DEPARTMENT

Professional Issues

Advanced Practice Nurse Fellowships: Creating Awareness, Creating Opportunities Meredith Kells, MSN, RN, CPNP, Kelly Dunn, MSN, RN, CPNP, Maurice Melchiono, MS, RN, FNP-BC, NE-BC, & Pamela Burke, PhD, RN, FNP, PNP, FSAHM, FAAN KEY WORDS Advanced practice nurses, nurse practitioners, fellowship, education, training

Section Editor Andrea Kline Tilford, MS, RN, CPNP-PC/AC, CCRN, FCCM Rush University College of Nursing Chicago, Illinois Meredith Kells, Inpatient Medicine Pediatric Nurse Practitioner, Boston Children’s Hospital, Boston, MA. Kelly Dunn, Short Stay Unit Discharge Coordinator, Boston Children’s Hospital, Boston, MA. Maurice Melchiono, Director, Ambulatory Programs, Boston LEAH Program Faculty (Leadership Education in Adolescent Health), and Co-Director for Nurse Training, Boston Children’s Hospital, Boston, MA. Pamela Burke, Associate Professor of Nursing, Northeastern University, Boston LEAH Program Faculty (Leadership Education in Adolescent Health), and Co-Director for Nurse Training, Boston Children’s Hospital, Boston, MA. Conflicts of interest: None to report. Correspondence: Meredith Kells, MSN, RN, CPNP, Children’s Hospital Boston, 300 Longwood Ave, 7 West Inpatient Medicine, Boston, MA, 02115; e-mail: [email protected]. edu. J Pediatr Health Care. (2015) 29, 297-301. 0891-5245/$36.00 Copyright Q 2015 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. Published online December 19, 2014. http://dx.doi.org/10.1016/j.pedhc.2014.10.003

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Very few specialty training programs are available for advanced practice registered nurses (APRNs), and those that do exist are underfunded. The Development of fellowship model has more nursing been an effective fellowship educational venue for our physician colprograms is an leagues. Medical feleffective strategy to lowships are a time of address the lack of training after residency when physicians specialty training hone their clinical and could advance and research skills APRNs’ clinical and within a particular area of specialization. research skills. Development of more nursing fellowship programs is an effective strategy to address the lack of specialty training and could advance APRNs’ clinical and research skills. Within the parameters of their training, certification, and state regulations, APRNs may practice in ambulatory or inpatient settings and may focus on certain subspecialty areas such as cardiology or pulmonology. However, unlike our physician counterparts, formal training for these subspecialty positions is often limited. Some APRNs may achieve high levels of specialization by first working in an area as an RN for a number of years and then continuing in that area when they transition to an APRN role. Other APRNs may come new to a patient population and learn through a specialized orientation, or learn on the job. This ‘‘on the job’’ training as an RN or APRN, while a valuable experience, May/June 2015

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does not replace formal education, training, and certification with that population and lacks the structure and breadth of a formal fellowship training program. The purpose of this article is to describe a variety of APRN fellowships, including the Leadership Education in Adolescent Health (LEAH) Interprofessional Fellowship Training Program at Boston Children’s Hospital, which two of the authors completed in 2011-2012 and 2012-2013. We will present an overview of available APRN fellowships, benefits and challenges of fellowships, and the potential role of fellowship training for APRNs in the changing state of health care. APRN FELLOWSHIPS Several fellowship programs have been created for new graduates of APRN programs. These fellowship programs are institution-specific and typically serve as a combination of orientation and specialty training. Established programs have been described in the emergency department (Varghese, Silvestri, & Lopez, 2012), perinatal care (Bradley & Spencer, 2011), and perioperative care (Graling & Rusynko, 2004; Sandhusen, Rusynko, & Wethington, 2004). These fellowships are usually found in large academic centers, but some opportunities may be found in community hospitals. An interprofessional fellowship program inclusive of APRNs offered at Monell Chemical Senses Center in Pennsylvania included doctorally prepared nurses (not exclusively APRNs) in a research setting (Blank, 1993). In this program, Nurse Fellows conducted research collaboratively with fellows in biochemistry, physics, and other scientific disciplines. Although the resources available in this program were beneficial, and participants gained advanced research and grantwriting skills, there was no clinical care component. The Neurovascular Education and Training in Stroke Management and Acute Reperfusion Therapy (NET SMART) fellowship (Alexandrov et al., 2009) prepares APRNs to provide neurovascular care and leadership. In this fellowship, academic content is standardized, and a supervising physician provides oversight of clinical training. Specific competencies such as interpretation of imaging studies and treatment of acute stroke are taught through video lectures and 80 hours of ‘‘clinical validation.’’ Pre- and post-testing showed that both new and experienced APRNs demonstrated knowledge growth and improved clinical competency. After training, fellows increased their clinical responsibilities and reported benefits of the program, including clinical experience, performance feedback, and networking (Alexandrov et al., 2009). In one health care system, research demonstrated the potential benefits of employer-offered APRN fellowship programs created to fill vacant positions in the operating rooms. The fellowship included classroom lectures, a skills lab, and precepting in the clinical 298

