Spotlight on Quality

JONA Volume 44, Number 12, pp 625-627 Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Postgraduate Nurse Practitioner Training What Nurse Executives Need to Know Charles T. Bush, MSN, RN, FNP-BC Nurse executives should be familiar with postgraduate nurse practitioner training programs. Supplemental training opportunities are gaining popularity across the country and are primarily funded by employers interested in recruiting and retaining qualified healthcare professionals. There is considerable variability in program learning objectives, clinical content, and titles used to describe participants’ roles. This article offers program descriptions, associated costs, and a call for evidence of their impact on a growing constituent of the healthcare workforce.

In an appeal to action, the Institute of Medicine advocates for innovative solutions to address healthcare workforce shortages, including the transformation of nursing education and practice to help meet our nation’s healthcare demand.1

Author Affiliation: Associate Clinical Professor, Schools of Nursing and Medicine, University of North Carolina at Chapel Hill; Doctor of Nursing Practice Student, College of Nursing, East Carolina University, Greenville, North Carolina. The author declares no conflict of interest. Correspondence: Mr Bush, University of North Carolina at Chapel Hill, CB 7460, Chapel Hill, NC 27599 (tom:[email protected]). DOI: 10.1097/NNA.0000000000000138

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The Institute of Medicine suggests, BState boards of nursing, accrediting bodies, the federal government, and healthcare organizations should take actions to support nurses’ completion of a transition-to-practice program (nurse residency) after they have completed a prelicensure or advanced practice degree program or when they are transitioning into new clinical practice areas.[1(pS9) Transitioning from registered nurse to nurse practitioner (NP) can be challenging as clinicians move into advanced practice roles. This adjustment in professional identity can impact confidence, impair development of the new role, and influence decisions to remain in the job and in the profession within the 1st year of clinical practice for new and experienced NPs.2 The terms residency and fellowship are currently used interchangeably to describe postgraduate NP training programs. This may serve to obscure the choice made by some NPs to pursue additional clinical training after graduation from an accredited nursing program and successful completion of national certification and state licensure. Postgraduate training for NPs is optional and not required for entry into practice. To address the potential confusion regarding the optional nature of postgraduate NP opportunities,

the NP Roundtable, a national collaborative of NP organizations, endorsed use of the term fellowship, which has traditionally been used to reference optional graduate training programs.3

Advanced Practice Postgraduate Education Needs Advanced practice nursing degree programs provide adequate didactic information and clinical experience for entry into practice as a novice clinician. More than 40 years of practice and dozens of quality studies provide robust evidence that advanced practice registered nurses, including NPs, provide safe, effective, and quality care without postgraduate training.4 Additional guidance and support after graduation, however, are vital for a timely and successful transition from novice NP to expert clinician. Mentoring promotes socialization into the NP role, fosters autonomy, and enables novice NPs to satisfy the demands of patient care and clinical productivity.5 Historically, new employees may have access to an experienced clinician within the organization for mentorship at the point of care. Few acute or primary care settings are structured to meet this expectation with a clinical mentor whose primary focus remains


Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Spotlight on Quality on their own practice goals. Leaders in the development of postgraduate NP training suggest that new clinicians should gain this valuable experience in a more supportive and consistent environment.6 The inability to support new NPs during transition to demanding and fastpaced practice settings can result in turnover and retention issues for employers. Managers should also understand that postgraduate training does not prepare NPs to function outside their formal populationfocused educational preparation and scope of practice. Postgraduate training programs should not expect to prepare NPs to practice with a new population focus or move between primary care and acute care settings.3 Current Programs Interest in postgraduate NP training continues to grow, and a recent Internet search revealed more than 30 programs offered through federally qualified health centers, academic medical centers, multispecialty health systems, and the Veterans Administration (VA). Efforts to support the educational environment and further develop skills necessary for the advanced practice role have influenced NP job satisfaction at the VA.7 BBoth are key to the nurse administrator in a time of difficult transitions and costly recruitments.[7(p387)

Schools of nursing have begun experimenting with paid, intensive clinical experiences as part of new degree curriculums. Vanderbilt University Schools of Nursing and Medicine have partnered with Vanderbilt University Hospital to offer a postmasters Doctor of Nursing Practice (DNP) curriculum with a 2 year paid critical care fellowship. The program combines mentored clinical practice


expectations with doctoral education competencies. Fellows serve as junior faculty members and practice as acute care nurse practitioners focused on a specific critical care population while applying evidence-based practice methods throughout the program.8 Similarly, the VA recently announced a psychiatric mental health NP residency at the Durham, North Carolina, Veterans Affairs Medical Center.9 Residents and experienced mentors will work side by side to treat a diverse population of patients with mental health issues. Residents accepted into the training program are eligible to apply to Duke University School of Nursing and use clinical projects developed at the VA toward their DNP degree. Limits on physician resident work hours10 and reductions in Medicare funding have driven demand for acute care NPs in specialty services in hospital systems.11 The number of NPs working in acute care and specialty settings has dramatically increased over the past decade, promoting the development of postgraduate training opportunities for NPs. To improve access to care and levels of quality, many specialty practices have incorporated NPs into their practice models.12 Nurse practitioners impact inpatient care teams by generating revenue, reducing length of stay, and standardizing quality metrics.13 BNot only are the postgraduate residency programs popular among NP graduates looking for additional mentorship and specialty training, but are also a relatively inexpensive way to recruit and retain new hires[.11(p333)

