Nurse Educator
Nurse Educator Vol. 40, No. 3, pp. 148-151 Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Recommendations for Nurse Practitioner Residency Programs Kameka Brown, PhD, MBA, MS, FNP & Anne Poppe, MS, RN & Catherine Kaminetzky, MD, MPH Joyce Wipf, MD & Nancy Fugate Woods, PhD, RN, FAAN The purpose of this study was to identify and prioritize critical aspects needed in the design and execution of new nurse practitioner (NP) residency programs. Subjects answered a series of questions on formulating residency programs and on key outcomes and cost measures related to their sustainability. These results serve as potential guideposts for future work in NP residency standardization and sustainability development. Keywords: graduate nursing education; nurse practitioner program; nursing practitioner residency; residencies
T
he role of nurse practitioners (NPs) continues to evolve and bridge critical health care gaps. Similar to the national call in the late 1960s, present-day NPs are viewed as a viable resource to fill primary care shortages across the country.1,2 However, today’s patients are much more complex than the patients of yesteryear. With a number of factors impacting patient complexity, staggering growth in the aging population, more patients in sub–acute care treated in outpatient settings, and technological advances, NPs are managing patient populations not envisioned in the original design of advanced practice programs.3 Graduate nursing programs have enhanced program offerings to better prepare NPs for practice, yet many NPs report feeling underprepared for the complex patients faced in the ambulatory setting.4 Nurse practitioner residencies offer an additional year of mentored training following completion of both graduate studies and licensure. Many novice NPs view this transition-to-practice Author Affiliations: Nurse Practitioner and Director (Dr Brown), Evaluation Coordinator (Ms Poppe), and Physician Director (Dr Wipf), Center of Excellence in Primary Care Education, and Director of Education (Dr Kaminetzky), VA Puget Sound Health Care System, Seattle, Washington; Clinical and Assistant Professor (Dr Brown), Professor and Dean Emeritus (Dr Woods), and Clinical Instructor (Ms Poppe), School of Nursing, and Assistant Professor (Dr Kaminetzky), and Professor (Dr Wipf), School of Medicine, University of Washington, Seattle. Dr Brown is now an Associate Chief Nurse for Primary Care - Northern California VA. This study was funded by a grant from Veteran Affairs Office of Academic Affiliations. The views presented in this article are the authors’ own and do not necessarily reflect the views or opinions of the Department of Veterans Affairs, the Veterans Health Administration, or any of the authors’ employers or affiliations. The authors declare no conflicts of interest. Correspondence: Dr Brown, 1660 S Columbian Way, S-123-COE, Seattle, WA 98108 ([email protected]). Accepted for publication: October 15, 2014 Published ahead of print: December 10, 2014 DOI: 10.1097/NNE.0000000000000117
148
year as a welcomed opportunity to ease into clinical practice with a supportive network of mentors available to offer motivation and instill clinical wisdom. Since the inception of the first residency in 2007, nearly 3 dozen residencies operate throughout the United States.5 However; a standardized framework for these programs does not yet exist.
Review of the Literature Contemporary NPs have experienced numerous changes in the advanced practice role. Graduate nursing programs expanded course offerings and clinical time to mirror the patient changes, extending the number of credits of many master’s programs with some equivalent with doctorate-level requirements. In 2004, the American Association of Colleges of Nursing issued a position statement adding DNP as the terminal degree for all NPs.6 This signaled an acknowledgement that additional time is needed for advanced practice preparation. The Institute of Medicine recommendations call for the implementation of nurse residency programs to transition new NPs into clinical practice areas, foster clinical readiness in critical access areas of need, and promote retention and leadership skills.7 Novice NPs were entering the workplace reporting underpreparation in much needed diagnostic interpretation skills. The role anxiety related to transition as a novice provider was high for many NPs who were unable to identify role models or workplace social networks for support.3 Such adjustment issues mitigate primary care provider shortages with new NP attrition. Recognized this problem, the Community Health Clinic of Connecticut designed a program to usher NPs into the novice provider role in a supportive environment.8 Akin to nursing residency programs, NP residencies provide mentored clinical time for residents to have dedicated discussion time with a more senior provider on how to manage patients.
