Building Clinical Trust in APP Programs

The Advanced Practice Provider (APP) workforce is growing dramatically, with the potential to improve access to care, clinician shortages and overall organizational performance. However, many health organizations struggle with building an APP program that functions optimally. Above all issues that may prevent APPs from reaching their full potential, a lack of trust is the foundational problem that must be addressed within healthcare organizations before progress can be made.

Clinical Trust vs. Organizational Trust 

Successful clinical teams foster trust and confidence among physicians, staff, and the community. But, what do we mean by trust? For our purposes, it is important to make a distinction between clinical trust and organizational trust. Interrelated and interdependent, it is necessary to explore both perspectives on trust and evaluate opportunities to improve.

Clinical trust means building relationships amongst team members based on clinical competency, professionalism, and defined roles/scope of practice. Creating clinical trust requires clear communication and accountability, with bidirectional feedback, guidance, and evaluation.

Organizational trust is the alignment between stated values and the realities of daily life within a company. Is the organization really what it says it is when it comes to processes, decisions, honest communication, and genuine concern for employees? Maintaining integrity requires consistent evaluation and early course correction.

Five Ways to Build Clinical Trust

#1: Comprehensive Organizational Supports. This includes essential factors that create the best possible environment for the APP program to be successful. Leaders must be vocal supporters of the APP program, clearly articulating the vision and goals for the team in the context of overall organizational strategy. It means establishing an effective leadership structure. It means investing in leadership training, coaching and development of the entire team to empower members to be active participants in its success. It means building robust evaluation and feedback mechanisms in addition to scheduling methodologies to ensure a well-rounded, capable clinical service. It means aligning incentives with stated goals.

#2: Select the Right People. Organizations must be crystal clear about what the word “right” means. Cultural fit and clinical abilities must be carefully assessed. You can teach skills, but you cannot change people’s values. Use behavioral interviewing, competency assessments and psychometric profiles. In the fierce competition for APP talent, groups must be realistic about the need for inexperienced recruits and how they will be developed. And remember, selection is just the beginning. You must keep good people. The inability to retain talent undermines clinical and organizational trust, and is very costly in dollars and disruption, putting strain on recruiting/onboarding resources, productivity, and teamwork.

#3: Excellence in Onboarding and Transition to Practice. Recent media attention has focused on the wide variability of APP training programs and their focus on general skills rather than specialty training. APP programs may get stuck in this area, with an urgency to fill clinical needs with new hires without proper support on the outset. At best, this leads to misunderstandings and at worst it sets new hires up for failure. Outlining expectations for transition periods is a way to identify knowledge gaps before unwanted events occur in practice. Routine competency-based assessments for new hires normalizes the variability in clinical acumen and allows the team to feel comfortable bringing new hires up to speed. Finally, do not overlook the advantage to bringing on new graduates – they are likely to be more malleable, less rigid about working norms, and lend themselves to coaching in the way the organization needs them to perform.

#4: Reliable Escalation Processes. Escalation refers to the timely resolution of clinical or professionalism concerns raised by a given party. This requires rapid physician availability to consult, verify or teach. It requires clear definition of escalation policies and procedures, in addition to training and management of collaborative relationships between oversight physicians and APP team members. The best escalation processes are designed to strike a balance between oversight and autonomy, leaning away from excessive micromanagement on one end and neglectful latitude on the other. Make sure escalation practices are inclusive, considering everyone on the care team, staff, nursing, patients, and families.

#5: Master the Skill of De-escalation. While formal escalation policies are common within APP programs, equal consideration must be given to the other side of the coin: de-escalating the countless informal concerns that occur during the routine course of business. These micro-events that potentially erode trust may include everything from low-level clinical/professionalism concerns to complaints about micromanagement, communication, process gaps, handoffs, or system challenges. Rapid assessment and validation of such concerns and making people feel heard is the job of the leader. Building trusting relationships is a two-way street, and continuously sharing feedback in a psychologically safe manner is the only way to build a healthy team.

Is your APP program struggling with clinical trust or other barriers to reaching its potential? Reach out to us to discuss more strategies to develop your teams in 2025!

By Rusty Holman, MD, MHM, founder of Resonate Leadership Lab, and Tracy Cardin, ACNP, SFHM