Strategies for recruiting NPs and PAs

Two hospitalists share their program's model for outreach, screening, and interviews.


According to the Society of Hospital Medicine (SHM)'s 2007–2008 State of Hospital Medicine report, only about 27% of hospital medicine groups included nurse practitioners (NPs) or physician assistants (PAs) at that time. Since then, NPs/PAs have proven their value in hospital medicine, working shoulder to shoulder with hospitalist physicians. In 2020, the report showed that 83.3% of hospital medicine groups had NPs/PAs.

Image by Getty Images
Image by Getty Images

These clinicians have become critical to serving a growing hospital medicine patient population. Meanwhile, from 2016 to 2020, the number of accredited NP graduate programs across the country increased from 424 to 518. Programs to train PAs follow a similar pattern: In 2016, there were 238 accredited programs, rising to 260 in 2020 and expected to exceed 300 soon.

This growing applicant pool poses a challenge to finding the best individual for any hospital medicine group. Mismatches between a clinician and the position or facility contribute to turnover. In 2020, according to SHM's report, about 47.2% of hospital medicine groups reported turnover of NPs/PAs annually, as did 92% of groups with 30 or more clinicians (compared to only 51% back in 2018). High turnover necessitates more recruitment drives, which are expensive and time-consuming.

Hence, a carefully designed, well-structured recruitment process is essential. An initial investment in selecting the right candidate pays extraordinary dividends later. Through years of experience, we have refined our process, divided into three different phases: outreach, screening, and interview.

Outreach

There is significant competition among recruiters to find the best applicants. To succeed in this competition, it is vital for a hospital medicine group to proactively develop a strong outreach program. A program may be as simple as word of mouth or might include widespread publicity through job websites or media. We have found that investment in online publicity offers an advantage over other approaches, with a broader reach that captures the attention of potential candidates quickly.

The posting of a vacancy should accurately describe the position and outline expectations clearly. Typical locations to post a position include an organization's website, professional association websites, and private job websites.

One of the most rewarding recruiting approaches is to collaborate with educational institutions. Hospital medicine groups can approach NP/PA schools, residency programs, and fellowships, particularly nearby ones. The best way to promote your practice with educational institutions is to offer mentorship through student preceptorships. Our group has hired 20% of our NP/PA workforce through this approach. When students rotate with a group, they get firsthand experience, and the group has an opportunity to show potential hires what it has to offer. This is a true win-win, as hospital medicine leaders also get to observe the NP/PA candidate in the clinical environment. Other ways to promote your hospital medicine group to local students include participation in job panel discussions or lectures on clinical or career topics. These strategies require time investment but can help build a robust network for future hiring.

Several fellowship programs have been designed for NPs and PAs, at least 10 of them specifically for hospital medicine. These fellowship programs are typically started by institutions as a pipeline for recruitment, but there may be more graduates than open positions. Hence, it could be valuable for hospital medicine groups to look for these programs and request that their open positions be shared with graduates for consideration. Thanks to the focused training in hospital medicine, fellowship graduates do not need as extensive onboarding and could be ready to work independently sooner.

Screening

Over the last two years, our group has experienced an exponential increase in applicants. Just two years ago, the center had more positions than applicants. Now, we receive about 20 applications per position. This makes it more important to have proper screening filters to find the best possible match, the next phase in our recruitment process.

The cover letter and curriculum vitae offer the first opportunity to assess potential candidates if they are not already known to the group. Develop your screening criteria based on institutional needs and expectations for a particular position, and use them to narrow the applicant list to the top few candidates appropriate for the available position.

At our group, after initial screening, candidates are contacted for telephone interviews. The phone interview offers a faculty member the chance to ascertain the candidate's potential fit with our group in an effective, efficient way. We make a point to focus on issues such as work culture, roles and responsibilities, life as a clinician in our program, and scheduling/time commitments. We discuss expectations, a quick overview of benefits, moonlighting opportunities, and the salary range for the position. Discussing salary up front avoids wasted time for both parties.

By the end of the call, the applicant should have a clear view of the position, and our faculty member should have an assessment of the applicant's interpersonal skills, potential fit with our group, qualifications, and specific areas of interest. If the applicant and our faculty leader feel that we should proceed after this thorough discussion, we request that the candidate provide a list of three references.

In checking references, we look for red flags and notable strengths. This can typically be accomplished through a five-minute phone call. References most frequently help confirm that the candidate would be a good match and that his or her goals align with the group's mission. Although it is fortunately uncommon, we have found that references at times reveal issues over the phone that they might not have included in a written letter of recommendation, making the minimal time investment required to briefly check with references worthwhile.

Interview

If the phone conversations with the candidate and references give a positive global impression, we invite the candidate for an interview. While we greatly prefer bringing in candidates for an on-site one-day interview, the COVID-19 pandemic has led to a modified interview process conducted virtually through an online platform. Whether virtually or in person, candidates meet with faculty members as well as administrative staff.