Volume 40 & Number 3 & May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Nurse Educator
In addition, programs universally offer continuity clinic sessions, specialty care clinics, and a didactic component. Continuity clinic sessions offer residents the opportunity to manage a group of patients and develop patient relationships across the yearlong experience. Specialty care exposure enhances resident preparation by focusing on a disease process and management. Specialty care areas with high referral wait times and limited practitioners are often featured in the residency program as many of these patients need to be managed by their primary care provider while awaiting specialty care appointments. Typical specialties include cardiology, endocrinology, orthopedics, dermatology, mental health, and women’s health.9 Variability exists between programs based on the availability of specialists to support residents. Finally, most residencies include didactic learning sessions, providing residents with case-based and classroomstyle learning in disease management and clinical conferences. Topic areas are general, such as chronic eye disorders, and focused, such as preventive care in persons with human immunodeficiency virus. All topics are a means to provide additional knowledge to enhance patient care. The level of didactic instruction is based on the program’s underpinning as a primarily clinical institution (eg, community clinic) versus a teaching institution (eg, academic medical facility). The spawning network of NP residency programs has not yielded consensus on the critical elements of a residency program that will lead to the most effective design. In addition, there is lack of consensus regarding financial and quality measures needed to make the business case for implementing an NP residency.
Center of Excellence in Primary Care Education In 2010, Veterans Affairs (VA) competitively selected 5 Centers of Excellence in Primary Care Education (CoEPCEs) to serve as training centers for team-based approaches to patient care in the VA’s Patient-Aligned Care Teams (medical home) model. VA Puget Sound Health Care System CoEPCE, in Seattle, Washington, works to advance education of interdisciplinary teams and develop clinical leaders including medicine residents, NP trainees, pharmacy residents, and psychology interns.10 Interprofessional primary care leaders are educated to deliver patient-centered care, transform delivery of health care services, and improve health outcomes through a collaborative team approach. A central focus of the Seattle CoEPCE is to develop skills needed for collaborative primary care practice during training. The CoEPCE curriculum incorporates both direct patient clinical experiences and interprofessional interactive seminars with longitudinal themes including team building, panel management, and multidisciplinary hands-on clinical sessions leveraging the unique training skills of each profession and melding together to reduce silos and promote communication.11 All 5 CoEPCE sites offer NP residency programs, with West Haven CoEPCE being the first post–master’s degree in 2011 and Seattle CoEPCE as the first post-DNP in 2013.12,13 Shortly after embarking on this endeavor, Seattle CoEPCE leadership sought to better understand the key elements of residency design needed for a successful and thriving proNurse Educator
gram. Thus, the purpose of this study was to explore essential elements of NP residencies offered by a varied audience of nursing stakeholders. Establishing consensus for developing programs to consider when initiating the residency development is the final outcome.
Methods This study involved the administration of written questionnaires and focus group discussions. The written questionnaires were developed by 1 of the authors and were reviewed for content validity and formatting by the CoEPCE team as well as 1 external expert RN researcher. The final questionnaires were divided into 2 main themes: (1) formulating an NP residency program and key outcomes and (2) cost measures for sustainability. With the exception of demographic information, each theme was bracketed into 3 major headings with 3 questions, each totaling 9 items for each theme (or 18 items); items were rated using a 5-point Likert scale. Specifically, the questionnaires contained items related to building a framework for a residency, resources needed to support residents and program implementation, characteristics of a successful resident, costs impacting sustainability, and fiscal benefits of a residency program. Participant demographic information included education level, current occupation, facility affiliation, and current NP residency status. The questionnaires were administered to attendees at a regional NP residency forum in September 2013 in Seattle, Washington. Prior to the forum, a digital survey was e-mailed to all invitees (n = 116) to identify their goals for the forum and was used as a registration method. Official registered participant count from this meeting was 53. At the beginning of the day, the CoEPCE team announced that the purpose of the forum was to produce and disseminate a toolkit that would inform development of future NP residencies. Participants addressed formulating an NP residency program during the morning sessions (a total of 9 questions) and key outcomes and cost measures for sustainability (a total of 9 questions) in the afternoon. Participants were placed into 7 groups. For both the morning and afternoon sessions, there were at least 2 groups to address each theme.
Analysis For the purposes of this forum, a recommendation was defined as a statement of action or need (related to a topic assigned to a work group) that should be assessed by specific parties such as health care institutions. Each recommendation was rated on the following scale: (1) low impact/low feasibility, (2) low impact/high feasibility, (3) high impact/low feasibility, (4) high impact/high feasibility, or (5) no opinion. For the first set of recommendations, impact was defined as the effect that a recommendation would have, if implemented, on creating a structured residency program. For the second set of recommendations, impact was defined as the effect the recommendation would have, if implemented, on quantitatively capturing and sustaining a viable residency program. For all recommendations, feasibility was defined as the ease of implementing a recommendation, considering time and resources. The rating scale was designed to offer a Volume 40 & Number 3 & May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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sense of importance as well as ease of implementation. A recommendation of low impact/low feasibility, for example, would have no importance in comparison to a recommendation of high impact/high feasibility.