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setting. A return on investment analysis conducted on this program demonstrated an improvement in recruitment and retention (Sandhusen, Rusynko, & Wethington, 2004). Nurse fellows who completed the program were asked to make a 2-year employment commitment in return for the financial investment allotted to fellowship training. Benefits of the fellowship included a core group of APRNs with specialty training in perioperative care. The Leadership Education in Neurodevelopmental and Related Disabilities (LEND) fellowship program is funded by the Maternal and Child Health Bureau (MCHB). LEND was initially developed in the 1950s to identify children with special health care needs. There are presently 43 LEND programs in 37 states (Association of University Centers on Disabilities, 2013). The fellowship is interprofessional and typically includes medicine, nursing, psychology, physical therapy, neurology, public health, social work, and other disciplines. The Nursing Trainee program is offered part time over 9 months, with lasting opportunities for networking and collaboration that continue after the fellowship has ended. The Nurse Fellow spends one day in clinical settings, as well as time on a core curriculum, research, and leadership activities. A nursing leadership fellowship program has also been described for APRNs. The Postgraduate Nursing Fellowship was designed at one medical center to be an administrative fellowship, in which an APRN worked in conjunction with the chief nursing officer. This fellowship included projects geared toward the fellow’s professional needs and interests and included project design and management (Mahaffey, Kaplan, & Triolo, 1998) to strengthen the APRN fellow’s career. The Robert Wood Johnson Foundation Executive Nurse Fellows program is an advanced leadership program for nurses in senior executive roles. The goal is to support the advancement of nurse leaders in ‘‘health services, scientific and academic organizations, public health and community-based organizations or systems, and national professional, governmental and policy organizations’’ (Robert Wood Johnson Foundation Executive Nurse Fellows, 2013). Twenty nurses are selected annually to participate in the 3-year fellowship, which requires a total of 4 weeks of full-time participation and distance learning; fellows may remain at their home institutions throughout the program. Participants do not need to be APRNs, although many of the Executive Nurse Fellows in the first three cohorts had masters or doctoral degrees in nursing or other fields. A survey conducted in 2010 sought to reveal the impact of the program on the 222 alumni. The respondents reported enhanced leadership skills, confidence, effectiveness, collaboration, public speaking, networking, policy development, and ability to effect change within one’s institution. Additionally, themes emerged of improved career and academic prospects Journal of Pediatric Health Care

(Robert Wood Johnson Foundation Executive Nurse Fellows, 2013). LEAH TRAINING PROGRAMS The federal MCHB of the Health Resources and Services Administration currently funds LEAH Programs at seven different institutions throughout the United States. The LEAH programs are interprofessional training programs designed to prepare professionals for adolescent health care, research, policy, and advocacy (MCHB, 2013). The seven LEAH programs vary in applicant criteria and fellowship format. The Boston LEAH Program fellows represent five disciplines: medicine, nursing, nutrition, psychology, and social work (Boston Children’s Hospital, 2013). Boston LEAH funds one nurse fellow per year. Nursing applicants must have a master’s degree, have worked with adolescents, and be able to commit to one day per week during the 10month fellowship (September through June), for which they are provided a small stipend. The LEAH nurse fellow is typically an APRN with several years of experience. At Boston Children’s Hospital (BCH), the LEAH faculty in the Division of Adolescent/Young Adult Medicine collaboratively developed the interprofessional curriculum, which consists of a weekly seminars in addition to a clinical component. These seminars include case-based learning modules, research methods, and writing and teaching workshops in which fellows enhance their skills for giving scholarly presentations and creating patient education materials. The weekly clinical component takes place in the BCH Adolescent Clinic, where the nurse fellow is paired with a clinical preceptor experienced in adolescent primary care; the preceptor is typically an APRN, but attending physicians may also serve in this role. Additional clinical experiences are selected from within the BCH system or from community partners to address the nurse fellow’s individual learning needs and interests, including an inpatient eating disorder treatment program and a health clinic in a juvenile correctional facility. All fellows are expected to incorporate advocacy and research or quality improvement into their work. In the longer term, the LEAH Nurse fellows are anticipated to make a contribution in the field of ambulatory or inpatient adolescent health care through research, clinical care, or health policy. Hennessey, Aruda, and Burke (2002) previously described the career achievements of 20 Boston LEAH Nurse Fellows. Examples of contributions made by former fellows included creating adolescent clinics in schools and urban high-risk communities, establishing funding for adolescent health education, advocating for policy changes, including APRN reimbursement, as well as conducting research and publishing scholarly articles. www.jpedhc.org

