Running head: APP TRANSITION TO PRACTICE

Supporting Advanced Practice Provider Transition to Practice: A Theoretical and Evidence-Based
Intervention
Amanda G. Dean
Arizona State University

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Abstract

New graduate nurse practitioners and physician assistants, also known as advanced practice
providers (APPs), face a significant number of challenges when entering professional practice. If the new
graduate does not receive sufficient guidance and support during this transition to practice (TTP), they
will likely experience significant psychological stress and anxiety. If an organization does not implement
measures to address TTP, the new graduate is much more likely to leave the current position within the
first two years of practice. An extensive literature review was conducted investigating the effects, and
necessary components of an orientation program which supports the new graduate through TTP. Using
Van Maanen & Schein’s (1979) Theory of Organizational Socialization, a comprehensive new graduate
orientation program was designed and implemented in large multi-specialty practice. Initial results
suggest that this program improves both the perceived organizational support felt by the new graduate, as
well as the new graduates’ affective commitment to the organization. Improvements in both these
dimensions have been shown to decrease turnover intention and increase retention of the employee.

Keywords: Nurse Practitioner, Physician Assistant, Advanced Practice Provider, Transition to
Practice, Orientation, New Graduate

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Supporting Advanced Practice Provider Transition to Practice: A Theoretical and Evidence-Based
Intervention
The transition from formal education to early career is a tumultuous time for any new graduate.
The transition for healthcare providers means now caring for patients independently and is an anxiety
inducing time for both the provider and their employer. Physicians have largely overcome this problem
with complex and lengthy residency programs. New graduate registered nurses often enter practice with
comprehensive orientation programs in addition to their formal education. In contrast, Physician
Assistants and Nurse Practitioners, collectively known as advanced practice providers (APPs), often enter
practice with no orientation, socialization or other methods to promote successful transition to practice.
Background
The preparedness of new college graduates entering the professional world has long been
questioned across many fields (Nicholson & Arnold, 1991; Holton, 2001). New graduate APPs are not
immune from this challenge. The APP enters their new practice having gone from expert student to
novice, inexperienced professional. Without guidance to navigate this time of transition, the APP can
experience alterations in professional identity, loss of confidence, and impaired role development
(Barnes, 2015). New graduate nurse practitioners commonly express themes of loss of control, anxiety,
feelings of isolation, disconnectedness, role ambiguity and a sense of disequilibrium during the first year
of practice (Kelly & Matthews, 2001; Hart & Macnee, 2007). Commonly reported is a lack of guidance
and support, uncertainty about clinical abilities, feelings of being unimportant to the practice and a
general absence of educational resources (Fenwick, et al., 2012; Hart & Macnee, 2007). Frustration and
disappointment with the care they were able to provide were also common (Fenwick, et. al., 2012). Many
experience feelings consistent with a transient imposter syndrome, a sense of “intellectual phoniness” and
a fear of being found out and forced to abandon their profession (Prata & Gietzen, 2007).
Organizations employing advanced practice providers have a significant incentive to promote
successful transition to practice. Lack of preparation and infrastructure for integrating APPs into clinical
practice often leads to attrition rates slightly above 30% in the first two years of practice (Sullivan-Bentz,

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et al, 2010). This turnover is extremely costly to the organization. Replacing the APP can cost $20,000 to
$123,000 depending on the role (Misra-Hebert, Kay and Stoller, 2004). This cost does not include any
potential lost productivity revenue, decreased clinical morale and potential patient dissatisfaction.
Numerous solutions have been proposed to create successful transitions to practice. One of the
most notable came from the 2010 Institute of Medicine (IOM) report, The Future of Nursing. The IOM
(2010) suggested that there should be an increase in the number of advanced practice residency programs.
While this idea is viable, it is costly and protracted as well as difficult to deploy in this time of healthcare
change (Wiltse Nicely & Fairman, 2015). Healthcare organizations will be well served to develop a
different way to create a successful transition to practice for APPs. The purpose of this project was to
evaluate the effect of a comprehensive orientation program on the experience of transition to practice.
Internal Evidence
In 2011, a multispecialty oncology practice was created as part of a larger integrated healthcare
delivery system (IHDS) in the southwestern U.S. The IHDS has not yet developed strategies to
appropriately recruit APPs and effectively integrate them into practice. As a result, APPs received no
formal training or integration activities upon joining the practice. The lack of structure led to hesitation by
the practice to hire new graduates. In the few cases the practice had previously hired new graduate APPs,
the experience had been “extremely nerve-racking and almost malignant in stress creation (L. Kocemba,
personal communication, September, 2015).” Additionally, this led APPs to question their abilities as a
provider and consider returning to work at lower levels of practice (K. Dearing, personal communication,
August, 2015). Similarly, data from a survey of recent Arizona State University nurse practitioner
graduates demonstrated that 66% of new graduates felt significant stress or anxiety regarding their work
for greater than three months after employment, and only 44% of respondents reported having a formal
orientation period (Farfour, 2016).

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This inquiry has led to the relevant PICO question: “For new graduate Advanced Practice
Providers(P), how does a structured orientation model (I) compared to no formal orientation (C) affect
transition to practice(O)?”
Literature Review
Search Strategy
An exhaustive literature search pertaining to the above clinical question was performed. The
following research databases were used to gather evidence: Cumulative Index to Nursing and Allied
Health Literature (CINAHL), US National Library of Medicine (PUBMED), Psychology Information
(PsycINFO), Cochrane Library, Proquest ABI/INFORM, Institute of Education Science (ERIC) and
Proquest Aerospace Database. The latter three databases were chosen as business, education and the
aerospace/military fields all are perceived as having a high initial investment into their new hires and
were suspected to have some valuable insight in practices for socializing new graduates. Keywords
included nurse practitioner (NP), physician assistant (PA), orientation, training, new graduate (NG),
transition, new employee (NE), socialization, organizational entry, and development.
Critical Appraisal
The literature describing interventions to guide successful promotion of transition to practice for
APPs is sparse. The evidence resulting from the new mass of post-graduate training programs is just now
becoming available but there is scarce data supporting other interventions at the organizational level.
Very little of the advanced practice literature focused on interventions to improve TTP, but instead it
described the lived experience of APPs during transition. To overcome this challenge, evidence was
reviewed from different professions including nursing, management, and engineering. The chosen twelve
studies varied in design from quasi-experimental to qualitative and were published from 2000 to present
(Appendix A). All of the articles sought to understand interventions which improve the experience of
newcomers to an organization or profession. Three theoretical frameworks were utilized frequently: Van
Maanen & Schein’s (1979) theory of organizational socialization; Meleis’ (2000) transition theory and
Kramer’s (1974) reality shock theory.

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Eight of the studies included were quantitative and utilized quasi-experimental, longitudinal
surveys and cross sectional survey designs (Appendix A). The phenomenon of transition to practice is not
one that can be studied in a randomized controlled setting. Too many variables influence the transition.
Three of the studies (Newhouse et al., 2007; Friedman, Cooper, Click & Fitzpatrick, 2011; Klein &
Weaver, 2000) had a control group, although none were randomized. The outcomes measured were
heterogeneous but included transition scores, retention, turnover and turnover intention, job satisfaction,
job performance and perceived support and socialization (Appendix B). Statistical analyses were also
heterogeneous. None of the studies chosen had inherent flaws in the study design or demonstrated
outright bias.
The remaining four studies were qualitative descriptive studies. All four focused on
understanding the common themes among transitions in professional practice, including both the negative
experiences as well as the supportive factors. Focus groups and semi-structured interviews were utilized
evenly. All of the studies had moderate sample sizes with twenty-one to eighty-one participants. Four
different types of data analysis were used. All studies had strong credibility, dependability and
confirmability. Transferability could appear limited but this is refuted by the common themes seen across
professional paradigms. Common themes include the importance of mentors and support networks at
work, the importance of regular feedback, and the positive perceptions of formal learning strategies.
Synthesis
Evidence directly related to the effect of a standard orientation on APP transition to practice is
limited. However, there is consistency when we compare the findings of the APP TTP studies (Barnes,
2015; Kelly & Mathews, 2001) to that of their nursing and business counterparts. Formal socialization
and orientation tactics are valued by newcomers, especially when they include the participation of a
dedicated mentor (Strauss et al., 2016; Kelly & Matthews, 2001; Korte, Brunhaver & Sheppard, 2015;
Milligan, Margaryan & Littlejohn, 2013). Orientation programs confer increased organizational
commitment and embeddedness, job satisfaction and at least short term improvement in job performance
(Ashforth, Sluss & Saks, 2007; Strauss et al., 2016; Allen, 2006). Finally, and arguably most important

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from an organizational perspective, orientation programs seem to increase retention and similarly reduce
turnover and turnover intention (Newhouse, Hoffman, Suflita & Hairston, 2007; Strauss et al, 2016;
Friedman, Cooper, Click & Fitzpatrick, 2011; Allen, 2006).
Evidenced Based Practice Model
The Academic Center for Evidence-Based Practice (ACE) Star Model (Appendix C) was utilized
as the guiding framework for the project. The model demonstrates the “conversion of research findings
from primary research results, through a series of stages and forms, to impact on health outcomes by way
of evidence-based care (Stevens, 2012).” The ACE Star model drives evidence based change through a
five-prong approach from discovery research to process and outcome evaluation. The model was chosen
as it provides a staged progression to implementing change but is not so structured as to prescribe a strict
step wise approach. It allows for flexibility and returning to previous stages as needed. As the TTP
program itself had to be designed from multiple different sources of evidence, a significant amount of
knowledge transformation was necessary and the ACE Star model was an appropriate fit.
Guiding Theory
The Theory of Organizational Socialization developed by Van Maanen and Schein (1979) was
chosen to guide the program development. Van Mannen and Schein (1979) defined organizational
socialization as the “process by which an individual acquires the social knowledge and skills necessary to
assume an organizational role (p.211).” The theory supposes that organizational socialization activities
can be grouped into one of six different set of tactics (Appendix D) or “the ways in which the experience
of an individual in transition from one role to another are structure for him by others in the organization
(Van Maanen & Schein, 1979: 34-35).” The tactics can either be more institutionalized, collective,
formal, sequential, fixed, serial and investiture, or more individualized, individual, informal, random,
variable, disjunctive, and divestiture. Depending on the organization and leaders’ approach to each tactic,
the newcomer can have a behavioral response which helps clarify their role within the organization,
reduce uncertainty and ultimately encourages either behavior conforming to the status quo (custodial role
response) or taking an innovative approach and challenging the norm (innovative role response). While

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Van Maanen & Schein’s theory did include the testing phase, many different researchers have carried the
work forward. Saks, Uggerslaev & Fassina (2007) tested different socialization tactics among new
graduates from various fields and discovered that collective, formal, sequential and investiture tactics
decrease role ambiguity while serial tactics decrease intentions to quit (Appendix D). Ashforth, Sluss and
Saks (2007) found that investiture was positively related to job satisfaction and organizational
identification and negatively related to intentions to quit. Similarly, Allen (2006) found that investiture
and serial tactics decrease turnover intention while collective, investiture and variable tactics promote job
embeddedness. Stress was found to be reduced when using collective and formal tactics, while
performance was improved with use of sequential and fixed tactics (Ashforth & Saks, 1996). Based on
these findings, an ideal TTP program would contain collective, formal, sequential, serial, fixed, variable
and investiture tactics to promote feelings of support and organizational embeddedness, improve job
satisfaction and performance, and decrease stress.
Program Design
Prior to determining any impact, a comprehensive transition to practice orientation program
needed to be designed. Success of the TTP program hinges on the ability to address the themes seen in the
literature, including addressing loss of control, role ambiguity, and feelings of isolation as well as
promoting opportunities for feedback, relationships with peers and support/mentorship provided to the
new graduate (Edwards, Hawker, Carrier & Rees, 2015). Each of the different components of the program
was designed to address one of these themes as well as to provide an optimal balance of the targeted
socialization tactics (Appendix E).
Orientation Objectives
Tan, Au, Cooper-Thomas and Aw (2016) discuss that creating learning goals for a newcomer to
an organization enables the newcomer to be attuned to various aspects of the organization, adopt
strategies that enable the development of new skills, and are necessary to promote adjustment to the new
role. Clearly defined orientation objectives were developed for new graduates joining the practice,

