Hematology/oncology APP onboarding important to 'close the knowledge gap'
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Almost 1.9 million new cancer cases are expected to be diagnosed this year, according to American Cancer Society.
As the volume of patients and complexity of care continue to rise, oncology medical services remain in high demand, highlighting the increased need for well-trained hematology/oncology providers. Although training for hem/onc physicians is strictly outlined with medical school, residency and fellowships, hem/onc APP training is not as clearly defined. Therefore, extensive training and onboarding for APPs is critical to provide an educational foundation to execute safe care to this vulnerable population and ultimately promote top of scope practice.
Initial orientation process
Hematology/oncology is a complicated field requiring formal onsite training for APPs.
Graduation from a nurse practitioner or physician assistant program alone will not adequately prepare these providers to enter the workforce. Very few APPs complete a hematology- or oncology-specific training program and have limited didactic materials throughout schooling on these topics. In fact, Hwa and colleagues found that 80% of surveyed APPs reported that less than 5% of their graduate curriculum pertained to this subspecialty.
The lack of specialty education in school leaves the new graduate unprepared for practice, highlighting the need for excellent mentoring and onboarding procedures. APP fellowships are a great option for training but may not be feasible for all new graduates. Consequently, if an APP is coming to a hem/onc practice as a new graduate or new to this subspecialty, an orientation structure and timeline are important to outline necessary medical knowledge, procedures, patient care knowledge, responsibilities and workflows.
In my experience, outlining the onboarding process in weeks or months has proved to be beneficial. At our institution, the onboarding process begins with an onboarding letter outlining the health system orientation, required classes and hem/onc resources (see Table) that is sent to every APP prior to their start date. At this time, the APP will be set up with appointments to learn the electronic medical record system, tour the facility and meet their new team during the first few weeks of orientation. The collaborative physician and chief APP will meet with the APP separately to form collegial relationships. Meetings with the clinical and leadership teams occur more frequently during onboarding to provide frequent check-ins with the new APP. A separate APP mentor also is assigned to provide support for questions or concerns.
A rough outline of our onboarding process continues as such:
Weeks 1 and 2: Complete required onboarding classes and meetings and begin ASCO’s Education Essentials for Advanced Practitioners. This course needs to be completed within the first year of practice.
Week 3: Provide broad inpatient and outpatient shadowing experiences that pertain to the subspecialty. These may include radiation oncology, pathology, pharmacy, infusion, supportive oncology and palliative medicine.
Week 4: Shadow MDs and APPs within the specialty area.
After practice- and system-level orientation classes are completed, as well as shadowing experiences, the APP will start to work directly with their clinical team. Transition into clinical practice may look different depending on clinical experience and the practice setting.
Transition into practice
Data from Hwa and colleagues and Key and colleagues suggest new hem/onc APPs begin to feel competent around 12 months to 24 months. In certain scenarios, APPs may be expected to immediately jump into clinical practice. But, for APPs new to hem/onc, this is unsafe and unrealistic, as there is a significant learning curve in hem/onc practice to avoid errors and poor patient outcomes.
Inpatient vs. outpatient APPs roles may require extended orientation periods depending on practice patterns and physician oversight. A close collaborative practice with the physician for the first few months during the transitional period is advantageous for the APP. Eventually, the APP should start to complete individual assessments with shared patient visits, discussing most cases with the physician and close supervision. The APP should begin to work more autonomously as he or she becomes more comfortable with the specialty and practice, with the goal of independently seeing patients. This will avoid duplication of work and enhance access to hem/onc care.
Around the 6-month mark, the APP should be independently seeing patients and collaborating with physicians with questions or complex cases. To avoid overwhelming the APP, patient volumes should gradually increase to allow time to review cases, research information and ask questions. Frequent check-ins with collaborative and backup physicians should occur to provide continued clinical feedback, opportunities for professional development and optimization of the APP role.
In conclusion, hiring and onboarding hem/onc APPs is imperative for team building, employee satisfaction and retention. Data from Melnic estimated that APP turnover costs are between $250,000 to $300,000 due to recruitment costs, onboarding and precepting time.
Retaining well-trained APPs is not only important for patient coverage and positive engagement from the clinical team, but also is most valuable for patients. Thorough onboarding is a worthwhile investment for cancer institutions that can help close the knowledge gap for hem/onc APPs.
- References:
- ASCO. Advanced practice provider onboarding and practice guide. 2020. Available at: practice.asco.org/sites/default/files/drupalfiles/2021-01/APP-Onboarding-Guide-1-18-21.pdf. Accessed June 21, 2021.
- Gilliland J. Melnic. How much does APP turnover really cost? 2019. Available at: www.melnic.com/how-much-advanced-practice-provider-turnover-cost/. Accessed June 21, 2021.
- Hart AM and Bowen A. J Nurse Pract. 2016;doi:10.1016/j.nurpra.2016.04.018.
- Hwa YL, et al. J Oncol Pract. 2019;doi:10.1200/JOP.18.00697.
- Key M. Oncol Issues. 2019;doi:10.1080/10463356.2018.1553423.
- Siegel RL, et al. CA Cancer J Clin. 2021;doi:10.3322/caac.21654.
- Vogel W. J Adv Pract Oncol. 2010;doi:10.6004/jadpro.2010.1.1.2.
- For more information:
- Camille Petraitis Valente, DNP, FNP-BC, is director of advanced practice for Levine Cancer Institute at Atrium Health and co-director of hematology/oncology APP fellowship. She can be reached at camille.valente@atriumhealth.org.
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