AUTHOR EXPERIENCES The first author’s clinical experience with persons diagnosed with eating disorders had been solely within the context of inpatient medical hospitalization. In an effort to gain more in-depth knowledge during the fellowship, she focused her clinical, research, advocacy, and writing activities on adolescents with eating disorders. She was able to bridge the gap between ambulatory and inpatient care and identified opportunities for improving the transition of care between hospital and home, including providing enhanced communication between ambulatory, inpatient, and community treatment providers. Since completing her fellowship in June 2012, she has commenced doctoral studies with a research focus on restrictive eating disorders to further elucidate best practices care during medical stabilization. The second author approached her LEAH Fellowship with a goal of enhancing her primary care clinical experience with adolescents and young adults and also sought opportunities for patient advocacy. Her PNP experience prior to the fellowship had been in acute care, where her role focused on discharge coordination. Because the discharge experience can be a vulnerable time for patients and their families, she was eager to explore strategies for engaging adolescents and improving their transition back to the community. The LEAH Fellowship training provided her with opportunities to use evidence-based clinical approaches with at-risk adolescents, including sexual minority or transgender teens, youth engaged in high-risk sexual behavior or substance use, and youth involved in gangs. During her LEAH Fellowship, she acquired expertise and confidence in working with vulnerable adolescents and providing interprofessional, collaborative care. After completing her fellowship, she continues to serve as discharge coordinator and has been able to provide developmentally appropriate and compassionate care, while navigating a complex health care system to access needed resources to improve adolescent health outcomes. BENEFITS AND CHALLENGES OF NURSE FELLOWSHIPS Workplaces that support collaborative, interprofessional teamwork are the ideal settings for health care. A cohesive health care team can provide safer, more cost-effective care and identify strategies to improve care systems (IOM, 2001). In an interview with 60 health professionals, Suter and colleagues (2009) outlined the importance of interprofessional team members’ understanding the scope of practice of their collaborators and effective professional-to-professional communication as a key focus in health care. These concepts, although briefly highlighted during undergraduate or graduate nursing training, are not typically a priority for the May/June 2015

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curriculum. It is our belief that fellowship training can fill this educational gap and ultimately improve overall patient outcomes. During their LEAH fellowship, the first two authors gained a deeper understanding of the scope of practice and professional backgrounds of their colleagues in social work, nutrition, adolescent medicine, and psychology. Likewise, they were able to educate their colleagues about nursing. This mutual understanding fostered a sense of camaraderie, interprofessional connections, and professional respect. Further, they acquired a richer understanding of the nursing profession and the nurse practitioner’s scope of practice. Their fellowship experience will continue to have a positive effect on future endeavors and enhance their care collaboration on behalf of patients. A fellowship experience allows APRNs to refine their skills in clinical care, teaching, research and advocacy, based on the focus of the fellowship program selected. Mentoring from faculty and peers across disciplines promotes skill development for public speaking and community engagement. Furthermore, fellowships often include research opportunities to extend knowledge and disseminate new ideas in the nursing literature. The challenges for APRN fellowships include lack of funding and paucity of training programs for nurses. The small number of The small number currently available nurse fellowships is a of currently barrier for APRNs who available nurse seek opportunities to fellowships is a augment their knowledge and skills while barrier for APRNs also developing experwho seek tise with certain patient opportunities to populations, many of whom are vulnerable. augment their For institutions workknowledge and ing with limited reskills while also sources, the task of finding funding to supdeveloping port fellowships and expertise with qualified faculty to certain patient organize and direct nursing fellowships populations, many may seem daunting. of whom are Nevertheless, the vulnerable. continued efforts to develop such educational opportunities are especially important as we look ahead to the future workforce needs in health care. THE APRN AND THE CHANGING LANDSCAPE OF HEALTH CARE The Future of Nursing report (IOM, 2011) describes a distinct role for nursing in the reshaping of the health 300

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care system under the Affordable Care Act. The IOM report specifically called for nurses to function to the full extent of their training and education and noted that there is room for improvement in nursing education. The authors of that report issued the following charge: To ensure the delivery of safe, patient-centered care across settings, the nursing education system must be improved. Patient needs have become more complicated, and nurses need to attain requisite competencies to deliver high-quality care (IOM, 2011, pp. 2-3).