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containing both collective and individual components, and were intended to frame the orientation period
and give the APP guidance on where to focus their efforts. Ten universal objectives were developed,
which remain constant across new graduate clinical subspecialties (Appendix F). An example of a
universal objective includes: “Develop appropriate diagnostics and therapeutic management plans as
appropriate in the care of the oncology patient.” In addition, individual objectives were chosen for each
new graduate based on the subspecialty they would be working in. The syntax of each objective was very
carefully chosen. Basics of the subspecialty which needed to be mastered sooner to be successful were
translated into objectives such as: “Understand and apply fluid resuscitation principles in the postoperative setting.” In contrast, those principles which the APP was not expected to have mastery of, but
simply begin to be aware of, were worded with much less finality: “Begin to understand the colon cancer
staging system.” The list of objectives was determined by the investigator as well as the APPs clinical
mentor. Role specific objectives ranged in number from twenty to forty (Appendix F). By providing both
common and individualized objectives, the new graduates have a more clearly defined role which is
unique to them (Cable, Gino & Staats, 2013).
Mentorship
The necessity of appropriate and available mentorship has been shown to be an enormous
component of a successful transition for both NPs and PAs (Hart & Bowen, 2016; Cusson & Strange,
2008; Polansky, 2011; Sullivan-Bentz, et al, 2010; Barnes, 2015). Mentors help model the role to the new
graduate as well as act as a champion for the new graduate growth. Effective mentorship has been shown
to contribute to a significant decrease in role ambiguity, thereby decreasing uncertainty and stress in
relation to professional identity (Jones, 2004). Mentorship is both a serial and investiture socialization
tactic. Doerkson (2010) determined that the best mentoring comes from those with the same credentials in
a similar role. However, this is not always feasible due to practice size, various clinical focuses and other
factors. To overcome this limitation, each new graduate was assigned, at minimum, one clinical mentor in
their same area of subspecialty. If these mentors did not have the same credentials, the new graduate was
also assigned an “APP Partner” who provides profession specific knowledge and support. As effective

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mentorship is important in improving job satisfaction and performance for the mentee (Brinkley & Brod,
2013), each mentor was provided a “tip sheet” to help facilitate good communication and guidance
(Appendix G; Eller, Lev & Feurer, 2014).
Clinical & Organizational Education
The traditional role of an onboarding or orientation program is to teach new employees “how
things are done around here” and to highlight company culture and values (Cable, Gino & Staats, 2013).
This is accomplished through attendance at the IHDS’ New Provider Orientation; a two-day program
which reviews pertinent policies, the mission and values of the organization, medical staff bylaws,
strategic clinical initiatives and the code of conduct. Following this course, all APPs also attend system
electronic health record education, complete several learning modules covering topics like federal
compliance and fraud prevention, and have an initial meeting with their direct supervisor to review
practice specific policies. These are the collective and fixed socialization tactics common to all new
providers in the IHDS.
Fixed, clinically focused education is also necessary. All new graduate APPs must complete
several different online basic oncology modules and complete training in the protection of human
subjects. This provides a solid base of knowledge in oncology and clinical trials. These modules can be
adapted based on the practice specialty. Finally, in a variable but sequential manner, each new graduate is
assigned weekly reading assignments by their mentor which are intended to further their role specific
knowledge and assist in achieving the orientation objectives (Appendix F). Polansky (2011) found that
nearly all PA’s provided this type of formal education in practice felt that it was valuable and improved
their early career experiences.
Progressive Responsibilities & Weekly Goal Setting
To reduce stress and anxiety, the new graduates were given a clearly defined timeline of the
expected progression of responsibilities (Appendix F). This progression, a sequential socialization tactic,
begins with time shadowing other providers, progresses to supervised activity, to semi-independent

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functions, where the mentor remains nearby, and finally largely independent practice by the end of twelve
weeks. This timed progression allows the APP to feel confident in where they are headed and what they
have accomplished so far, which is crucial to a successful transition (MacLellan, Leavett-Jones, &
Higgins, 2015). The progression of responsibilities is tied with expected weekly goal setting. At the
beginning of each week, the APP is instructed to set a realistic goal, like “Complete documentation on
five patients daily” or “Understand gram negative antibiotic selection”. The APP then shares that goal
with their mentor, who helps modify the goal if too lofty and ensures that the APP has the opportunity to
achieve this goal within the week. This is designed to give the new graduate an objective measure of their
own increasing proficiency as well as build and protect their professional confidence (MacLellan, LevettJones & Higgins, 2015).
Practice Immersion
Two other common themes in the literature are feelings of isolation and lack of knowledge about
the resources available (Cusson & Strange, 2008; Kelly & Matthews, 2001; MacLellan, Levett-Jones &
Higgins, 2015). Also, Marincic & Ludwig (2011) reported a statistically significant difference in entrylevel PAs’ feelings of competence in collaborating with other care providers to achieve patient-centered
care. As inter-professional practice and appropriate resource utilization are increasingly important in
healthcare today, the TTP orientation had to address these themes. During the first six weeks of the
program, the APP was allocated time with other members of the care team with whom they would have a
future collaboration. This included other providers in different subspecialties like medical oncology,
gastroenterology, or others with whom they would frequently collaborate. The practice immersion
included a full day with rehab services, learning the scope of what services physical therapy, occupational
therapy, and speech therapy were able to offer. The APPs also had time with specialty nursing services,
like wound care and case management, and time with their pharmacy colleagues. This was designed to
increase the APPs feelings of belonging to a team, ability to effectively collaborate with other disciplines,

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promote open communication and make the APP more aware of the resources available to them as they
begin to work with patients.
Opportunities for feedback
New graduates commonly reported a lack of confidence in their actions and their acquired
knowledge (Cusson & Strange, 2008; MacLellan, Levett-Jones & Higgins, 2015; Barnes, 2015; Prata &
Geitzen, 2007). Regular opportunities for feedback and progress evaluation, as well as reassurance can
help APPs overcome these challenges. A progress meeting is scheduled every four weeks during
orientation and includes the APP, their primary mentor and the APPs direct leader. Prior to the meeting,
all three attendees are asked to consider an area of success for the APP as well as one area of opportunity.
The meeting begins by asking the APP about the areas with which they feel more confident, learning
insights gained, and that for which they are most proud. The leader and mentor then share their perception
of the successes of the APP. The conversation then turns to areas of opportunity but they remain framed
positively and all participants share how they are going to support the APP to achieve success. These
meetings, an investiture tactic. serve as a critical tool to ease the transition from new graduate to
professional and help facilitate confidence and growth (Goodwin-Esola, Deely and Powell, 2009).
Evaluative Questions
Four evaluative questions were designed to assess the impact of the program on transition to
practice. First, does the theory based orientation program impact the organizational support felt by the
APP? Second, does the program influence role clarity/ambiguity? Third, does the orientation program
promote feelings of professional competence for the APP? Finally, does the program impact the affective
organizational commitment of the APP?
Methods
Evaluation of these questions and the programs efficacy was measured using four validated
scales. Each scale has widely established and accepted validity and reliability and all questions were
answered on a Likert scale.

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The perceived organizational support scale (POSS) seeks to quantify the degree of support and
assurance felt by the employee that the organization will provide the aid to carry out one’s position
effectively and to deal with stressful work conditions (Rhoades & Eisenberg, 2002). The Role Ambiguity
Scale was used to assess a lack of necessary information regarding role expectations (Rizzo, House and
Lirtzman, 1970). The perceived competence scale is a four-item questionnaire which is customized to the
domain being studied which was used to measure the APPs feelings of having the level of knowledge, or
proficiencies, needed to deliver an effective work product (Williams & Deci, 1996). Finally, the affective
commitment scale (TCM-ACS), one of three subscales in the TCM Employee Commitment survey, was
chosen to measure the employee’s emotional connection to and identification with the organization
(Meyer & Allen, 1991). Higher levels of affective commitment have been repeatedly linked to lower
levels of turnover and turnover intention (Zargar, Vandenberghe, Marchand, & Ayed, 2014;
Vandenberghe & Bentein, 2009; Bartley-Daniele, 2014).
These four scales were combined with two initial screening questions and ten demographic
questions to create a thirty-eight question survey (Appendix H). Prior to data collection, institutional
review board approval was sought and exemption was granted. No risks to participants were identified
other than those of normal daily activities. The survey was hosted using Qualtrics and participants
received an invitation to participate via email. No identifiable data was collected, including IP addresses.
Data was analyzed using SPSS 23.

Results
Both a comparison (non-TTP) and intervention (TTP) cohort were created. Twenty-nine new
graduate advanced practice providers were identified throughout different practice sites in the IDHS. All
had completed their formal education within the preceding twelve months. All were sent an invitation to
participate, regardless of practice site, and twenty surveys were returned. The non-TTP cohort had fifteen
respondents, twelve of whom qualified for inclusion. Two participants were excluded due to having had a

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previous job as an advanced practice provider, and one was excluded as they had participated in a formal
post-graduate training program. Five respondents new-graduate APPs were hired by the oncology practice
during the project time. These five were the TTP cohort, who participated in the transition to practice
orientation, and were surveyed between sixteen to eighteen weeks of employment. Both cohorts contained
PAs and NPs and both were primarily female and Caucasian (Appendix I). The TTP cohort was
completely in specialty care settings, while the non-TTP cohort had nearly thirty percent of respondents in
primary care. In the non-TTP cohort, six respondents indicated that they had zero components of a formal
orientation program upon hire, three had clear orientation objectives, four had a formal orientation
schedule, one had a dedicated mentor and two were given an expected progression.
Each of the four tools was scored for the respondents and the two cohorts were compared. On
observation, there appeared to be higher average scores, with smaller deviation, for all four of the
assessment tools in the TTP cohort (Appendix J). The TTP cohort had markedly higher average scores,
greater than ten points, on both the TCM-ACS and the POSS, while the PCS and the RAS had less
variation (Appendix J). It should be noted that, despite the common themes of self-doubt and feelings of
incompetence, both of these groups scored highly on the PCS with only one respondent scoring below the
neutral midpoint of sixteen. This was similarly observed with the RAS, with only one respondent below
the midpoint.
Although the scores between the two groups were found to have normal distributions, the groups
did not have equal variance and were not randomized so the assumptions for a standard t-test could not be
met. A Mann-Whitney U test was used to determine any statistical difference between the cohorts
(Appendix K). The cohort which participated in the TTP program was noted to have statistically
significant higher scores on both the TCM Affective Commitment scale (Z= -2.54, p=.009) and the
Perceived Organizational Support scale (Z=-2.75, p=.004). There was no statistically significant different
between the scores of the two cohorts on the Perceived Competence scale (Z=-.053, p=.96) or the Role
Ambiguity Scale (Z=-1.43, p=.16).

