Introduction: Transition Challenges Among Medical Assistants

My organization employs approximately 850 medical assistants (MAs), considered nursing support, in ambulatory care. There is a wide range of educational and experiential backgrounds among the MAs; some have completed MA diploma or associate degree programs, and others gained experience via on-the-job training through a previous employer. Formal education programs vary considerably in clinical preparation, ranging from fully online to robust hands-on clinical experiences. In Pennsylvania, certification and graduation from an MA program are not required, and MAs begin practice with markedly different levels of clinical skills, professional behaviors, and workplace readiness.

In late 2024, the MA turnover rate at my organization reached 38%, and engagement scored 3.66, prompting ambulatory leadership to conduct an A3 analysis to understand contributing factors. Ambulatory leadership conducted stay interviews with various MAs and categorized their feedback into themes. Among the themes were opportunities to strengthen practice readiness through onboarding and professional development. As part of a broader operational strategy to improve MA engagement and retention, this information was shared with my NPD director and me, along with a request to develop a residency-style program to boost clinical training and preparation for the “real world.” Key findings included:

• Variable clinical exposure and limited hands-on clinical skill readiness
• Lack of professional and workplace readiness skills
• Challenges with pace and expectations of role
• Difficult to train in flow due to staffing barriers

The literature is clear: turnover disrupts clinical flow, fragments care continuity, and carries significant cost (Lyon, C. et al., 2022). What is less clear is how nursing professional development (NPD) departments can intentionally design the onboarding experience of MAs to strengthen engagement and retention from the start.

Residency and transition-to-practice (TTP) models are well established in nursing and are associated with improved competence, satisfaction, and retention (Baharum et al., 2023; McGregor et al., 2024; Cadavero et al., 2025). In 2025, the American Academy of Ambulatory Care Nursing (AAACN) collaborated with the national Vizient/AACN Nurse Residency Program to integrate ambulatory-specific TTP content (AAACN, 2022; Vizient, 2025). The collaboration reflects a growing recognition that structured transition support is needed across practice settings, including ambulatory environments where MAs practice. At my organization, MAs practice in ambulatory settings, making these principles particularly relevant. While MA-specific literature remains limited, the expansion of these principles into ambulatory nursing provided a relevant conceptual foundation for this MA work.

Inputs: Diagnosing the Ambulatory MA Transition Gap

In early 2025, my NPD director and I applied ANPD Standard 2, Diagnosis, by partnering with ambulatory leaders to analyze the A3 findings, onboarding practices, key partner feedback, orientation evaluations, and first-year turnover data. Findings validated variability in clinical skill readiness, inconsistent orientation experiences (length and quality), and a need for greater preceptor support. More than 25% of first-year turnover was related to policy violations, highlighting challenges in professional behavior and workplace socialization. Despite these gaps, MAs generally reported feeling welcomed, supported, clear about role expectations, and confident.

A SWOT analysis of the proposed MA residency-style program identified both opportunities and implementation challenges. Leaders anticipated benefits related to retention, engagement, professional growth, and belonging, while highlighting barriers such as staffing coverage, scheduling constraints, learner fatigue, and leadership support needs. These findings reinforced the need for a targeted strategy to support both early-practice success and workforce stability.

Throughputs: A Two-Part Design for MA Transition to Practice

Although the initial request was for a residency-style program, our assessment revealed two distinct onboarding challenges: variability in foundational clinical skills at entry and professional and workplace transition challenges. Because traditional residency programs support progressive professional development rather than remediation of foundational clinical skills, a residency model alone would not address the full scope of the problem. As a result, the concept evolved into a broader TTP strategy designed to support both immediate clinical readiness and continuous professional development. This was particularly important given the percentage of first-year turnover associated with policy violations, suggesting a need for structured support in professional behaviors, workplace expectations, and organizational socialization.

In response, I led a two-part design:

1. Expanded, skill‑based orientation program to address foundational clinical skills early
2. Longitudinal residency-informed MA TTP program to support role transition, professional development, and workforce readiness over time

The primary intended outcome was to positively impact retention among those enrolled in the program. Additional intended outcomes included increasing engagement among novice MAs and fostering professional identity development through support of professional behaviors aligned with organizational expectations. Although these outcomes are important indicators of successful transition to practice, they are more difficult to measure objectively than retention.

Expanded Clinical Skills Day

The NPD department expanded MA orientation from a one-day event to a standardized two-day skills-focused experience for all newly hired MAs, establishing a standardized clinical foundation regardless of prior education, training, or experience. Examples of prioritized high-impact clinical skills included medication reconciliation, injections and reconstitution, dosage calculations, electrocardiograms, and emergency preparedness.

MA Transition-to-Practice Program

A 12-month TTP program was simultaneously designed for graduates of the organization’s MA program academic partner to align with graduation cycles.

Key elements included:

• Hybrid model: learners attend in-person at regional sites with a local facilitator and NPD presenters deliver live content virtually across all locations to ensure consistency.
• On-site facilitators lead learners through discussion-based learning and reflection.
• Self-paced virtual programming is offered to those unable to attend live.
• Professional development topics such as emotional intelligence, communication, time management, well-being, and professional identity are covered.

