promotes long-term career success, benefiting both the individual and the organization. The next pillar is ongoing education. Continued education tailored to the specific clinical role is essential to keep APPs up-to-date with the latest advancements and best practices in their field. It ensures that their knowledge evolves with the demands of their specialty, helping them stay proficient in delivering high-quality care. This commitment to lifelong learning allows APPs to expand their expertise and grow within their roles, which ultimately improves patient outcomes and keeps APPs engaged in their work. The third pillar is skill development. Simulation and hands-on training are excellent methods to reinforce both clinical and decision-making skills. These opportunities provide APPs with a safe environment to practice complex procedures, refine their techniques, and improve their confidence without compromising patient safety. Skill development sessions ensure APPs are prepared for real-world scenarios, enhancing their ability to handle critical situations effectively. The final pillar is feedback and evaluation. Regular performance assessments and feedback sessions are crucial for guiding APPs' growth. Constructive feedback helps them understand their strengths and identify areas for improvement, while also aligning their performance with organizational expectations. These sessions provide APPs with clear goals, actionable insight, and the opportunity to continue to refine their skills. They also reinforce a culture of ongoing development and professional accountability. Combining mentorship, ongoing education, skill development, and regular feedback creates a comprehensive support system for APPs. This holistic approach not only accelerates professional growth, but also improves retention by fostering a positive and supportive learning environment. If you have been practicing for a long time, you may find yourself wondering, why do we need this? I have never had anything like this, and I turned out okay. And I agree. Some of my best and brightest APPs started 20 years ago, were assigned patients on day one, followed a resident model through their training, and did just fine. But times have changed, and we must change too. Two of the biggest factors in this decision are demand and growth. Over the last decade, the number of advanced practice providers, particularly nurse practitioners and physician assistants, has grown dramatically in response to increasing health care demands. To put this into perspective, the Bureau of Labor Statistics projects that employment of NPs will grow by 46% from 2021 to 2031. 46%, far outpacing the average growth rate for all occupations, which is 5%. This represents an estimated 112,700 new NP jobs over that 10-year period. Similarly, for physician assistants, the projected growth rate is 28%, which translates to around 38,400 new PA jobs. Why this growth? Hospitals and clinics are increasingly relying on APPs to fill gaps in care, especially as physician shortages persist and the demand for health care services rises, particularly in underserved and rural areas. APPs are being called upon to provide more primary and specialized care, leading to a significant expansion of their roles. With this rapid influx of APPs into the health care system, it is essential to recognize the impact of the need for structured transition programs. As more APPs enter the workforce, there is a growing need for programs that prepare new providers for independent practice, ensure they are confident, competent, and ready to handle the challenges of modern health care settings. Without proper onboarding and transition support, APPs may struggle to adjust to their roles, leading to potential burnout, turnover, and decreased productivity. Structured programs help mitigate these risks by offering mentorship, hands-on training, and ongoing education. As the APP workforce continues to expand, health care organizations must invest in these transition programs to ensure APPs can meet patient care needs effectively and continue to thrive in their careers. The rapid growth of the APP workforce presents both an opportunity and a challenge. By implementing structured transition programs, health care systems can ensure that new APPs are fully equipped to meet the increasing demands of patient care, enhancing both retention and productivity. To recap, APP retention and productivity remain significant challenges for healthcare organizations. As we've discussed, the demands on the healthcare system are rising, and APPs play an increasingly crucial role in meeting patient care needs. Without proper support, both retention and productivity will suffer, impacting the quality of care and increasing turnover. Effective transition-to-practice programs are one of the best ways to address these challenges. By providing structured onboarding, mentorship, and continued education, these programs can ensure that new APPs feel confident and supported as they enter practice. In turn, this leads to improved retention, higher job satisfaction, and faster productivity gains. As the demand for APPs continues to grow, driven by physician shortages and expanding healthcare needs, the necessity for comprehensive transition programs becomes even more critical. The more APPs we bring into the workforce, the more important it is to have a robust system in place so we can help them succeed from day one. We've identified the barriers. Limited resources, We've identified the barriers. Limited resources, time constraints, institutional resistance, and lack of standardization. But overcoming these obstacles requires institutional commitment and investment. This means prioritizing long-term gains over short-term financial concerns, and ensuring that APPs have the resources and support they need to thrive in their roles. In conclusion, making the investment in a well-structured transition program not only benefits APPs, but also enhances the overall efficiency and effectiveness of the healthcare system. I'll leave you with this final thought. Moving forward, healthcare institutions need to recognize the value of these programs and take concrete steps to develop, standardize, and sustain them for the future success of their APP workforce. That concludes my presentation. Thank you very much for spending a part of your day with me.

Advanced Practice Providers

transition-to-practice programs

UT Health Houston

onboarding program

healthcare workforce

physician shortages