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Discussion

The generalization of these results is clearly impaired by the small intervention group size.
Recruitment into the intervention group was less robust than anticipated due some financial difficulties of
the greater IHDS, which imposed a brief hiring freeze, significantly slowing the expected recruitment of
new providers into the practice. Likewise, restructuring within other areas of the IHDS eliminated the
feasibility of conducting the TTP program at other practice sites. More participants will be needed to
create a stronger assessment of the program. It is also difficult to rule out the influence of other factors,
such as organizational culture, leadership structure or relationships with peers, on the experience of
transition to practice. However, the initial results of this small cohort are very promising for
organizations. There is clearly a difference in support felt by the new graduates who have participated in
the TTP program versus those who have not.
Statistically significant increases were noted in the TTP cohort for both affective commitment
and perceived organizational support (POS) which has positive implications for the organization. POS is
an antecedent to affective commitment and is positively related to individuals feeling their organization is
fair, has supportive leadership, and is willing to listen to their individual needs (Rhoades & Eisenberger,
2002). In turn, the employee has a greater affective commitment to the organization, is much less likely to
quit, is much more positive while at work and is likely to have improved job performance (Rhoades &
Eisenberger, 2002). This improved affective commitment and associated decrease turnover intention is
important to the concept of TTP as the hallmark of a failed transition is turnover, either to another
organization or return to a previous lower level of practice (MacLellan, Levett-Jones & Higgins, 2015).
Long term follow up will be needed to assess if this is a transient elevation in scores and if the retention
rates of the TTP cohort are longer than those of the non-TTP cohort.
Interestingly, both cohorts scored highly on the PCS and RAS. The role ambiguity scale mean
was 32.6 out of a possible 42. This suggests that both cohorts have generally good role clarity. These
higher scores could likely be contributed to the IHDS’ stance that advanced practice providers be utilized

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in a manner that is appropriate to the scope of their licensure and training. The IHDS operates in a lean
business model so there is not an abundance of role overlap in most practice settings. However, given that
some of the non-TTP respondents were surveyed later than twelve to eighteen weeks into practice, it
could be that these scores are falsely elevated after time has elapsed and roles have been further clarified.
The overall perceived competence scale mean was 22.5 out of 28 points, suggesting stronger
feelings of professional confidence among these groups. Whether there is something in the IHDS’ culture
that is contributing to this increased feeling of competence or if formal education is better preparing
graduates for transition would need to be explored further. However, these scores do seem to compare
favorably with Hart & Macnee’s (2016) research in which nearly forty percent of a large nurse
practitioner cohort stated they felt “generally well prepared for practice.” Similarly, Farfour (2016) found
that over fifty percent of new graduate NPs began to feel confident in the role within the first six-months
practice.
Given the findings of this small cohort, and the more recent surveys of new graduates perceived
competence, one could question if it is truly the competence of the new graduate APP that a TTP program
should focus on, or if it should instead be centered around supporting the new graduate. In an effort to
improve transition to practice, post-graduate training programs are becoming more common-place in the
United States. Carolinas’ Health System, a leader in post-graduate NP residencies, states the mission of
their program is to “develop foundation specialty-specific skills and knowledge (Taylor, Broyhill &
Burris, 2017).” However, does this focus truly benefit the new graduate in their first, independent role?
The APP is gathering more medical and clinical knowledge in these programs, but are they truly
preparing them for the realities of practice? Data does not yet exist to answer these questions, but it seems
that there is still the potential for substantial transition shock after post-graduate training. In reality the
availability post-graduate training programs are unlikely to meet the current workforce demand for NPs
and PAs in the near future. As such, it is in the organizations best interest to provide a structured
transition to practice program for new graduate advanced practice providers.

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Sustainability & Future Opportunities
The design and implementation of the TTP orientation program has identified an area of need
within the IHDS and is currently being viewed as a likely solution to improve transition throughout the
system. Five factors influence the sustainability of any program; the ability to modify or adapt the
program, having a champion, fit with the organization’s mission and procedures, perceived benefits to
staff and support from stakeholders (Shceirer, 2005). The transition to practice program has been
developed to be adaptable to a wide range of specialties and care settings. There is a universal structure
and multiple tools built to customize the content of the program to the unique needs of the role the new
graduate is filling. For posterity, all of the tools have been saved to multiple digital sources along with
clear instructions on utilization. The program has been disseminated to two other practices within the
IHDS, that anticipates utilizing it in the late spring. Initial feedback was positive with appreciation for the
clear guidelines developed and the ease of adapting the program. The TTP orientation program has many
different champions in the oncology practice but also has the support of the system Chief Nursing Officer,
the associate Chief Nursing Officer of the academic medical group and the Chief of Clinical Services for
the community medical group. This support senior system level has created a unique future opportunity.
In an effort to deploy the program further, the IHDS has created a steering committee with an initial
deliverable being dissemination and expansion of the TTP orientation program.
Conclusion
Transition to practice can be a time of high stress, self-doubt and confusion for the new graduate
advanced practice provider. Organizations have a vested interest in promoting a smoother transition for
these APPs. Many small, low cost interventions can help support the APP, and also increase
organizational embeddedness and decrease turnover intention which are directly beneficial to the
organization. While further testing is needed, this structured orientation program serves as a starting point
to assist organizations successfully support the APP during the transition to practice.

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Ashforth, B., Sluss, D. M., & Saks, A. M. (2007). Socialization tactics, proactive behavior, and newcomer
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23
Appendix A

Table 1
Literature Review Evaluation Table
Quantitative Research
Citation

Conceptual
Framework

Design/
Method/Purpose

Sample/Criteria

Rush, Adamack,
Gordon, Janke &
Ghement (2015).
Orientation &
transition
program
component
predictors of
NGN workplace
integration
Country: Canada
Funding: Grants
from the Michael
Smith Foundation
for Health
Research
Bias: None Noted

NS (Meleis’
Transitions
Theory)

Design: Crosssectional survey
Method:
Administration of an
online survey with 5
sections:
demographics,
orientation to the
employer/nursing unit,
general transition,
specific new graduate
transition program and
the Casey-Fink
Graduate Nurse
Experience Suvey.
Purpose: Examine the
relationships between
selected components
of NGN transition
programs and
transition experiences

Sample: n=245
NGNs
Demographics:
90.6% Female;
46.9% NGNs
working more than
a year; 39.2%
working for 6 mon
to 1 year; 12.7%
less than 6
months;
Orientation
94.89% had
formal orientation,
length of
orientation
<2weeks-44.8%;
2-4 weeks-27.6%;
4+ weeks-27.6%
Inclusion Criteria:
NGNs in British
Columbia who
graduate in 2010;
working in acute
care
Exclusion Criteria:
Work setting out
of acute care;
NGNs graduating
outside of 2010

Major Variables
and Definitions;
or hypotheses
tested
IV 1: Presence of
a formal
orientation phase
IV 2: Orientation
phase- <2 weeks
IV 3: Orientation
2-4 weeks
IV 4: orientation >
4 weeks
IV 5: Hours work
in first 2 weeks
DV 1:NGN
transition scores
DV 2:
organizing/prioriti
zing scores
DV 3:
communication/le
adership scores;
DV 4: support
scores;
DV 5:
Professional
satisfaction scores;
DV 6: stress
scores

Tools

Data
Analysis

Findings/
Results

Level of evidence/
Decision for Use

Casey
Fink
Graduate
Nurse
Experien
ce
Survey;
SPSS

Descriptiv
e statistics
for
demograp
hics;
ANOVA
with
Tukey’s
post-hoc
text; t
tests; chi
squared;
regression
analysis

IV 4= DV 1 Significantly
higher scores. P= .0002;
mean=76.46; SD 8.04
No significant difference
between DV 1 for IV 2 &
IV 3

LOE: III
One of few studies to specifically
look at orientation as part of
transition.
Only orientation > 4 weeks made
an impact on TTP.
Also highlighted importance of
early immersion in clinical work
Weaknesses: Data collection only
at one point in time, hard to tell if
transition experience remained
impacted by orientation. Low
response rate from initial pool of
1008 NGNs identified. NGNs
without orientation phase made up
less than 10% of sample. Could
have easily set up quasiexperimental design with control
group of no orientation vs
orientation group.

IV 3= significantly higher
scores
DV 3: p=.0152
DV 4: p=<.001
DV 5: p= -.004
IV 1= significantly higher
DV 1
Mean = 74.2 v 68.93 p
<.0001
95% CI 3.16-7.39
IV 1=significantly higher
DV 2: p=.0254
DV 3: p=.002
DV 4: p< .001
DV 5: p<.001
IV 5> 49hrs: significantly
higher DV 1 p=.006 CI
95% 1.05-6.02

Key
ADN-Associates Degree in Nursing; APN-Advanced Practice Nurse; a/w-associated with; BSN- Bachelors of Science in Nursing; CCNFP-Critical Care Nurse Fellowship Program; DV-Dependent
Variable; FNP-Family Nurse Practitioner; H-Hypothesis; HCP-Healthcare Provider; IV-Independent Variable; JS-job satisfaction; LOE-level of evidence; m-Months; MSN-Masters of Science in
Nursing; ncs-newcomers; NGN- Newly graduated nurses; NNLI-Novice Nurse Leadership Institute; NP-Nurse Practitioner; NS-Not Stated; NSig-Not significant; org-organizational; RCT- Randomized
Controlled Trial; RN-Registered Nurse; RQ-Research Question; r/t- related to; SPRING-Social and Professional Reality Integration for Nurse Graduates; soc- socialization; SO-Standard Orientation;
TTP-Transition to Practice; VA-Veterans Affairs;

APP TRANSITION TO PRACTICE

24

Citation

Conceptual
Framework

Design/
Method/Purpose

Sample/Criteria

Barnes (2015).
Exploring the
factors that
influence nurse
practitioner role
transition.
Country: United
States
Funding: Grant
from Sigma
Theta Tau
Bias: None noted

Meleis’
Transitions
Theory

Design: CrossSectional Survey
Method: A
convenience sample
found at national NP
conference, recruited
via flyers and posters
and then given an
anonymous
questionnaire
Purpose: To examine
the relationship
between NP role
transition, prior RN
experience and a
formal orientation

Newhouse,
Hoffman, Suflita,
Hairston (2007)
Evaluating an
innovative
program to
improve NGN
socialization into
the acute care
setting.
Country: USA
Funding: Grant
from the Nurse
support program,
Maryland Health
Services Cost
Review
Commission
Bias: None noted

Donabedian’
s method for
assessing the
quality of
medical care

Sample: n=352
Mean age 47.3;
88.6% female;
81.8% white;
86.6% had MSN;
47.9% FNP;
57.1% working in
outpatient
Inclusion Criteria:
Practicing in direct
patient care, hold a
graduate degree,
speak and read
English, and have
been working as
NP for at least 6 m
Exclusion Criteria:
Practicing before
1990.
Sample: Baseline
data n=73; PostTest at 6 months
n=237; Post-Test
at 12 months
n=212
Inclusion Criteria:
NGNs at a large
academic center
participating in
SPRING;
comparison group
NGNs not
participating in
SPRING
Exclusion Criteria:
RNs in practice <1
year
Attrition: 10%

Design: Quasiexperimental, post-test
only, control group
Method: NGNs who
completed SPRING
were compared to
NGNs who did not;
three survey
instruments were used
and analyzed; as well
as retention rates. Data
collected over a 3years
Purpose: Tests whether
an internship program
improves new nurse
graduate retention,
sense of belonging, org
commitment, and
anticipated turnover

Major Variables
and Definitions;
or hypotheses
tested
IV 1: Prior RN
experience
IV 2: Receiving a
formal orientation
in first NP position
DV 1: NP role
transition- score
determined by the
NPRTS scale.