Cost and Commitment The majority of postgraduate NP training programs are funded by em-

ployers interested in recruiting and retaining qualified health professionals to meet immediate and growing workforce needs. The costs of developing and maintaining NP postgraduate training programs include NP salary and benefits, decreased revenue from preceptor productivity, facility overhead costs, and related administrative expenses.7 Annual cost per trainee can reach $100,000, with two-thirds supporting the cost of the new NP and the rest supplementing lost preceptor productivity (D. Taylor, DNP, e-mail communication, April 2014). In most cases, the full cost of training is employer funded. A portion of the cost can be offset through billable clinical activity performed by the trainee during the program. Some programs require an employment commitment to the sponsoring organization after completion of training, while others consider the program an investment in a positive work environment that fosters collaboration and overall retention of growing and critical components of the health care workforce.

Summary Nurse executives have the opportunity to champion postgraduate NP training programs. Designing programs for recent NP graduates and experienced NPs transitioning to new practice settings can help ensure adequate retention and job satisfaction of a rapidly growing and important segment of the clinical workforce. Current orientation programs for new personnel provide support for integration into the employer organization, but there are few models to guide the development and transition of NPs in new clinical settings and roles. Nurse executives can help standardize program content, learning

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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Spotlight on Quality objectives and clinical expectations across health systems. A structured transition to practice program has the potential to enhance recruitment and improve retention of cost effective workforce constituents. Common terminology for postgraduate NP training should be adopted and the term fellowship used to reflect the optional nature of graduate training opportunities for NPs.3 Postgraduate training is not intended to prepare NPs to function outside their educational preparation and scope of practice; however, it is targeted to smooth the transition to practice. Supplemental training is expensive, and there is no published evidence to date supporting that postgraduate NP training improves patient outcomes, clinician competency, self-reported confidence, or job satisfaction among participants. This is an area for future study. Federal and state funding sources should be considered to support the development of consistent learning objectives, formats, and clinical competencies as new models are explored. Research is needed to discover how postgraduate NP training impact the efficiency, quality, and value of care provided by this important

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and rapidly growing segment of our nation’s healthcare workforce.


REFERENCES 1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. 2010/the-future-of-nursing-leadingchange-advancing-health.aspx. Updated December 11, 2013. Accessed July 2, 2014. 2. Cusson RM, Strange SN. Neonatal nurse practitioner role transition: the process of reattaining expert status. J Perinat Neonatal Nurs. 2008;22(4):329-337. doi:10.1097/01.JPN.0000341365.60693.39; 10.1097/01.JPN.0000341365.60693.39. 3. AANPVthe NP roundtable’s discussion paper on NP education and post-graduate training, content/article/82-legislation-regulation/ policy-toolbox/np-policy-essentials/445aanp-and-the-np-roundtable-jointstatements. Updated May 6, 2014. Accessed July, 2 2014. 4. Newhouse RP, Stanik-Hutt J, White KM, et al. Advanced practice nurse outcomes 1990-2008: a systematic review. Nurs Econ. 2011;29(5):230-250. 5. Hill LA, Sawatzky JV. Transitioning into the nurse practitioner role through mentorship. J Prof Nurs. 2011;27(3): 161-167. doi:10.1016/j.profnurs.2011 .02.004. 6. Flinter M. Residency programs for primary care nurse practitioners in federally qualified health centers: a service







perspective. Online J Issues Nurs. 2005; 10(3):6. Goudreau KA, Ortman MI, Moore JD, et al. A nurse practitioner residency pilot program: a journey of learning. J Nurs Adm. 2011;41(9):382-387. doi:10.1097/ NNA.0b013e31822a7315; 10.1097/NNA .0b013e31822a7315. DNP ACNP intensivist fellowship. http:// fellowship.html. Accessed July 2, 2014. Applications now being accepted for nurse practitioner residency at the Durham VA medical center. http://nursing.duke .edu/news/applications-now-beingaccepted-nurse-practitioner-residencydurham-va-medical-center. Updated March 31, 2014. Accessed July 2, 2014. Philibert I, Friedmann P, Williams WT, ACGME Work Group on Resident DutyHours.AccreditationCouncilforGraduate Medical Education. New requirements for resident duty hours. JAMA. 2002; 288(9):1112-1114. doi:jco20102 [pii]. Harris C. Bridging the gap between acute care nurse practitioner education and practice: the need for postgraduate residency programs. J Nurse Pract. 2014; 10(5):331-335. Dower C, Christian S (Eds). Physician Assistants and Nurse Practitioners in Specialty Care: Six Practices Make It Work. San Francisco, CA: University of California; 2009. Kapu AN, Kleinpell R, Pilon B. Quality and financial impact of adding nurse practitioners to inpatient care teams. J Nurs Adm. 2014;44(2):87-96. doi:10.1097/ NNA.0000000000000031; 10.1097/ NNA.0000000000000031.


Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Postgraduate nurse practitioner training: what nurse executives need to know.

Nurse executives should be familiar with postgraduate nurse practitioner training programs. Supplemental training opportunities are gaining popularity...
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