The nature of a candidate's interaction with the administrative staff is a vital component. The way candidates treat administrative staff may reveal a lot about their interpersonal skills and respect for others. Each candidate will also have face-to-face interviews with three or four hospitalist physicians for about 30 minutes each. Candidates also meet with representatives of the advanced practice provider (APP) group. Based on availability, some APPs meet with candidates individually as well. A brief evaluation form is completed by all evaluators. This form has three standard questions to elicit strengths, weaknesses, and an overall impression of the candidate's potential for hire.

Following these individual and group interviews, the candidate participates in a clinical panel discussion. Pre-employment personality tests and group discussions are now common in non-health care industries. Inspired by the concept of a group discussion, the panel is an avenue for the interviewee and interviewers to get to know each other. This panel discusses different scenarios that a candidate could encounter in day-to-day practice with our group. Given significant variability in skill sets among applicants, the scenarios are valuable for providing an objective assessment of a candidate's clinical skills in hospital medicine.

Our clinical panel is comprised of two physicians, two senior NPs/PAs, and one moderator (nonclinical administrative staff) who discuss five to six different cases. Each scenario includes presenting symptoms, vital signs, physical examination, essential labs, and imaging findings. Every case scenario has a sub-scenario (such as a new symptom developing while hospitalized or a worsening existing symptom) and a few follow-up questions.

This panel discussion might appear daunting for some candidates. To alleviate concerns, our moderator speaks with a candidate prior to the panel to demystify the process and provides a pep talk to foster a positive atmosphere. This role of the moderator is vital. The moderator additionally acts as a timekeeper during the panel to keep on schedule.

Candidates' responses to the scenarios are assessed in four categories: medical knowledge (depth of clinical knowledge, understanding of the clinical scenario and appropriate work-up), problem-solving ability (ability to effectively address issues like someone leaving AMA), critical thinking (presenting differentials for a particular scenario and rapidly responding), and resource utilization and collaboration (knowledge and use of available resources within the system, consultation when appropriate). A scale of 1 to 5 is used to score candidates on each category in each scenario, with 5 as the highest score.

When the position involves cross-cover duty on swing or night shifts, a supplementary section is added to the clinical panel. In this section, called the rapid-fire round, we pose open-ended questions to simulate nursing calls during cross-cover shifts. These scenarios compel candidates to think about differential diagnoses and respond accordingly. Questions are designed to assess candidates' problem-solving ability and critical thinking, particularly under pressure. For example, candidates are asked to respond to a nurse calling about a patient with chest pain and stable vitals.

Our clinical panel offers a more objective measure of an applicant's clinical skills than a typical interview or reference check. Before it was introduced, we relied heavily upon the references and screening questions to assess a candidate's ability to manage the degree of complexity encountered in our patient population. An assessment of the shortcomings of our process inspired the creation of the clinical panel. It also offers the candidate a good overview of common scenarios that might come up, as well as a better understanding of our patient population and clinical expectations.

After the panel discussion, the panelists review their grading together. Scorecards with comments are then submitted to the recruitment committee.

The COVID-19 pandemic introduced challenges to this process, but it did not affect our basic structure. Instead of on-site visits and lunches, now we connect virtually with candidates through online platforms. There are certainly limitations as we don't provide facility tours, and virtual interviews can feel less personal, but we are adapting and the overall steps remain the same.

Based on evaluations from one-on-one interview assessments, group meetings, and the clinical panel discussion, the recruitment committee meets within two to three business days and makes the final determination on which candidate to select for the position. It is imperative to move efficiently after an interview, as some desirable candidates may have multiple offers.

Conclusion

This comprehensive recruitment process includes multiple important steps that require coordinated efforts from the group. Time investment is crucial to develop an outreach program, screen potential applicants from a growing pool of NP/PA candidates, and optimize the interview.

The recruitment process can be refined with time, as the recruitment committee observes what works well and what aspects are suboptimal. Our historical practice of posting a position in a single location has blossomed into an outreach program in which we proactively reach out to candidates through multiple strategic postings, opportunities for shadowing/observerships at our institution, and queries to schools in our community.

We frequently review each component of the recruitment process to ensure we continue to adapt. Our faculty member leading the recruitment effort collects feedback from candidates after the interview process. This can be valuable information. If, for example, salary is a hindrance to recruitment, hospital medicine leaders might need to advocate for pay raises.

The data supporting our approach are limited to verbal feedback, and we have a relatively small sample size, but based on individual interviews with new hires and existing faculty, we believe that new recruits are fitting well within the organization, with improved working relationships and better job satisfaction among clinicians, since its implementation in April 2019. Faculty involved in our recruitment process have more confidence in the abilities of incoming NPs/PAs. Candidates selected through this well-structured recruitment process have a smoother onboarding process. We also expect that employee retention will be better.