Tools

Data
Analysis

Findings/
Results

Level of evidence/
Decision for Use

Nurse
Practitio
ner Role
Transitio
n Scale
(NPRTS
); SPSS

Sample t
tests;
Multiple
regression
analysis

IV 1 :
r -.08 p .12
B –.01 SE .01
B -.08 t -1.56 p .12
IV 2:
r .29 p< .001
B 6.24 SE 1.11
B .29 t 5.61 p .000

LOE: III
Although a weaker study, does
lend evidence to the idea that
structure at onboarding helps
improve role transition.
Strengths: NPs who received
structured orientations have easier
transitions and are more satisfied
with their roles. Large sample
size. No bias noted. First study
focusing on these IVs.
Weaknesses: Large portion of NP
transition effected by other
factors; convenience sample; selfreported data; NPs with various
years of experience, transition
could have been forgotten.

If IV 2 present, DV higher
t350=-5.62
p< .001

IV 1: Orientation
program (SO vs
SPRING)
DV 1: Org
Commitment DV
2: Sense of
belonging; DV 3:
anticipated
turnover
DV 4: Retention

Organiza
tion
Commit
ment
Question
naire;
Modifie
d
HagertyPatusky
Sense of
Belongin
g
Instrume
nt;
Anticipa
ted
Turnove
r Scale;
SPSS

ANOVA
with posthoc test

DV 1: no significant
difference
DV 2: no significant
difference between groups
DV 3 @ 6 m
p= .009
DV 4 @ 12 m:
x2 6.032 p .014
Descriptively higher @ 18
& 24 m.

LOE: II
Although the paper describes a
nurse residency program, it is
truly a year-long orientation
program as the expected outcome
at the end of the year is that the
RN will remain employed at the
same institution.
Shows that a transition program
makes a significant difference on
turnover and turnover intention.
Strengths: Quasi-experimental
design, Presence of a control
group; Used proven instruments;
Measurements at multiple time
points.
Weaknesses: No demographic
data collected; low baseline data
responses;

Key
ADN-Associates Degree in Nursing; APN-Advanced Practice Nurse; a/w-associated with; BSN- Bachelors of Science in Nursing; CCNFP-Critical Care Nurse Fellowship Program; DV-Dependent
Variable; FNP-Family Nurse Practitioner; H-Hypothesis; HCP-Healthcare Provider; IV-Independent Variable; JS-job satisfaction; LOE-level of evidence; m-Months; MSN-Masters of Science in
Nursing; ncs-newcomers; NGN- Newly graduated nurses; NNLI-Novice Nurse Leadership Institute; NP-Nurse Practitioner; NS-Not Stated; NSig-Not significant; org-organizational; RCT- Randomized
Controlled Trial; RN-Registered Nurse; RQ-Research Question; r/t- related to; SPRING-Social and Professional Reality Integration for Nurse Graduates; soc- socialization; SO-Standard Orientation;
TTP-Transition to Practice; VA-Veterans Affairs;

APP TRANSITION TO PRACTICE

25

Citation

Conceptual
Framework

Design/
Method/Purpose

Sample/Criteria

Strauss, Ovnat,
Gonen, Lev-Ari,
Mirahi (2016)
Do orientation
programs help
new graduates?
Country: Israel
Funding: NS
Bias: None Noted

Kramer’s
Reality
Shock
Theory

Design: CrossSectional Survey
Method:
Purpose: To determine
whether NGN
transition included a
structured orientation
program and to assess
the effectiveness of the
program from the
NGNs perspective

Sample: 79 NGNs
from 3 different
hospitals in Israel;
89% female; mean
age 31; 78% had
up to 2-years
experience
Inclusion Criteria:
Nurses who
graduated a
maximum of 5
years ago

Friedman,
Cooper, Click,
Fitzpatrick
(2011) Specific
NGN critical care
orientation:
Retention and
financial impact.
Funding: NS
Country: United
States
Bias: None Noted

Benner’s
Novice to
Expert
Theory

Design: Retrospective,
descriptive design
Method:
Purpose: To determine
the effect of a
specialized orientation
program (CCNFP) on
retention of NGN and
the net cost of this
orientation program

Sample: n= 90
NGNs at two
tertiary care
hospitals; 30
NGNs hired in
2004 undergoing
standard
orientation; 60
NGNs hired in
2007 with CCNFP
orientation. Mean
age 30; 87%
female
Inclusion Criteria:
Acceptance to the
CCNFP by
rigorous 3 stage
interview process

Major Variables
and Definitions;
or hypotheses
tested
IV 1: Structured
orientation
program
DV 1: JS
DV 2: Ability to
adapt to the
ward/job
DV 3: Supportperceived support
NGNs received
DV 4: Retentionwhether the
orientation
program
influenced staying
with employer
IV 1: Orientation
program (SO vs.
CCNFP)
DV 1: Retention at
3 months
DV 2: Retention at
6 months
DV 3: Retention at
9 months
DV 4: Retention at
12 months
DV 5: Length of
employment
DV 6: Cost of
orientation
program
DV 7: Annual
Percent Turnover
DV 8: Savings
based on turnover
rates

Tools

Data
Analysis

Findings/
Results

Level of evidence/
Decision for Use

Survey
develope
d by the
authors
but
tested
for
internal
consiste
ncy;
SPSS

t tests;
regression
analysis

DV 1:
t .86 p<.001
r2 .28 p<.05
DV 2:
t .82 p<.001
r2 .19 p>.05
DV 3:
t .86 p< .001
r2 .46 p<.001
DV 4:
t .05 p>.05
r2 -.08 p>.05

LOE: III
Simple study looking at the value
of orientation from the NG
perspective.
Strengths: Simple tailored study
with high predictive value; survey
tested for internal consistency
Weaknesses: Small sample;
Respondents answering survey
from memory as many had been
multiple years out from
orientation

SPSS,
historica
l HR
data

Pearson
Chisquared;
two
sample ttest

DV 1
x2 6.86 df 1 p .009
DV 2
x2 2.14 df 1 p .144
DV 3
x2 8.00 df 1 p .005
DV 4
x2 5.95 df 1 p .015
DV 5
t -2.26 p .03
m 262.90 (sd 126.38) vs m
321.67 (sd 92.74)
DV 6
CCNFP increased
expenditure by $954, 718
DV 7
12 % vs 6.2%
t 1.22 p .247
DV 8
Potential savings estimate
of $1,367,100

LOE: V
Turnover reduction not
statistically significant but
significant in practice and
significant cost savings.
Despite weaker study design, one
of few studies to put a price on the
actual orientation program as well
as the cost savings. Cost savings
was calculated conservatively and
potential savings for APPs likely
much higher. Program used is a
52 week long program, weeks 2652 are independent work. Weeks
1-9 simulation, certification
course, professional seminars and
RN mentorship. Weeks 10-26
preceptorships shifts; weekly
meetings/educational sessions and
completion of a clinical pathway
Study was limited by a small
convenience sample.

Key
ADN-Associates Degree in Nursing; APN-Advanced Practice Nurse; a/w-associated with; BSN- Bachelors of Science in Nursing; CCNFP-Critical Care Nurse Fellowship Program; DV-Dependent
Variable; FNP-Family Nurse Practitioner; H-Hypothesis; HCP-Healthcare Provider; IV-Independent Variable; JS-job satisfaction; LOE-level of evidence; m-Months; MSN-Masters of Science in
Nursing; ncs-newcomers; NGN- Newly graduated nurses; NNLI-Novice Nurse Leadership Institute; NP-Nurse Practitioner; NS-Not Stated; NSig-Not significant; org-organizational; RCT- Randomized
Controlled Trial; RN-Registered Nurse; RQ-Research Question; r/t- related to; SPRING-Social and Professional Reality Integration for Nurse Graduates; soc- socialization; SO-Standard Orientation;
TTP-Transition to Practice; VA-Veterans Affairs;

APP TRANSITION TO PRACTICE

26

Citation

Conceptual
Framework

Design/
Method/Purpose

Sample/Criteria

Ashforth, Sluss,
Saks (2007).
Socialization
tactics, proactive
behavior, and
newcomer
learning.
Country: United
States
Funding:
Funding by a
Department of
Management
Fellowship at
Arizona State
University
Bias: None Noted

Van Maanen
& Schein’s
Theory of
Organization
al
Socialization

Design: Longitudinal
Survey
Method: Survey
administered at three
different time
intervals; 1 week
before graduation, 4
months after the
participants start date,
and 7 months after the
start date.
Purpose: To examine
how soc processes
jointly affect soc
content and adjustment

Sample: n=150;
tested for and
ruled out attrition
bias; 52% female;
from a wide
variety of
occupations and
industries
Inclusion Criteria:
Engineering and
business graduates
from 2002 to
2003; employed
full time postgraduation
Exclusion Criteria:
Continuance of
jobs held before
graduation, plans
to enroll in
graduate school,
discontinued
employment
during survey
period,
international
graduates
returning to their
home country.

Major Variables
and Definitions;
or hypotheses
tested
H1:
Institutionalized
soc(a)/Investiture(
b) will be
positively a/w nc
learning.
H2: Nc proactive
behavior will be
positively a/w nc
learning.
H3: Nc learning
will be positively
a/w performance,
js, and org
identification and
negatively a/w
intentions to quit.
H4: The process of
soc will be directly
and positively a/w
performance, js
and org
identification, and
negatively a/w
intentions to quit.
H5:
Institutionalized
soc will be
negatively a/w
role innovation
and proactive
behavior will be
positively a/w role
innovation.

Tools

Data
Analysis

Findings/
Results

Level of evidence/
Decision for Use

Jones’
measure
of
formal
tactics;
Ashforth
& Saks
measure
of
investitu
re;
Ashforth
&
Blacks
behavior
scale;
Morriso
n’s
measure
of
socializa
tion

LISREL;
Path
coeffecien
ts

H1a:
P .17 p<.05
H1b:
P .07 not significant
H2:
P .37 p<.01
H3a:
P .32 p<.01
H3b:
P .18 p<.05
H3c:
P .18 p<.05
H3d:
P -.03 not significant
H4:
Partially support
H5a:
P -.16 p<.05
H5b:
P .29 p<.01

LOE: III
Institutionalized socialization
efforts as well as proactive
behavior by the nc improve
learning. Learning experienced by
nc was positively correlated with
performance and js but did not
change intention to quit. Efforts to
improve socialization and learning
for ncs should have a positive
effect on transition
Strengths: Large sample size,
longitudinal design; multiple
variable tested
Weaknesses: Homogeneous
sample; no control for possible
moderating variables.