Outputs: Learning from the First Cohort 

Early data from the first cohort reveal promising signals that the program was both feasible and valued by participants and leaders, despite operational challenges associated with ambulatory practice settings:

• Enrollment: 90.9% of eligible academic-partner graduates transferred into MA roles (20 of 22).
• Attendance: The clinical skills day achieved 100% attendance across staggered start dates; the live TTP sessions ranged from 78.9% to 100% attendance.
• Alternate access: There was nearly 100% completion of self-paced virtual programming for missed live sessions.

At the conclusion of the first year, 75% of MA TTP participants remained in MA roles and 80% remained with the organization (20% turnover). Although the system's overall first-year MA turnover rate increased to 44% during the same period, direct comparison is limited because program participants were existing employees who transitioned into MA roles from other positions and therefore were not included in the first-year turnover metric. As a result, the groups are not directly comparable. While this limits direct comparison of turnover outcomes, the retention of program participants provides an encouraging signal that warrants further study in future cohorts.

During the implementation period, overall MA engagement scores within the organization increased from 3.66 to 3.90. Although this improvement cannot be directly attributed to the TTP program due to concurrent organizational initiatives, it represents an encouraging trend within the targeted workforce population.

Several opportunities for refinement were identified to inform the future of the program:

• Encourage standardization of site-level orientation practices to reduce variability in onboarding experiences (such as not having a designated preceptor, or having a separate assignment from preceptor)
• Address operational barriers that contribute to missed live learning sessions
• Re-evaluate program length, as 70% of participants and 50% of leaders perceived the 12-month duration as longer than necessary

Discussion: Retention as a Designed Experience

Retention is an experience we have the power to design. By pairing an expanded skills orientation with a longitudinal TTP structure, greater consistency in onboarding across a diverse ambulatory environment was created. The findings reinforce that retention challenges extend beyond clinical competency alone. The percentage of first-year turnover associated with policy violations highlights the importance of supporting professional behaviors, workplace expectations, and organizational socialization as part of the transition experience.

At the same time, the program surfaced important realities. Orientation quality varies across sites, and additional leadership support is needed to address operational barriers affecting participation. These findings present opportunities to further strengthen onboarding consistency and transition support.

Conclusion

Early results suggest that pairing an expanded clinical skills day with a TTP program is a feasible and scalable approach to MA onboarding and retention. The most important lesson from this work is that successful transition requires both foundational clinical skill development and structured support for professional integration. NPD departments are uniquely positioned to design these experiences and create the conditions that foster engagement and retention.

As the program matures, opportunities remain to expand participation beyond academic partner graduates, strengthen preceptor infrastructure, refine engagement strategies, and evaluate long-term outcomes.

References

American Academy of Ambulatory Care Nursing. (2022). Ambulatory care registered nurse residency white paper. https://www.aaacn.org/practice-resources/transition-practice/nurse-residency-program/white-paper

Baharum, H.; Ismail, A.; McKenna, L.; Mohamed, Z.; Ibrahim, R.; Hassan, N.H. (2023). Success  factors in adaptation of newly graduated nurses: A scoping review. BMC Nursing, 22, 125.

Berggren, A.; Sandoz, A.; Carrillo, A.; Heusinkvelt, S. (2024). Standardized onboarding increases  intention to stay with the organization. Journal of Nurse Practitioners, 20, 105011.

Cadavero, A. A., Pena, H., Brooks, K., Kester, K. M., & Granger, B. B. (2025). A transition to practice  intervention to improve retention. Nurse Leader, 23(4). https://www.nurseleader.com/article/S1541-4612%2825%2900014-X/fulltext  

Duchscher, J. B., & Windey, M. (2018). Stages of transition and transition shock. Journal for Nurses  in Professional Development, 34(4), 228–232. https://doi.org/10.1097/NND.0000000000000461

Lyon, C., English, A., Cebuhar, K., & Emerick, J. (2022). Don’t leave me! Strategies for medical staff  retention. Family Practice Management, 29(3), 5–9. https://www.aafp.org/pubs/fpm/issues/2022/0500/p5.html

McAleer, R., Hanson, L., & Kenny, A. (2023). Characteristics, attributes, and outcomes of allied  health transition to practice programs: A mixed method systematic review. Focus on Health Professional Education, 24(3). https://doi.org/10.11157/fohpe.v24i3.635  

McGregor, H.M.; Scott, M.; Gorham, R.; Hunt, E. (2024). Impact of nurse residency programs on  retention and job satisfaction: An integrative review. European Scientific Journal, 20, 1.

National Healthcareer Association. (2022). Retention best practices: IU Health reduces medical  assistant turnover by 85% with career ladder program and NHA certification [Case study]. https://info.nhanow.com/hubfs/Case%20Studies/NHA_IUHealth_Case_Study.pdf

Vizient, Inc. (2025, March 26). Vizient/AACN Nurse Residency Program announces collaboration  with American Academy of Ambulatory Care Nursing for ambulatory curriculum [Press release]. FinancialContent. https://markets.financialcontent.com/stocks/article/bizwire-2025-3-26-vizientaacn-nurse-residency-program-announces-collaboration-with-american-academy-of-ambulatory-care-nursing-for-ambulatory-curriculum