In 2013, one of our emergency department (ED) teams found itself in the challenging position of training five new physician assistants (PAs) at once.
Following our practice's internship model
, recent graduates and PAs transitioning from another specialty were paired with an experienced colleague for 12 to 15 shifts. This arrangement was intended to provide extra support as the new hires sharpened their skills and practiced managing multiple patients.
The new hires seemed to make good progress during this orientation/training period. But once they "graduated" and started working independently, they struggled with various aspects of the job. Some couldn't keep up with the department's brisk pace or meet their productivity goals, while others struggled with documentation or medical decision-making. For several months, the new hires relied heavily on their more seasoned colleagues to get through each shift.
As I debriefed with this team, I realized we had been shortsighted in focusing all our training on our new hires. Simply put, being a seasoned veteran doesn’t necessarily equate to being an effective preceptor. The preceptors also need training to maximize their abilities to transmit their knowledge and clinical skills.
In short, preceptors need help to become great teachers.
After hearing similar sentiments from teams around the country, we decided to rethink how our organization on-boards new hires. From these conversations, a new "master trainer" model has been conceived.
The Growing Need for Trainers
For many physician groups and hospitals, recruitment and retention of PAs and nurse practitioners (NPs) has become a survival imperative. These professionals are increasingly filling the access gap created by physician shortages and expanding healthcare coverage. And as reimbursement shifts toward fixed payments, organizations are increasingly looking to PAs and NPs for cost-effective care.
According to the US Bureau of Labor Statistics, the number of PA positions is expected to grow by 38 percent
between 2012 and 2022. But as new grads join the workforce in increasing numbers, there are proportionally fewer "veterans" to mentor them and help them bridge the knowledge gap
between school and practice.
Seasoned providers who are transitioning to a new environment can also benefit from training and mentoring. My own group is working to integrate PAs and NPs into all practice lines of our multispecialty organization, and the transitions can be difficult. For example, a provider moving from a urology practice to the ED goes from seeing patients one at a time in a linear fashion to managing multiple complex cases at once. He or she also needs time to master procedures like suturing, joint reduction, casting and nasal packing.
In short, the need for preceptors has never been greater. But as any clinical leader will tell you, enlisting them is easier said than done.
Where Have All the Trainers Gone?
I have found through networking that most PAs and NPs are altruistic and really want to give back to their professions. But the pressures of medicine and business can be daunting, and altruism alone is not enough for most to step forward.
In my opinion, there are four reasons why seasoned providers hesitate to become preceptors.1. They worry they aren’t adequate.
While most veterans are quite confident in their own skills and decisions, taking on a teaching role means answering the more complex “why” questions.2. They don't have time.
Most preceptors do their training and mentoring during their clinical hours. This can require quite a balancing act, especially when the site is already short-staffed with PAs and NPs. Doing the preceptor job well means attention to:
3. It doesn't make financial sense.
- Learning goals and benchmarks for both the program and organization.
- Understanding teaching and learning styles and marrying these to individuals.
- Awareness of cultural and age differences that impact learning. (We currently have three generations in the workforce, each with very different values and perspectives toward work.)
- Judgment: knowing when to step in and when to let the trainee persevere through a difficult situation. Sometimes the latter approach is appropriate to help new professionals develop situational awareness and medical decision-making.
- Guiding succinct, meaningful documentation.
Most sites don't compensate preceptors for the additional time and mental effort the role requires.4. Their contributions aren't recognized.
In many places, training is just something providers are expected to do once they reach a certain point in their careers or based on the needs of their work environment.
So what happens when there's a dearth of preceptors? One solution my group has employed is to allocate resources to new hires. Sending a new hire to external courses like the Emergency Medicine Boot Camp, creating educational webinars, modules and developing-skills seminars are beneficial.
Such programs do a great job teaching procedures and core knowledge. However, they don't provide a mechanism of real-time reinforcement or immediate feedback on the job. Nor do they help the new provider integrate into the team, hospital and practice.
Inspiration from Baristas
The idea for a better long-term solution to the training issue came to me while I was chatting with my neighbor, who's a regional manager for Starbucks.
Have you noticed that a Starbucks nonfat, light-whipped vanilla latte tastes exactly the same, whether you order it in Chicago, Los Angeles or Shanghai? That's because Starbucks created a “Barista School” a few years ago. They used a core group of "master baristas" to train “trainer baristas,” who then took that training and knowledge back to their respective Starbucks locations.
As a follow-up, the “master baristas” travel to the stores to assess the education happening there. When they see a local trainer deviating from protocol, they step in and provide real-time knowledge assessment and retraining on the spot. This approach provides quality assurance, keeps training consistent and ensures that the brand delivers a uniform customer experience.
This got me thinking. Could we apply the same model within our practice? What if we created a robust, centralized preceptor program that not only taught new skills but also instilled our mission and values — all while increasing new hire retention and promoting earlier effectiveness?
Ideas Take Shape
In 2014, our practice started laying the groundwork for such a program, with emphasis on the following elements:
- Train the trainer course. This would be open to PAs and NPs who seek career development by serving as preceptors at their sites. Under the supervision of master trainers, participants would have the opportunity to “sharpen the saw” by self-assessing their current knowledge fund, learning how to effectively adapt their teaching style to different learning styles and by honing their skills with practical simulation and role-play. Master trainers would then visit the sites to observe the training process and provide additional guidance and support.
- An elevated role for preceptors. Both master trainers and site-level preceptors would be recognized for their contributions. This might take the form of CME credits, access to professional development opportunities, recognition at group events and even awards.
- Support for new professionals. Having a robust education program would allow more sites to formalize their new hire on-boarding and education programs. This will serve as a valuable recruiting tool and strengthen our group's relationships with PA and NP training programs. It would also improve retention and earlier effectiveness of new hires and lessen the financial and emotional toll of cyclic attrition and rehiring.
- Concrete learning goals. We would work to formalize the curriculum of knowledge, skills and competencies for each role in such a program. In that way, the learners of today can become the preceptors of years to come as they develop their careers.
- Quality: Most importantly, the goal of such a program would be to deliver a consistent, high-quality product to our patients, regardless of which “shop” they visit.
Response to the idea has been enthusiastic. We've already identified several program educators and clinical instructors within our practice's ranks who would likely serve as our inaugural master trainers. Local PA and NP training programs have also expressed enthusiasm and have offered the use of a simulation lab and other facilities. We've also gained initial interest and support from some professional groups, including the Physician Assistant Education Association (PAEA)
and American Academy of Physician Assistants (AAPA)
While the program is in its early stages, we hope to report back from time to time on our progress. Our greatest hope is that we can develop a solid model that can be adapted by hospitals and practices across the country.
In the meantime, I would encourage those providers with a desire to pass on their knowledge and skills to do so. PA and NP programs are starving for clinical preceptors. You don’t have to know everything. No one expects that. Don’t be so afraid of not knowing everything that you don’t take the time to share what you do
know. Your experience and dedication are crucial to shaping future clinicians and professionals.
How does your team meet the challenge of onboarding new providers? Comment below to tell us about it.
[Image credit: "Dr. Breuder Nursing Lab Simulation 2013 23" by COD Newsroom licensed under CC BY 2.0]