The transition into the advanced practice role has been historically difficult (Dillon et al., 2016; Pleshkan and Hussey, 2020). Difficulties new graduates face include the sudden increase in expectations, patient care requirements, feelings of inadequacy, and lack of preparedness to make clinical decisions. New graduate advanced practice providers (APPs) are often not ready to practice to the full scope of their license, and lengthy orientations have often become necessary to safely transition them to the world of clinical practice (Morgan et al., 2020). For the same reason, post-graduate residencies and fellowships have become more commonplace across a wide variety of specialties besides critical care.

APPs face multiple challenges and are called upon to make important patient care decisions every shift. These decisions require sound clinical judgment, which takes time to develop (Giuffrida et al., 2023). APPs must be supported through the process of developing clinical judgment. While the literature on transition to practice for nurse practitioners and physician assistants is growing, there is a lack of high-quality research on the ideal way to onboard and orient the new graduate APP to critical care, much less the subspecialty of neurocritical care. How should an orientation program be structured? Should the profession move towards requiring the ever more popular post-graduate residencies or fellowships? A head-to-head study comparing APP knowledge and competencies among those completing such a post-graduate program vs. on-the-job training would be an ideal research question to begin addressing these issues.

In the meantime, the Neurocritical Care Society’s Advanced Practice Provider Orientation Course© (the “Orientation Course”) has proven to be a useful tool to assist in new graduates’ transition into the practice of neurocritical care, and I have designed structured APP orientations around this course with much success. In the absence of high-quality literature specifying ideal APP orientation to the neuro ICU, I recommend that APP supervisors and neuro ICU medical directors use the Orientation Course to provide proper onboarding to new graduate APPs. In my experience, several organizations that provide APPs with access to this course often leave the APP to review the course independently. This is problematic because this leaves the new graduate APP without structure. The new graduate is uncertain of which content is most advantageous to review, first, second, and so on. Furthermore, the course is a financial investment that hospitals should seek to utilize to the fullest extent. I have developed and used an orientation program in the onboarding of APPs using the Orientation Course and outside resources (Table 1). Aside from the educational component, the APP should be introduced to increasing patient care demands in a stepwise fashion over the course of six months.

Ideally, the hospital system would provide access to the Orientation Course. While the APP is undergoing credentialing, the APP should begin by learning the foundations of the anatomy of the central nervous system, neurologic exam, and metabolic encephalopathy. If Advanced Cardiac Life Support (ACLS) has not yet been obtained, the APP should take an ACLS course approved by the American Heart Association. To keep the learning fresh, the rest of the readings may wait until the APP has been cleared to start in the ICU. The orientation program should ideally take place on day shift so the APP has the benefit from learning during rounds and can receive the benefit of more intensive resource availability during daytime hours.

Weeks 1-3

During the first few weeks of orientation, the APP should not be expected to assume direct patient care duties. Rather, the APP should perform neurologic exams both during and outside of rounds to master the neurologic exam. Because the APP has read about neuroanatomy and the neurologic exam, the APP should be critiqued on his or her performance of the exam, as well as questioned about the significance of any abnormal findings noted. Discussions should also revolve around lesion localization so that the material in the readings is brought to life. This should be connected to any demonstrable pathology on neuroimaging when possible.

If possible, the APP should participate in acute stroke evaluations in the emergency department or in other hospital locations. This will allow the APP to practice quickly performing a neurologic exam and calculating the NIHSS score proficiently. During this time, the APP should obtain NIHSS stroke certification and begin Emergency Neurologic Life Support (ENLS) modules. ENLS modules coincide with weekly readings from the Orientation Course. Preceptors and APP supervisors should ensure that the APP meets the expected outcomes for this module and during all future weeks of the orientation program.

Weeks 4-5

During this block, the APP should assume total care of 1 neuro ICU patient. All care should be under the direct supervision of the preceptor, APP supervisor, or physician. The APP should consult with his or her preceptor or APP supervisor and a patient should be selected. Ideally, a patient with a diagnosis corresponding to the weekly readings should be selected to allow for correlation between the readings and the care provided to the patient.

After handoff report has been completed, the APP should review patient data including vital signs, imaging findings, laboratory studies, and previous progress notes and consultations. The APP should speak to nursing staff and obtain updates on the patient’s condition and then perform a neurologic exam prior to rounds. The APP should formulate a preliminary care plan and be ready to present the patient and this plan during ICU rounds. All care should be under the direct supervision of the preceptor, APP supervisor, or physician. All contemplated changes to the plan of care should first be discussed with the preceptor.