Furthermore, the IOM directed the nursing community to develop competencies and leadership initiatives that put nursing on the front lines of the redevelopment of the health care system. Nurse leaders are called to be partners with our physician colleagues in the face of the changes already occurring in the wake of health care legislation. Fellowship opportunities for APRNs can be vital adjuncts to enhancing the nursing educational system and advancing health care. As part of the charge for nurses to deliver safe, patient-centered care, a great deal of focus has been placed on the concept of the ‘‘medical home’’—that is, high-quality, culturally sensitive, comprehensive care coordination provided through primary care practices. The current concern about the potential nationwide shortage of primary care physicians has put the spotlight on APRNs as providers who can bridge that workforce gap. Antonelli and Antonelli (2004) have highlighted how APRNs can serve as additional resources to provide experienced care coordination, while streamlining and reducing operating costs. A burgeoning health care issue is the growing population of patients of all ages with complex medical needs who are living in the community but not receiving primary care. We need to harness educational ingenuity and fund APRN fellowship training to meet such patient care needs. CONCLUSION In summary, we cited examples of APRN fellowship programs, discussed the experiences of the first two authors in the LEAH nurse fellowship program, and highlighted the benefits, challenges, and opportunities for future APRN fellowships. We hope this article will inspire nurse practitioners to seek out or create fellowship opportunities in their specialty area. We encourage administrators to consider the benefits of implementing programs in their institutions and implore funders to consider the value added by fellowship training for nurses. In the face of the current changes in the health care system and increased practice opportunities for nurse practitioners, APRNs with fellowship training experience are invaluable members of the interprofessional health care team. Journal of Pediatric Health Care

REFERENCES Alexandrov, A. W., Brethour, M., Cudlip, F., Swatzell, V., Biby, S., Reiner, D., . Yang, J. (2009). Postgraduate fellowship education and training for nurses: The NET SMART experience. Critical Care Nursing Clinics of North America, 21(4), 435-449. Antonelli, R., & Antonelli, D. M. (2004). Providing a medical home: The cost of care coordination services in a community based, general pediatric practice. Pediatrics, 113, 1522-1528. Association of University Centers on Disabilities. (2013). About LEND. Retrieved from http://www.aucd.org/template/page.cfm?id= 473 Blank, D. M. (1993). Postdoctoral study in a multidisciplinary research center: An alternative to more traditional nurse fellowships. Journal of Professional Nursing, 9(1), 23-26. Boston ChildrenÕs Hospital. (2013). Bostonleah.org. Retrieved from http://www.bostonleah.org Bradley, J., & Spencer, M. (2011). Perinatal Nurse Fellowship Program: An innovative approach to self-study and hands-on perinatal nursing education for community hospitals: A pilot study. Journal of Obstetric, Gynecologic & Neonatal Nursing, 40, 43-44. Graling, P., & Rusynko, B. (2004). Kicking it up a notch—successful teaching techniques. Association of Perioperative Registered Nurses Journal, 80(3), 459-460. Hennessey, J. X., Aruda, M., & Burke, P. (2002). Adolescent nurse fellows: Inspiring leaders in action. Clinical Excellence for Nurse Practitioners, 5(6), 29-33.

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Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academy Press. Mahaffey, T. L., Kaplan, T., & Triolo, P. K. (1998). A nursing fellowship—building leadership skills. Nursing Management, 29(3), 30-32. Maternal Child Health Bureau. (2013). LEAH: Leadership Education in Adolescent Health. Retrieved from http://mchb.hrsa.gov/ training/projects.asp Robert Wood Johnson Foundation Executive Nurse Fellows. (2013). Overview and resources. Retrieved from http://www. executivenursefellows.org/overview-resources.php Sandhusen, A. E., Rusynko, B. S., & Wethington, N. P. (2004). Return on investment for a perioperative nurse fellowship. Association of Perioperative Registered Nurses Journal, 80(1), 73-81. Suter, E., Arndt, J., Arthur, N., Parboosingh, J., Taylor, E., & Deutschlander, S. (2009). Role understanding and effective communication as core competencies for collaborative practice. Journal of Interprofessional Care, 23(1), 41-51. Varghese, J. R., Silvestri, A., & Lopez, P. (2012). Reaching new heights: Development of the emergency department nurse practitioner fellowship program. Pediatric Emergency Care, 28(1), 6-7.

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Advance practice nurse fellowships: creating awareness, creating opportunities.

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