Key
ADN-Associates Degree in Nursing; APN-Advanced Practice Nurse; a/w-associated with; BSN- Bachelors of Science in Nursing; CCNFP-Critical Care Nurse Fellowship Program; DV-Dependent
Variable; FNP-Family Nurse Practitioner; H-Hypothesis; HCP-Healthcare Provider; IV-Independent Variable; JS-job satisfaction; LOE-level of evidence; m-Months; MSN-Masters of Science in
Nursing; ncs-newcomers; NGN- Newly graduated nurses; NNLI-Novice Nurse Leadership Institute; NP-Nurse Practitioner; NS-Not Stated; NSig-Not significant; org-organizational; RCT- Randomized
Controlled Trial; RN-Registered Nurse; RQ-Research Question; r/t- related to; SPRING-Social and Professional Reality Integration for Nurse Graduates; soc- socialization; SO-Standard Orientation;
TTP-Transition to Practice; VA-Veterans Affairs;

APP TRANSITION TO PRACTICE

27

Citation

Conceptual
Framework

Design/
Method/Purpose

Sample/Criteria

Allen(2006)
Do org soc tactics
influence nc
embeddedness
and turnover?
Country: United
States
Funding:NS
Bias: None Noted

NS (Van
Maanen &
Schein’s
Theory of
Organization
al
Socialization
)

Design: CrossSectional Survey
Method: Participants
voluntarily completed
electronic survey with
information to link to
their employee records
so that turnover data
could be collected in 1
year. Data analysis
was promised to be
confidential and no
identifying data was
shared with the org
Purpose: To examine
if different
socialization tactics
influence nc turnover
and embeddedness

Sample: n=259
members of a
large financial org;
Located in 82
cities, 18 states
and represent 152
different cost
centers; 66%
femal; mean age
35; 55% college
graduates
Inclusion Criteria:
Employed <12
months
55 (24.8%) of the
original sample
had left the org
within 1 year

Major Variables
and Definitions;
or hypotheses
tested
IV 1: Collective
tactics-common
learning
experiences with
group
IV 2: Formal
tactics- clearly
defined soc
activities
IV 3: Sequential
tactics- sequential
learning activities
IV 4: Fixed
tacticsinformation about
timinig of each soc
stage or step
IV 5: Serial
tactics- mentors or
role models
provided
IV 6: Investiture
tactics: positive
social support
DV 1: Turnover
DV 2:
Embeddedness
On-the-job: Links
that tie an
individual to their
org while they are
at work.
DV 3:
Embeddedness
Off-the-job: Links
that tie an
individual to their
org while they are
not at work.

Tools

Data
Analysis

Findings/
Results

Level of evidence/
Decision for Use

Turnove
r
recorded
from org
records;
Jones’
Soc
Tactics
Scale;
Embedd
edness
survey
by
Mitchell
et al,

Descriptiv
e
statistics;
correlatio
n
coefficient
s;
Hierarchal
logistic
regression

DV 1
IV 1
r -.08 Not significant
09 Not significant
IV 2
r -.09 not significant
.13 Not significant
IV 3
r -.06 not significant
.46 Not significant
IV 4
r -.07 not significant
.22 Not significant
IV 5
r -.15 p <.05
-.83 p <.05
IV 6
r -.12 p <.05
-.65 p <.05
DV 2
IV 1
r .29 p < .01
.22 p <.01
IV 2
r .20 p < .01
.12 Not significant
IV 3
r .49 p < .01
-.08 Not significant
IV 4
r .38 p < .01
.21 p <.01
IV 5
r .31 p < .01
.03 not significant
IV 6

LOE: III
Find a relationship between org
soc tactics, like a formal
orientation proram, increases on
the job embeddedness which then
has a negative relationship with
turnover.
Strengths: Strong sample,
increased generalizability; strong
statistical tools used; reliable,
tested tools
Weaknesses: Does not focus on
new grads; one time point studied
for all dimensions.

Key
ADN-Associates Degree in Nursing; APN-Advanced Practice Nurse; a/w-associated with; BSN- Bachelors of Science in Nursing; CCNFP-Critical Care Nurse Fellowship Program; DV-Dependent
Variable; FNP-Family Nurse Practitioner; H-Hypothesis; HCP-Healthcare Provider; IV-Independent Variable; JS-job satisfaction; LOE-level of evidence; m-Months; MSN-Masters of Science in
Nursing; ncs-newcomers; NGN- Newly graduated nurses; NNLI-Novice Nurse Leadership Institute; NP-Nurse Practitioner; NS-Not Stated; NSig-Not significant; org-organizational; RCT- Randomized
Controlled Trial; RN-Registered Nurse; RQ-Research Question; r/t- related to; SPRING-Social and Professional Reality Integration for Nurse Graduates; soc- socialization; SO-Standard Orientation;
TTP-Transition to Practice; VA-Veterans Affairs;

APP TRANSITION TO PRACTICE

28
r .49 p < .01
.38 p <.01
DV 3
IV 1
r .-.04 not significant
01 Not significant
IV 2
r .-.08 not significant
.16 Not significant
IV 3
r ..04 not significant
.09 Not significant
IV 4
r ..04 not significant
.01 Not significant
IV 5
r ..02 not significant
.09 Not significant
IV 6
r ..09 not significant
.10 Not significant
Effect of DV 2 & DV 3 on
DV 1
DV 2
R -.23 p < .01
-.87 p <.01
DV3
r -.05 not significant
.08 Not significant

Key
ADN-Associates Degree in Nursing; APN-Advanced Practice Nurse; a/w-associated with; BSN- Bachelors of Science in Nursing; CCNFP-Critical Care Nurse Fellowship Program; DV-Dependent
Variable; FNP-Family Nurse Practitioner; H-Hypothesis; HCP-Healthcare Provider; IV-Independent Variable; JS-job satisfaction; LOE-level of evidence; m-Months; MSN-Masters of Science in
Nursing; ncs-newcomers; NGN- Newly graduated nurses; NNLI-Novice Nurse Leadership Institute; NP-Nurse Practitioner; NS-Not Stated; NSig-Not significant; org-organizational; RCT- Randomized
Controlled Trial; RN-Registered Nurse; RQ-Research Question; r/t- related to; SPRING-Social and Professional Reality Integration for Nurse Graduates; soc- socialization; SO-Standard Orientation;
TTP-Transition to Practice; VA-Veterans Affairs;

APP TRANSITION TO PRACTICE

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Citation

Conceptual
Framework

Design/
Method/Purpose

Sample/Criteria

Klein & Weaver
(2000). The
effectiveness of
an
organizationallevel orientation
training program
in the
socialization of
new hires.
Country: USA
Funding: NS
Bias: None Noted

NS
(Feldman’s
Theory of
Socialization
; Van
Maanen &
Schein’s
Theory of
Socialization
)

Design: QuasiExperimental
Method: A 3-hour
orientation program
was offered to all fulltime employees,
employed less than 6
months, on a volunteer
basis. Surveys were
sent to all new
employees prior to
orientation and 1 to 2
months following
orientation, regardless
of orientation
attendance.
Purpose: To examine
the impact of attending
a voluntary,
organizational-level
new employee
orientation training
program on
organizational soc.

Sample: n= 116;
55 experimental,
61 control;
Subjects worked
in 8 different
departments and
held 70 different
job titles. 30%
professional; 36%
clerical; 12%
technical. Had
been with
company mean of
87 days. 83%
white; 70%
female; mean 35
years-old; 41%
with college
degrees; 28% with
advanced degrees
Inclusion Criteria:
High school
diploma or higher;
Employees with
tenure <6 months,
Exclusion Criteria:
Employees who
attended
orientation prior to
first survey;
faculty members;
instructors or
student employees

Major Variables
and Definitions;
or hypotheses
tested
H1: Employees
attending
orientation will be
more socialized
than employees
not attending
orientation.
H2: Orientation
attendance will be
positive r/t
affective
organizational
commitment.
IV 1: Orientation
attendance
DV 1: History
Dimensionknowledge of orgs
traditions,
customs, myths,
stories and rituals
DV 2: Language
Dimensionemployee
understanding
language and
vernacular of org
DV 3:
Goals/values
dimensionemployees
understanding of
orgs mission and
goals.
DV 4: People
dimension-degree
to which employee
has satisfying
work relationships

Tools

Data
Analysis

Findings/
Results

Level of evidence/
Decision for Use

Soc
scale
created
by Chao
at al.;
Org
commit
ment
scale
created
by Allen
& Meyer

Chi
squared;
one way
ANOVA;
descriptiv
e
statistics;
ANCOV
A

H1:
DV 1
2
.25 p<.01
DV 2
2
.01 not significant
DV 3
2
.06 p<.05
DV 4
2
.14 p<.01
DV 5
2
.03 not significant
H2:
R2 .00 F .10 not
significant
DV 1
.26 F 7.49 p<.01
DV 2
-.04 F .20 not significant
DV 3
.31 F 11.78 p<.01
DV 4
.09 F 1.10 not
significant
DV 5
.01 F .02 not significant

LOE: III
Findings suggest orientation
attendance had a significant effect
on helping newcomers learn the
history as well as the goals and
values of the org. It also helped
promote satisfying work
relationships. However,
orientation attendance did not
affect org commitment. Suggests
that orientation attendance could
positively impact transition to
practice through promotion of
work relationships and
understanding the org culture and
mission, vision and values.
Strengths: Quasi-experimental
design, higher level of evidence
for this phenomenon; larger
sample size spanning multiple
professions; strong tools used with
verified internal validity.
Weaknesses: Non-randomization;
no control for other factors that
could have impacted results;
employees were not necessarily
new and mean time with org was
close to 90 days

Key
ADN-Associates Degree in Nursing; APN-Advanced Practice Nurse; a/w-associated with; BSN- Bachelors of Science in Nursing; CCNFP-Critical Care Nurse Fellowship Program; DV-Dependent
Variable; FNP-Family Nurse Practitioner; H-Hypothesis; HCP-Healthcare Provider; IV-Independent Variable; JS-job satisfaction; LOE-level of evidence; m-Months; MSN-Masters of Science in
Nursing; ncs-newcomers; NGN- Newly graduated nurses; NNLI-Novice Nurse Leadership Institute; NP-Nurse Practitioner; NS-Not Stated; NSig-Not significant; org-organizational; RCT- Randomized
Controlled Trial; RN-Registered Nurse; RQ-Research Question; r/t- related to; SPRING-Social and Professional Reality Integration for Nurse Graduates; soc- socialization; SO-Standard Orientation;
TTP-Transition to Practice; VA-Veterans Affairs;

APP TRANSITION TO PRACTICE

30
DV 5:
Performance
dimension-degree
to which employee
becomes proficient
at their job

Qualitative Research
Citation

Conceptual
Framework

Design/
Method/Purpose

Sample/Criteria

Research
Questions

Kelly,
Mathews
(2001).
Transition to
first position
as NP.
Country:
United States
Funding: Grant
from the
Illinois league
for Nursing
Bias: None
Noted

NS (Meleis’
Transition
Theory)

Design:
Qualitative
DescriptivePhenomenology
Data Collection:
Focus group
interviews
Data Management:
Sessions
audiotaped then
later transcribed;
interpretation of
data in debriefing
meetings
immediately
following
interviews
Purpose: Obtain a
better
understanding of
the transitional
process of the
graduate to the
first position of
NP.

Sample: n= 21;
volunteer,
convenience
sample
Inclusion
Criteria: NP
graduates from a
Chicago
university; <7
years of practice;
practicing in
central Illinois
Exclusion
Criteria: None
Noted

How do NPs
perceive their
preparation for the
transition to their
new role? Are
their perceived
losses as well as
gains in the
transition to NP?
What are the
perceived barriers
and facilitators in
the transitional
process to NP?
What are the
coping strategies
perceived as most
helpful in the
transitional
process to NP?