This should be the general flow each week for the rest of the orientation.

Week 6

During this week, the APP should be allowed off service to shadow a radiologist for a full week to learn the basic principles of neuroimaging interpretation. Thereafter, the APP should review all neuroimaging on patients under his or her care and discuss those findings with the preceptor. Only after independent review of the imaging study should the APP read the radiologist’s report. Then, the APP should go back to the imaging study to look for the findings noted in the radiologist's report. This consistent behavior will improve the APP’s ability to identify abnormal pathology. During rounds, the APP should be consistently encouraged to attempt to interpret scans, with the appropriate counseling and teaching as appropriate.

Weeks 7-8

The APP should begin to manage 2 ICU patients as well as ICU admissions under direct supervision. The APP should be evaluated on his or her ability to manage these additional responsibilities. While the APP may have been performing vascular access procedures previously, it is at this time that the APP should consistently focus on increasing competency on vascular access procedures. To the extent feasible, all such procedures in the ICU should be performed by the APP. Cardiac POCUS should be introduced to the APP and the APP should perform at least five POCUS procedures each shift under direct observation. The APP should begin more active ventilator management under direct supervision.

Week 9

The APP has now reviewed the modules on airway and ventilator management. The APP should be partnered with a CRNA or anesthesiologist. After observing several endotracheal intubations, the APP should be allowed to perform at least 10 intubations under direct supervision. The preceptor should select uncomplicated patients. Prior to performing any intubations, the APP should be able to verbalize anatomy of the airway, steps of the procedure, and all pertinent considerations. If hospital policy does not permit intubation by APPs, then this block can be repurposed towards more dedicated time learning about mechanical ventilation.

Weeks 10-13

During this block, patient care demands increase. At this time, the APP should have a structured conversation in which his or her performance to date is evaluated. This should be a constructive conversation in which a needs assessment is done and all parties can discuss the APP’s progress. The preceptor should have ample opportunity to discuss his or her observations and suggestions for improvement. If the APP has performed enough of a particular procedure to be signed off, the APP should be signed off at this time. The APP should be reminded to keep logs of all procedures. If needed, a corrective plan should be developed to assist the APP get back on course. The APP should continue to focus on POCUS proficiency.

Weeks 14-17

During this block, patient care demands become more intensive. The APP should carry a panel of at least six patients and manage these patients under direct supervision. The ENLS course should be completed during this time. Another structured conversation should take place during this block in week 15, as this is the last block in which all activity must take place under direct supervision. This evaluation should take a critical look at any areas of needed improvement and the APP should not be allowed to progress into the indirect supervision phase until these remedial needs have been addressed. It is at this time, that the preceptor, APP supervisor, and medical director should begin identifying whether an orientation program should likely be extended for the APP.

Weeks 18-25

This is the final block of the orientation program. The APP should finish the educational modules early in the block. At this time, the APP should be practicing with indirect supervision. Furthermore, the APP should be managing all patients in the neuro ICU, unless the ICU is particularly large and it is felt that the volume of patients is too much for one provider. The APP may manage patients and perform procedures without direct observation, but backup support should be immediately available. The APP should not have solo responsibility for patients on ‘off shifts’ or other times of fewer resources. Preceptors should allow the APP to make clinical decisions and develop plans of care reasonably autonomously.

The block culminates in a final structured ‘check-in’ in which the preceptor, APP supervisor, and medical director formally review the APP’s progress. A decision should be made at this time whether to release the APP from orientation. While now off orientation, the APP should be placed on the staffing matrix with a more experienced provider for the next six months to the extent possible. The APP’s patient load should be carefully selected for the next six months so that the load is not overly complex during this novice year, with complexity of patients gradually increasing.

It should be noted that these recommendations reflect my own thoughts on best practices in the orientation of a new graduate APP to the neuro ICU. It is my sincere hope that more research will be forthcoming on the ideal method to onboard an APP to neurocritical care. Importantly, these recommendations do not constitute clinical practice guidelines nor a consensus statement. These recommendations should not be used for policy, regulatory, or medicolegal purposes. They are only a practical educational guide to benefit neuro ICUs that decided to add new graduate APPs to the neurocritical care team. With concerted effort, these recommendations can greatly facilitate APP onboarding and decrease frustration with the difficult transition to practice.

Table 1. Sample APP orientation program.

†APP will obtain certificate of completion for all modules and pass “Check your knowledge” assessment for all modules.

*includes evaluating laboratory and diagnostic data on pre-rounds and presenting patient and developing preliminary plan of care on rounds.