For NPs, Residency Programs Gain Favor


 
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By Shannon Firth and Laura Marsan FNP-C

After completing her master's degree as a nurse practitioner, Corinna Michels, ARNP, a primary care clinician in Yakima, Wash., traveled to Cali, Colombia, on a Fulbright grant to research prenatal care before entering practice.

"I knew I wanted to have a little bit more support" on her return than classmates who appeared to be floundering in their career choices, said Michels.

She discovered the Sollus Northwest Family Nurse Practitioner Residency Program, part of the Yakima Valley Farm Worker's Clinic, a group of community based health centers dedicated to serving vulnerable populations with complex health needs. The region is a major produce-growing area with large numbers of immigrant workers, many of them undocumented. Out of 20 applicants, she was among only three residents to secure a spot in the program.

Since 2007, post-graduate programs like the one Michels attended, have grown across the U.S. but, lacking the consistent federal funding that supports physician residencies, their development and sustainability remain uncertain.

Changes in the American healthcare system have thrust nurse practitioners into roles not envisioned when the specialty was first introduced. Their patients now often have complex health needs -- multiple chronic illnesses, psychosocial problems, and inadequate supports -- and the hospital systems and clinics that hire them are struggling to keep them in safety net primary care settings.

A 2010 Institute of Medicine report recommended the development, funding and evaluation of post-graduate "transition-to-practice" training programs for nurse practitioners. The report, however, noted that safety and quality of care data across multiple settings offers little evidence for mandating such programs.

Making The Case

The drive for nurse practitioner residencies has been supported by a small body of qualitative research and in particular the needs expressed by graduates of nurse practitioner programs.

A 2004 survey found 87% of nurse practitioners said they would be interested in post-graduate training if it were available to them. Only 10% of the sample -- 562 respondents from two nurse practitioner conferences -- felt they were well prepared for practice and 51% said they were "somewhat" or "minimally" prepared

Having worked in primary care since the 1980s, Margaret Flinter, APRN, PhD, senior vice president and clinical director of the Community Health Center in Middletown, Conn., watched "brilliantly educated, amazingly committed," new nurse practitioners struggle in their first year of practice.

"The amount of clinical experience and training that one has in that context ... is insufficient for people to enter practice particularly in the very challenging environment of the role of primary care provider and the setting of community health centers," she said.

In 2007, she founded the nation's first nurse practitioner residency, and its basic design has been replicated by programs across the country, consisting of specialty rotations, supervised hours by physicians and nurse practitioners in primary care, time working in a partner clinic, and lectures. There are now 38 such programs nationally, by one count.

Lack of Funding

The federal government, through the Centers for Medicare and Medicaid Services, subsidizes the mandatory physician residency programs. In contrast, most current nurse practitioner residencies, even those in so-called Federally Qualified Health Centers, are internally funded.

Flinter and others continue to lobby for government monies to expand residencies. In 2008, an amendment authorizing the establishment of a residency training demonstration program for family nurse practitioners in federally qualified health centers and other safety net sites passed as part of the Affordable Care Act. She called it an "almost win," since Congress never made the appropriation.

A 2014 bill with monies for the programs, introduced by Sen. Bernie Sanders (I-Vt.), failed to pass.

The Health Resources and Services Administration issued 3-year grants for developing nurse practitioner residencies from September 2010 to 2013 to three sites. However, at least two of these programs have since closed, according to Flinter.

One obstacle to coaxing more federal money is that very little hard evidence exists to demonstrate an impact of post-graduate nurse practitioners residencies on performance. Proponents argue the field is too new to expect proof.

Pay Cut

As well, there are concerns that such program, as long as they remain voluntary, might not attract many participants. Some nurse practitioners voiced concerns that residency programs would, in effect, involve taking a pay cut to do essentially the same work in a more difficult environment.

"For some people it's a solution looking for a problem," said David Vlahov, RN, PhD, former dean at the University of California San Francisco's School of Nursing.

But he agreed that, especially for NPs who've completed a direct master's entry program and are eager for that additional "supervised practice," there can be clear benefits.

The chance to work alongside other clinicians, building "rapport and confidence" in each other's skills is incredibly valuable, Vlahov said.

At the Center for Advanced Practice (CAP) Fellowship at Carolinas Healthcare System, based in Charlotte, N.C., the largest fellowship in the country, there are 10 applicants for every one spot, said Britney Broyhill, DNP, ACNP-BC, who prefers the term "fellowship." There are 68 fellows at CAP, where the program includes both physician assistants and nurse practitioners.

Nationally, most residents are paid 60% of market value and receive benefits, said Flinter. The VA Centers of Excellence in Primary Care Education (CoEPCE) program allocates stipends.

As for job satisfaction, two researchers conducting a survey of 254 NPs found that almost 70% of those completing residencies were "satisfied" or "very satisfied" whereas just over 50% of those without post-graduate education rated themselves that way.

"The opportunity for growth," said lead author Charles T. Bush, DNP, of the University of North Carolina, is one of the strongest determinants of satisfaction among the study's participants, and that increased opportunity spells higher incomes.

"If satisfaction translates to retention, employers can get a return on their investments by funding these programs," he said.

The researchers acknowledged the study was limited by its recruiting methods: emailing invitations to program directors.

Straw Man

In 2014, several prominent nursing groups issued a statement that declared, "NPs are prepared to provide safe, high quality patient care from the point of graduation."

Implying that there may be a move afoot to make residencies mandatory, the statement continued, "There is no evidence to justify additional delays or costs to taxpayers to support mandatory post-graduate training or to impose ADDITIONAL regulatory constraints to the new NP upon entry into practice" [emphasis original].

The source of the groups' concerns is unclear. Flinter has never called for making residencies a requirement. None of the sources interviewed suggested it, either.

"What I would like to see is that every new nurse practitioner who wants to be a primary care provider and feels like to be the best primary care provider they can be in the setting they'd like to be in [and] would like to do a residency, I would like for there to be the capacity for each of them to find a residency," Flinter said.

"Everybody shares the same goal, you want nurse practitioners that have the breadth and the depth of preparation to be confident and qualified in their roles as NPs," said Kitty Werner, MPA, executive director for the National Organization of Nurse Practitioner Faculties (NONPF).

Intensify Master's Level Training?

She understands the rationale for developing residencies (she, too, prefers the term "fellowship") but would rather see intensive training better integrated into master's level educational programs, such as the 4-year $200 million Graduate Nursing Education (GNE) demonstration project funded by the Centers for Medicare & Medicaid Services, and included in the Affordable Care Act as a helpful intervention.

Licensing for nurse practitioners requires 400-600 clinical hours "precepted" by a nurse practitioner or physician, explained Linda Aiken, PhD, RN, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing -- one of the sites chosen for the GNE demonstration.

Aiken said the shortage of preceptors is "the single biggest barrier to increasing the number of nurse practitioners in primary care," she said.

She views preceptor programs and residencies as two paths seeking out the same point. But, she added, "I think the train is going towards preceptors and not towards residencies in terms of public support."

Asked whether both educational models could be supported by government programs, she said, "I don't personally think it's feasible that they would both be funded by external sources."

However, she's confident residency programs could be "very useful, if they could be financially supported."

 

Laura Marsan, FNP-c, has applied for NP residency programs in the past. Some of the sources in this story are individuals she met during that process.


 
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