Credibility/Transferability/
Dependability/Confirmabili
ty
Credibility: Interviewers
included those outside the
nursing field and not involved
with the project; focus groups
held until saturation.
Transferability: 4 separate
focus groups help, although it
is decreased due to
geographically limited sample
comprised largely of NPs in
rural areas
Dependability: Analysis
conducted as a group and
continued until a consensus
was achieved
Confirmability: Each finding
is well supported by interview
quotes

Data
Analysis

Findings/
Results

Comparativ
e Content
Analysis

Themes: Loss of control of
time and privacy; sense of
isolation; relationship
changes and losses; role
ambiguity; significant
personal satisfaction of role;
importance of a support
network
TTP often spans many years,
but the first year is
highlighted as the hardest.
NPs feel isolated as they are
treated differently than both
nurses and physicians. Loss
of work/life balance is
common. Role ambiguity,
due to large variations in NP
practice, add stress and
confusion to the role. Most
frequently mentioned coping
strategy was network of
support people. Collaborating
physician/NP relationship is
crucial for support in
transition.

Level of
evidence/
Decision for Use
LOE: V
Highlights
struggles of the
first year of ttp.
Lots of stress
caused by role
ambiguity and
lack of clear
practice
guidelines Also
focuses on the
importance of a
professional
support network
to ease transition.
Strengths: Study
design
appropriate.
Strong credibility
and
dependability.
Weaknesses:
Sample was small
and
geographically
contained, limits
generalizability

Key
ADN-Associates Degree in Nursing; APN-Advanced Practice Nurse; a/w-associated with; BSN- Bachelors of Science in Nursing; CCNFP-Critical Care Nurse Fellowship Program; DV-Dependent
Variable; FNP-Family Nurse Practitioner; H-Hypothesis; HCP-Healthcare Provider; IV-Independent Variable; JS-job satisfaction; LOE-level of evidence; m-Months; MSN-Masters of Science in
Nursing; ncs-newcomers; NGN- Newly graduated nurses; NNLI-Novice Nurse Leadership Institute; NP-Nurse Practitioner; NS-Not Stated; NSig-Not significant; org-organizational; RCT- Randomized
Controlled Trial; RN-Registered Nurse; RQ-Research Question; r/t- related to; SPRING-Social and Professional Reality Integration for Nurse Graduates; soc- socialization; SO-Standard Orientation;
TTP-Transition to Practice; VA-Veterans Affairs;

APP TRANSITION TO PRACTICE

31

Citation

Conceptual
Framework

Design/
Method/Purpose

Sample/Criteria

Research
Questions

Korte,
Brunhaver,
Sheppard
(2015).
Interpretations
of org soc: the
expectations
and
experiences of
ncs and
managers.
Country:
United States
Funding:
Grants from
the Center for
the
Advancement
of Engineering
Education &
Stanford
University
Department of
Engineering
Bias: None
Noted

NS (Van
Maanen &
Schein’s
Theory of
Organization
al
Socialization
)

Design:
Qualitative
Method: Case
study method
grounded in a
naturalistic
paradigm; semistructured
interviews using
the “critical
incidents”
approach
Purpose: To
understand the
expectations and
experiences of
recent graduates as
they socialized
into their new jobs
and the related
expectations and
experiences of
managers
supervising them.

Sample: N=41
NC Engineers,
15 managers.
From 3 different
U.S. based
organizations;
NCs had
graduated in the
last 6 to 18
months;
managers
supervised 8 to
20 engineers and
had previous
experience
supervising NCs.

What are the
expectations of
new engineers and
their managers
about the
socialization
process?
Do the
expectations of
new engineers and
managers differ?
Why or why not?
What are the
actual experiences
of new engineers
and their managers
during
socialization?
How do the
experiences relate
to their
expectations?
How do the
interactions of
expectations and
experiences help
or hinder the
socialization
process of newly
hired engineers?
What might be
done to improve
the socialization
experiences for
ncs and managers?

Credibility/Transferability/
Dependability/Confirmabili
ty
Credibility: Interviews
recorded and transcribed
verbatim; separate researcher
confirming accuracy.
Subjects interviewed 10- 12
times until saturation Prelim
findings discussed with
participants for feedback &
confirmation
Transferability: Respondents
from 3 different orgs,
increases ability to generalize
the findings.
Dependability: Clear coding
process with verification by
independent researcher
Confirmability: All major
findings are supported by
direct quotes

Data
Analysis

Findings/
Results

Constant
Comparativ
e method.

Newcomer expectations:
Managers should provide
explicit, formal orientation
and training.
Managers should provide
direct and meaningful
guidance
Managers should not be
bothered or asked for help
NCs expect to receive some
help from coworkers and
value local mentors
NCs value being accepted
among their peer group and
appreciate efforts to help
guide this acceptance.
Manager expectations:
NCs need to rely on more
experiential, informal
learning
NCs want more direct
guidance
NCs should take more
initiative

Level of
evidence/
Decision for Use
LOE: V
Although out of
the HCP
literature,
engineering is
also a very
technical field
which requires
transition from
academia to
reality. Study is
very thorough
and exhaustive
and evaluates not
just the
experiences of
the NCs but what
their expectations
were and what
would have
further helped.
Also reveals
some of the
contrast between
NC expectations
and
administrative
expectations.

Key
ADN-Associates Degree in Nursing; APN-Advanced Practice Nurse; a/w-associated with; BSN- Bachelors of Science in Nursing; CCNFP-Critical Care Nurse Fellowship Program; DV-Dependent
Variable; FNP-Family Nurse Practitioner; H-Hypothesis; HCP-Healthcare Provider; IV-Independent Variable; JS-job satisfaction; LOE-level of evidence; m-Months; MSN-Masters of Science in
Nursing; ncs-newcomers; NGN- Newly graduated nurses; NNLI-Novice Nurse Leadership Institute; NP-Nurse Practitioner; NS-Not Stated; NSig-Not significant; org-organizational; RCT- Randomized
Controlled Trial; RN-Registered Nurse; RQ-Research Question; r/t- related to; SPRING-Social and Professional Reality Integration for Nurse Graduates; soc- socialization; SO-Standard Orientation;
TTP-Transition to Practice; VA-Veterans Affairs;

APP TRANSITION TO PRACTICE

32

Citation

Conceptual
Framework

Design/
Method/Purpose

Sample/Criteria

Research
Questions

Dyess &
Sherman
(2009). The
first year of
practice:
NGNs’
transition and
learning needs.
Country:
United States
Funding: None
Bias: None
Noted

Kramer’s
Reality
Shock
Theory

Design:
Qualitative
Descriptive
Method: Pre and
post-program
focus groups using
hermeneutic
analysis. Focus
groups asked
semi-structured
questions; sessions
audiotaped and
transcribed; coded
on review
Purpose: To
examine the
experience of
NGN transition as
well as their
learning needs
both pre and post
involvement in the
NNLI.+

Sample: n=81;
mean age 32;
93% female;
80% in acute
care settings
Inclusion
Criteria: ADN or
BSN graduates
with less than 12
months
experience;
Candidates
agreed to
complete 1 year
program and an
evidenced based
project

What are the lived
experiences of
NGNs in the first
year of practice?
What do NGNs
believe would
improve
transition?

Credibility/Transferability/
Dependability/Confirmabili
ty
Credibility: Interviews
recorded and re-reviewed on
multiple occasions during
coding. Focus group
facilitators not associated
with the study.
Transferability: Somewhat
compromised as the NGNs
surveyed were identified for
their perceived leadership
potential as well as
willingness to participate in a
year-long program.
Dependability: Use of proven
hermeneutic analysis
Confirmability: Themes and
recommendations confirmed
with subject quotes

Data
Analysis

Findings/
Results

Hermeneuti
c Analysis

Themes:
Mixed feelings of confidence
and fear
Less than professional
communication from other
HCPs
Horizontal violence
Feeling overwhelmed and
isolated
Regular complex critical
decision-making
Receiving contradictory
information from peers
Recommendations:
Long term support through
first year of practice
Interdisciplinary
communication seminars
Strategies for identifying and
responding to horizontal
violence
Regular conversations with
and an open door to
leadership
Extended transition support
for more complex specialties
Consistent preceptors who
focus on the positive

Level of
evidence/
Decision for Use
LOE: V
Allow focusing
on NGN, study
not only seeks to
explain the
experiences of
transition but also
asks NGNs what
would have been
more helpful.
Structure and
mentorship are
common themes
throughout the
article.

Key
ADN-Associates Degree in Nursing; APN-Advanced Practice Nurse; a/w-associated with; BSN- Bachelors of Science in Nursing; CCNFP-Critical Care Nurse Fellowship Program; DV-Dependent
Variable; FNP-Family Nurse Practitioner; H-Hypothesis; HCP-Healthcare Provider; IV-Independent Variable; JS-job satisfaction; LOE-level of evidence; m-Months; MSN-Masters of Science in
Nursing; ncs-newcomers; NGN- Newly graduated nurses; NNLI-Novice Nurse Leadership Institute; NP-Nurse Practitioner; NS-Not Stated; NSig-Not significant; org-organizational; RCT- Randomized
Controlled Trial; RN-Registered Nurse; RQ-Research Question; r/t- related to; SPRING-Social and Professional Reality Integration for Nurse Graduates; soc- socialization; SO-Standard Orientation;
TTP-Transition to Practice; VA-Veterans Affairs;

APP TRANSITION TO PRACTICE

33

Citation

Conceptual
Framework

Design/
Method/Purpose

Sample/Criteria

Research
Questions

Milligan,
Margaryan &
Littlejohn
(2013).
Learning at
transition for
new and
experienced
staff.
Country: UK
Funding:
Industryacademic
partnership
grant
Bias: None
Noted

NS (Van
Maanen &
Schein’s
Theory of
Organization
al
Socialization
)

Design:
Qualitative
Descriptive
Data Collection:
Semi-Structured
Interviews
Data Management:
Data analyzed
using a grounded
theory approach
using codes
emerging from the
data. All
interviews coded
by a single
researcher; then
cross-checked by
two further
researchers
Purpose: To
improve the
understand of the
learning and
development that
occurs during
initial and
subsequent role
transitions within
knowledge
intensive
workplaces.

Sample: n= 30;
8 novices-less
than 3 years
experience, 10
mid-career
workers- 3-10
years, 12
experienced
workers-11 or
more years.
Sample included
engineers,
chemists, human
resources and
procurement
specialists.
Respondents
from 12 different
countries
Inclusion
Criteria:
Technical and
commercial
professionals
operating in the
energy sector.
Exclusion
Criteria: Lack of
a major role
change in the
previous 3 years

RQ1-What are the
learning
experiences of
new and more
experienced
workers
undergoing
transition?
RQ2- What are the
org soc
experiences of
new and more
experience
workers?

Credibility/Transferability/
Dependability/Confirmabili
ty
Credibility:
No mention of interviewing
until saturation was reached;
peer debriefing used.
Transferability: Although
individuals from one country,
they are from variable
professions and countries
Dependability: Coding was
done using grounded theory
approach by one researcher
and verified by two
researchers
Confirmability: Findings
confirmed by direct subject
quotes.

Data
Analysis

Findings/
Results

Grounded
Theory
Approach

RQ 1 Eight modes of learning
emerged: Formal learning
(classroom, online, etc);
learning by doing; Learning
by discussing with others;
mentoring; learning by
teaching; observation; trial
and error; self-study
Novices utilized formal
learning; observation and
learning by doing as top 3
methods. Novices recognized
link between formal and
experiential learning as the
only way they could make
sense of formal learning.
Half of the novices reported
learning much from their
mentor and felt it was a
valuable part of their
transition. Few of the
experienced workers were
assigned a mentor.
RQ 2 Induction (Orientation)
was highly valued by novices
as provided a critical role to
experience a larger
understanding of the
organization.
Three components of
orientation which were most
important: formal learning;
learning by
doing/observation; social
networking.
Experienced workers were
not assigned to formal
orientation programs cited
frustration with no time set
aside for learning their new

Level of
evidence/
Decision for Use
LOE: V
Highlights
transition of both
novice and
experienced
workers in
transition.
Important
concept for APPs
as many will be
experienced in
the healthcare
field but will be
experiencing
large role
transition.
Small sample size
limits
generalizability.

Key
ADN-Associates Degree in Nursing; APN-Advanced Practice Nurse; a/w-associated with; BSN- Bachelors of Science in Nursing; CCNFP-Critical Care Nurse Fellowship Program; DV-Dependent
Variable; FNP-Family Nurse Practitioner; H-Hypothesis; HCP-Healthcare Provider; IV-Independent Variable; JS-job satisfaction; LOE-level of evidence; m-Months; MSN-Masters of Science in
Nursing; ncs-newcomers; NGN- Newly graduated nurses; NNLI-Novice Nurse Leadership Institute; NP-Nurse Practitioner; NS-Not Stated; NSig-Not significant; org-organizational; RCT- Randomized
Controlled Trial; RN-Registered Nurse; RQ-Research Question; r/t- related to; SPRING-Social and Professional Reality Integration for Nurse Graduates; soc- socialization; SO-Standard Orientation;
TTP-Transition to Practice; VA-Veterans Affairs;

APP TRANSITION TO PRACTICE

34
role.
Both novices and experienced
workers recognized the value
in a mentor to use as a
resource person when
experiencing difficulties.
Both groups also realized the
importance of social
networking as a way to
integrate into the organization
and recognized their
transition would have been
more difficult without these
efforts

Key
ADN-Associates Degree in Nursing; APN-Advanced Practice Nurse; a/w-associated with; BSN- Bachelors of Science in Nursing; CCNFP-Critical Care Nurse Fellowship Program; DV-Dependent
Variable; FNP-Family Nurse Practitioner; H-Hypothesis; HCP-Healthcare Provider; IV-Independent Variable; JS-job satisfaction; LOE-level of evidence; m-Months; MSN-Masters of Science in
Nursing; ncs-newcomers; NGN- Newly graduated nurses; NNLI-Novice Nurse Leadership Institute; NP-Nurse Practitioner; NS-Not Stated; NSig-Not significant; org-organizational; RCT- Randomized
Controlled Trial; RN-Registered Nurse; RQ-Research Question; r/t- related to; SPRING-Social and Professional Reality Integration for Nurse Graduates; soc- socialization; SO-Standard Orientation;
TTP-Transition to Practice; VA-Veterans Affairs;

APP TRANSITION TO PRACTICE

35
Appendix B

Table 2
Synthesis Table
Author

Rush

Barnes

Newhouse

Strauss

Friedman

Ashforth

Allen

Klein

Kelly

Korte

Dyess

Milligan

Year

2015

2015

2007

2016

2011

2007

2006

2000

2001

2015

2009

2013

x

x

x

x

x

Domain
Healthcare
Business/Other

x
x

x

x

x
x

x

Study Design
Cross-Sectional Survey

x

x

x

x

x

Quasi-Experimental

x
x

Longitudinal Survey
x

Retrospective-Descriptive

x

Qualitative-Focus Group

x
x

Qualitative-Semi-Structured
Interview

x

Sample
n

245

352

73/237/212

79

90/30/60

150

259

55/61

x

APPs
Nursing (non-APPs)

x

New Graduates

x

x

x

x

x

Institutionalized Soc

x

81

30

x

x

x

x
x
x

x

x

x

x

x

Intervention
x

41/15

x

Newcomers (not NGs)

Formal Orientation

21

x

x

x

x
x

x

x
x

APP TRANSITION TO PRACTICE
Author

36

Rush

Barnes

Newhouse

Strauss

Friedman

Transition Score











Retention











Ashforth

Allen

Klein







Kelly

Korte

Dyers

Milligan

Outcomes

Turnover

NSig

Org
Commitment/Embeddedness

NSig







Sense of Belonging/Good
Work Relationships

NSig













Job Satisfaction





Job
Performance/Adaptability





Length of Employment











Turnover Intention











Level of Soc

NSig

NSig






Descriptive Themes
Loss of Control/Feeling
Overwhelmed

x

x

Sense of Isolation

x

x

Importance of guidance and
feedback

x

x

x

x

Benefit of structure to
transition

x

x

x

Value of orientation efforts

x

x

x

x

x

Importance of peer
relationships

x

x

Importance of Consistency

x

x

Need ongoing support

x

Learn by doing

x

x

x

x

Importance of/learn from
mentors

x

x

x

x

APP TRANSITION TO PRACTICE
Appendix C
Figure 1. ACE Star Model of Knowledge Transformation

APP TRANSITION TO PRACTICE
Appendix D
Table 3

Van Maanen & Schein’s Socialization Tactics
Tactic Producing Custodial
Role Response

Tactic Definition

Tactic Producing Innovative
Role Response

Collective

Newcomers have common experiences as a group
in collective tactics, or are left to have unique
individual experiences

Individual

Formal

If using formal tactics, newcomers are given
specific experiences tailored for them, separate
from the day to day work of others; or, in informal
tactics, are placed into the day to day environment
and learn as they go

Informal

Sequential

Sequential tactics include giving Newcomers a
progression of steps during the socialization period
with a clearly prescribed path; or while random
tactics do not have a clear progression plan

Random

Variable

Fixed socialization tactics are performed on a
given timeline and are similar for all newcomers;
variable activities are tailored to the unique needs
and experiences of the newcomer

Fixed

Serial

Serial tactics include exposing newcomers to
experienced mentors; while disjunctive tactics
allow the newcomer to “make their own way”

Disjunctive

Divestiture

Investiture reinforces the newcomers self-identity
and provides social and organizational support.
Divestiture strips away self-identities then builds
them back up in terms of the organization.

Investiture

APP TRANSITION TO PRACTICE

39
Appendix E

Figure 2. MindMap of Program Components and Socialization Tactic Type

APP TRANSITION TO PRACTICE
Appendix F
Figure 3. Orientation outline including objectives and progression
DIVISION OF SURGICAL ONCOLOGY
BANNER MD ANDERSON CANCER CENTER
APP Orientee: PA-C
Provider Mentor(s):

AGNP
MD

APP Partner:
Primary Focus:

PA-C
Urology

GENERAL COURSE OBJECTIVES: At the end of the 12-week training period, the new APP will:
1.
2.
3.

Be proficient at correctly performing history and physical assessment.
Be proficient at communicating H&P findings with other providers.
Develop appropriate diagnostic and therapeutic management plans for both acute and chronic conditions as
appropriate in the care of the oncology patient.
4. Become proficient at timely documentation of clinic visits in alignment with BMDACC Documentation
Completion Guidelines
5. Become proficient at appropriate billing and/or coding of clinic visits and procedures in alignment with
BMDACC Coding Completion Guidelines
6. Become proficient at correctly ordering the appropriate laboratory and diagnostic studies
7. Correctly refer patients to appropriate consult services, including medical oncology, radiation oncology,
surgical oncology, pain management or integrative medicine.
8. Become proficient at navigating and using Cerner.
9. Be able to identify basic resources available within the cancer center and Banner as a whole.
10. Understand appropriate scope of practice in relation to state and federal laws and regulations, as well as
Banner bylaws.
ROLE SPECIFIC COURSE OBJECTIVES: At the end of the 12-week training period, the new APP will:
Prostate Cancer
1.
2.
3.
4.
5.
6.
7.

8.

Understand the basic presentation and epidemiology of patients with prostate cancer
Understand accepted screening practices, and intervals, for prostate cancer in both patients with a prostate
and those who are post prostatectomy.
Understand the initial approach to a patient with elevated PSA and/or suspicion of prostate cancer
Begin to understand how to appropriately stage a patient diagnosed with prostate cancer.
Begin to understand Gleason scoring and TNM staging of prostate cancer
Begin to understand the typical metastatic pattern of prostate cancer.
Begin to understand the different treatment options for a patient presenting with prostate cancer.
a. Surgery
b. Radiation
c. Hormonal & Anti-neoplastic therapies
d. Active Surveillance
Understand the basic indications for surgical intervention in the patient with prostate cancer.

APP TRANSITION TO PRACTICE

9.

a. Resectability
b. Performance Status
Begin to understand the different surgical options for a patient with prostate cancer.

Bladder Cancer
1.
2.
3.
4.
5.
6.

Begin to understand the epidemiology, initial presentation and risk factors for bladder cancer.
Understand the initial work up for bladder cancer.
Begin to understand the treatment options for bladder cancer.
Begin to understand the indications for surgical intervention, and different operative approaches for the
patient with bladder cancer.
Begin to become familiar with caring for a urostomy.
Be aware of the current clinical trial BMDA offers for bladder cancer

Renal Cell Carcinoma
1.
2.
3.
4.
5.

Begin to understand the differential for a newly diagnosed kidney lesion, including characteristic features
of a renal cell carcinoma (RCC).
Understand the basic epidemiology and risk factors for development of RCC.
Understand the initial work-up and treatment for RCC.
Understand the indications for surgery in a patient with RCC and begin to understand the different
operative approaches.
Begin to understand the possible short and long term complications of nephrectomy.

Testicular Cancer
1.
2.
3.

Begin to understand the differential for a newly diagnosed scrotal/testicular mass.
Begin to understand the basic epidemiology and risks factors for testicular cancer.
Begin to understand the initial work-up and treatment, including the role of surgery, in the patient with
testicular cancer.

General Urology & Surgical Management
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Continue to develop skills as a surgical first assistant.
Understand the basic work-up and management of benign prostatic hypertrophy
Begin to understand the potential causes of and treatment approach to erectile dysfunction.
Understand the basic work-up and approach to hydronephrosis.
Understand the basic work-up and approach to hematuria, both frank and microscopic
Understand management of indwelling urinary catheters and the role of voiding trials
Understand indications for, ordering of and management of continuous bladder irrigation
Become familiar with indications for and management of nephrostomy tubes
Become familiar with indications for and management of ureteral stents
Become familiar with appropriate pre-operative education and orders including:
a. Appropriate pre-operative testing & clearance
b. Appropriate Bowel Prep
c. NPO Guidelines
d. SCIP Guidelines and appropriate antibiotics
11. Understand the basic post-operative care of a patient after abdominal surgery:
a. Fluid & Electrolyte Management
b. SCIP Guidelines & appropriate antibiotics
c. Pain Control

APP TRANSITION TO PRACTICE
d.

12.

13.

14.
15.
16.
17.

Drain & Wound Management
i. Management of clean vs contaminated vs dirty wounds
e. DVT & Pneumonia Prophylaxis
f. Nutrition & Bowel management
Understand the basic initial work up and management of post-operative alarm symptoms:
a. Hypotension
b. Change in Mental Status
c. Hypoxia
d. Decreased Urine Output
e. Tachycardia
f. Bleeding
g. Fever
Understand the more common short and long term complications of urologic surgeries, including their
presenting symptoms and initial work up and management:
a. Infection
b. Ureteral Stricture
c. Fistula
d. Adhesions and Obstruction
Understand the initial approach to the patient with bowel obstruction and the difference between small and
large bowel obstruction.
Understand the initial workup and management of a patient concerning for acute abdomen.
Begin to understand the various treatment options for acute and recurrent UTIs in cancer patients.
Begin to understand the various treatment options for urinary incontinence

RECOMMENDED READING/RESOURCES :
1.
2.
3.
4.
5.
6.

Physician Assistants: AZ Regulatory Board of Physician Assistants Revised Statutes for PAs.
https://www.azpa.gov/Statutes-Rules/PA%20Statutes.aspx
Up-To-Date
Wieder’s Pocket Guide to Urology 5th-edition
MD Anderson Surgical Oncology Handbook
Smith & Tanagho’s General Urology
Weekly reading assignments to be provided by mentors

REQUIRED ONLINE MODULES:
1.
2.
3.
4.

All Banner Learning Center Modules
Cerner Training
MD Anderson Modules https://cms.mdanderson.org/access/content/group/250bac46-a90e-4b26-9eed7dc6ff6b40f1/content/cmeDisclosure.html
CITI Training: www.citiprogram.org

WEEKLY PROGRESSION:
This progression is intended to serve as a guide for how you will begin to master different aspects of our practice
over the next twelve weeks. Depending on different factors within the practice, you may progress quicker or slower
in each area. This is a general template. To see true progression, you are expected to set a goal each week and
share with your mentor. We will discuss these goals further in your first orientation meeting.
Week One:

“Getting Organized”

APP TRANSITION TO PRACTICE
















Attend required on- boarding meetings.
Meet with Leader to review orientation objectives
Become familiar with different clinical and administrative spaces on campus.
Organize cubicle space, and inform AA’s of needed supplies.
Obtain Cerner, Outlook, Banner Learning Center and EMSS access.
Get Pager, or have cell phone set up for web paging
Obtain recommended articles from supervisor
Provide supervisor and AA’s with contact info
Obtain contact lists from AA’s
Review Orientation Manual
Order lab coats, order business cards, Obtain scrub machine access.
Complete any required Banner Learning Center Modules
Complete any required CITI training
Complete MD Anderson CME Modules
Complete any outstanding credentialing/privileging paperwork.

Week Two, Three & Four: “Learning Clinic”
 Shadow providers in clinic as assigned
 Learn how to navigate Cerner outpatient module
 Learn proper note type and documentation guidelines from preceptors, refer to BMDACC documentation
and Coding Guidelines in Orientation Manual as needed
 Begin to understand billing practices and order entry
 Slowly begin to incorporate order entry and documentation into practice as appropriate
 As appropriate and as delegated, begin to obtain history and physical on patients, discuss differential
diagnoses and plans with preceptor
 Complete any assigned reading or “homework” as delegated by preceptors
 Attend GU Tumor Board
 Attend all appropriate division or APP meetings.
 Complete any pending week 1 items
 Week 4-Meet with Leader & Mentors for orientation check-in
Week 5-10:
“Putting it All Together”
 Work with preceptors to start to determine appropriate treatment plans, how you would document, etc.
 Identify how to place appropriate orders in Cerner
 Each week increase number of patients you are seeing in conjunction with preceptors in both clinic and the
inpatient setting, report physical findings, differential diagnosis and plan to preceptor for feedback.
 Begin to develop accurate differential diagnoses and treatment plans for common patient presentations
 Continue to work on order entry, documentation and billing accurately.
 By week six, you should be able to do a complete note on a common presentation, with little feedback from
your preceptor.
 Become more comfortable discussing pathological findings and treatment plans with patients.
 Each week should show some progression in knowledge and comfort level
 Complete any assigned reading or “homework” as delegated by preceptors
 Attend GU Tumor Board.
 Attend all appropriate division or APP meetings.
 Week 7 & 10-Meet with Leader & Mentors for orientation check-in
Weeks 11-12
“Go Live Weeks”
 Plan to begin to see patients independently in clinic, with mentor and collaborating provider feedback as
needed
 Continue to work on all unmet objectives above.
 Meet with Leader & Mentors to complete end of orientation evaluation

APP TRANSITION TO PRACTICE
Appendix G
Figure 4. Mentor Guidelines
Tips for Effective Mentoring
Thank you for agreeing to help mentor the newest member on your team. New APPs are motivated and
want to learn, they just need someone to guide them into the correct space. Below are some tips to help make sure
you both get the most out of this relationship and that the APP can be successful at our center.














There is no such thing as too much communication.
o The more you are accessible, approachable and honest, but not harsh, the more the APP will
benefit and feel comfortable to learn.
Set clear expectations and goals each week, and more often as necessary.
o If you refer to the APP’s orientation plan that you were given, you will see an expected timeline
for progression. This should provide you with an appropriate pace for your mentee, and prevent
frustration on your part.
o
Work with your mentee each week to determine appropriate goals and let them know your
expectations for what they should be handling.
Let your mentee share in your passion.
o What keeps you motivated at work? Share your passion for that with your mentee. They will
benefit in seeing your enthusiasm and it will inspire them to find their own niche over time.
Try to connect personally
o Mentees need to connect to feel safe and that someone within the organization cares for their
growth and development. Knowing them personally will allow mutual respect to be built.
Trust your mentee.
o Mentees need to feel trusted to grow. They need the space to forge their own path, give them that
room. Let them come up with their own care plans, and intervene when it is appropriate. The
sooner you allow the APP to grow the sooner they will be able to become a critical member of
your team.
o Make sure you find the correct balance between independence and collaboration. Allow the APP
to do the portions of the care that they feel comfortable with, but until they are versed in
management, collaborate with them in developing the plan of care.
Convey knowledge in an interesting way.
o Critical thinking is so much more than recalling anatomy or differential diagnosis from memory.
When a mentee asks questions, don’t just answer them. Try to find a way to pose the question
back to the APP so that they have to critically think through it.
o Look ahead in your schedule, if you see a new diagnosis, have the APP do some reading
beforehand about that diagnosis. Ask them to give you a five-minute synopsis before you see the
patient.
Lead by example.
o Intimidation is not routinely a part of APP training and as such, they will not respond well to it.
Try to be a role model instead of just a teacher or a boss.
o Be cognizant of your interactions with others as well. If you expect your mentee to be respectful of
your whole team, you should be as well.

APP TRANSITION TO PRACTICE
Appendix H
Figure 4. Complete Survey
Screening Questions to Determine Inclusion/Exclusion
1) Is this your first role as an advanced practice provider?
Yes
No
2) Have you participated in any post-graduate training program (APP residency or fellowship)?
Yes
No

TCM Affective Commitment Scale
Instructions
Listed below is a series of statements that represent feelings that individuals might have about the company
or organization for which they work. With respect to your own feelings about Banner Health, please
indicate the degree of your agreement or disagreement with each statement.
1 = strongly disagree
2 = disagree
3 = slightly disagree
4= undecided
5 = slightly agree
6 = agree
7 = strongly agree

1) I would be very happy to spend the rest of my career with this organization.
2) I enjoy discussing my organization with people outside it.
3) I really feel as if this organization's problems are my own.
4) I think that I could easily become as attached to another organization as I am to this one.
5) I do not feel like 'part of the family' at my organization.

APP TRANSITION TO PRACTICE
6) I do not feel 'emotionally attached' to this organization.
7) This organization has a great deal of personal meaning for me.
8) I do not feel a strong sense of belonging to my organization.

Perceived Organizational Support Scale
Listed below is a series of statements that represent feelings one might have with regards to their organization. With
respect to your own feelings about Banner Health, please indicate the degree of your agreement or disagreement
with each statement.
Likert Scale 1-7, 1=Strongly Disagree and 7= strongly agree
1) My organization values my contribution to its well being
2) My organization fails to appreciate any extra effort from me
3) My organization would ignore any complaint from me
4) My organization really cares about my well-being
5) Even if I did the best job possible, my organization would fail to notice
6) My organization cares about my general satisfaction at work
7) My organization shows very little concern for me
8) My organization takes pride in my accomplishments at work
Perceived Competence Scale
Please respond to the following statements in terms of how true they are for you as an APP.
Likert Scale, 1-7, 1=not at all true, 7=very true
1) I feel confident in my abilities as an advanced practice provider
2) I am capable of caring for complex patients.
3) I am able to function as an active member of my clinical team.
4) I feel able to meet the needs of my patients

APP TRANSITION TO PRACTICE
Role Ambiguity Scale
With respect to your role as an APP, please indicate the degree of your agreement or disagreement with each
statement.
Likert Scale 1-7, 1=Strongly Disagree and 7= strongly agree
1) I know exactly what is expected of me.
2) I know that I have divided my time properly
3) I have a clear explanation of the work to be done.
4) I feel certain about how much authority I have
5) I know what my responsibilities are
6) Clear, planned goals and objectives exist for my job.
Demographic Survey
1.

Are you a: Nurse Practitioner Physician Assistant

2.

Which Banner entity is your primary practice site:
Banner MD Anderson Cancer Center
Banner Medical Group
Banner University Medical Group
Another Banner Entity

3.

Which setting do you work in: Primary Care Setting Specialty Care Setting

4.

When did you complete your formal APP education program:
In the past 6 months
Greater than 6 months ago but less than 12 months
>12 months ago

5.

Sex: Male Female

APP TRANSITION TO PRACTICE
6.

Age:

7.

Race: Caucasian African American Hispanic/Latino Native American Other Prefer not to answer

8.

Did you work in healthcare prior to your role as an APP: Yes No
a.

If yes, in which role:

b.

For how many years did you previously work in health care:

APP TRANSITION TO PRACTICE
Appendix I
Table 4

Demographics of Sample
Full Cohort

Intervention Cohort

N=17

N=5

Nurse Practitioner

10 (58.8%)

2 (40%)

Physician Assistant

7 (41.2%)

3 (60%)

Male

4 (23.5%)

1 (20%)

Female

13 (76.5%)

4 (80%)

Average Age

32 (+ 5.44)

29.8 (+5.35)

Previous Healthcare Experience

12 (70.6%)

2 (40%)

<6 Months

4 (23.5%)

0 (0%)

6 Months to 12 Months

6 (35.3%)

4 (80%)

>12 Months

7 (41.2%)

1 (20%)

Primary Care

5 (29.4%)

0 (0%)

Specialty Care

12 (70.6%)

5 (100%)

15 (88.2%)

4 (80%)

African American

1 (5.8%)

0 (0%)

Latino/Hispanic

1 (5.8%)

1 (20%)

Profession

Sex

Time Since Graduation

Practice Setting

Race
Caucasian

APP TRANSITION TO PRACTICE
Appendix J
Table 5

Assessment Tool Mean Scores and Ranges
Intervention Cohort

Non-Intervention Cohort N=12

N=5
MeanTCM-ACS Score

46.2 (+4.34)

32.9 (+10.59)

40-51

11-47

49.8 (+4.60)

32.6 (+11.66)

POSS Min-Max

44-55

9-48

Mean PCS Score

23.6 (+2.30)

22.2(+4.43)

22-28

14-28

35.0 (+2.54)

31.7 (+5.91)

32-39

22-41

TCM-ACS Min-Max

Mean POSS Score

PCS Min-Max

Mean RAS Score

RAS Min-Max

APP TRANSITION TO PRACTICE
Appendix K
Table 6

Mann-Whitney U Results
Assessment Tool

Cohort

Median

TCM Affective Commitment Scale
TTP

45.0

Non-TTP

34.0

Perceived Organizational Support Scale
TTP

48.0

Non-TTP

32.5

Perceived Competence Scale
TTP

22.0

Non-TTP

23.5

Role Ambiguity Scale
TTP
Non-TTP

35
31.5

Z

p

-2.538

.009

-2.747

.004

-.053

.959

-1.426

.160