Results A total of 52 questionnaires were completed and used in the analysis (a response rate of 98%). The sample consisted of 96% (n = 51) women; 37% had a master’s degree in nursing. Respondents selected all occupant characteristics that best described their current role and were able to select more than 1 option. Most participants were currently practicing (26%) in a teaching medical center (33%) as a certified NP (24%). The majority of attendees participating in the forum planned to develop a residency (44%). Participants resided in states largely on the West Coast of the United States (89%). Of those states represented, 50% have independent practice authority for advanced practice nurses. Twenty-five percent of states represented have the most limiting scope of practice for advanced practice nurses.14 Characteristics of forum participants clustered around common themes. The majority of participants (70%) represented clinical practice settings in comparison to education, policy, or professional organizations. While 36% of participants reported having an existing residency program, 56% of participants were currently designing or had plans to develop a residency program in the future. One hundred fifty-two recommendations were formulated during the 2 roundtable discussions. Eight-five recommendations related to critical aspects needed to build an NP residency, and 67 recommendations related to sustaining and key measures for residency programs. The Table provides an example of participant responses and ratings for each theme.
Recommendations for Formulating an NP Residency Program Participants found high potential and impact in the formulation of a residency program. Nearly 30% of recommendations were considered high impact/high feasibility; these were items participants viewed that could be enacted with relative ease and lead to maximum impact. Such recommendations included developing a stronger evaluation component to the program. The highest-ranked recommendations were the need for programs that included leadership component, were interprofessional in nature, and demonstrated a collaborative practice. Participants acknowledged that some recommendations would be challenging to adopt as a standard for all residency programs across sites. This included inclusion of specialty care rotations, identifying agencies to support the residencies, and equal liability insurance to that of physician counterparts. Seven percent of recommendations were rated as low impact/low feasibility. Recommendations for Key Outcomes and Cost Measures Related to Sustainability Of more than 150 recommendations, 11% were viewed as simple to implement and yielding the measurable clinical and cost outcomes to promote sustainability. These included increasing the number of patients seen by residents, clinical quality measures such as emergency use and readmission rate and burnout surveys at time intervals during residency. The NP providing critical care was noted as having low impact/high feasibility, indicating a recommendation would be easy to initiate (high feasibility) but would yield little benefit (low impact) to residency program standardization. Participants conceived the areas of site leadership, financial savings, assigned patient load, and cultural change as
Table. Recommendations for NP Residency Programs Formulating an NP Residency Program Building a framework Development of strong evaluation component to quantity program results Inclusion of specialty care clinical rotations Resources and support Program tailored to individual’s experience and interest Identify key stakeholders to support residency implementation (community, legislature, private vendors, private insurers, providers) Identify external funding sources to support residency and preceptor salary Description of a successful NP resident Commitment as care provider to clinical skills mastery Developing awareness of role as team member on clinical team Equal contributor to quality improvement and clinical practice enhancement Key Outcomes and Cost Measures for Sustainability Desired outcomes Increase in number of patients seen Retention of mentors and trainees Impact measures Burnout survey Readmission rate Decrease in productivity Costs and benefits Staff recruitment—pipeline of already trained NPs NP to provide critical care Saving orientation costs
H/H L/L H/L L/L H/L H/H H/H L/L H/H H/L H/H H/H H/L H/L L/L H/H
Abbreviations: H/H, high impact/high feasibility; H/L, high impact/low feasibility; L/H, low impact/high feasibility; L/L, low impact/low feasibility.
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Nurse Educator
being the most challenging to standardize and overcome in residency program design. Four percent of participants viewed these aspects as having low feasibility and low impact in overall program design.
Conclusions Our results indicate that there is continuing need for NP residency program standardization. With a focus largely on primary care NP residency programs, the survey suggests recommendations that can be implemented in both clinic and teaching hospital settings nationwide. Furthermore, the results provide new program aspects that will produce little effect so as to avoid common pitfalls from established programs. The final list of ‘‘must haves’’ agreed on by participants included (1) interprofessional training, (2) leadership/ policy component, (3) quality improvement and scholarship dimension, (4) diagnostic skill honing and special skill readiness (eg, electrocardiogram readings), and (5) dedicated mentorship and role development. Participants collectively agreed that NP residency programs cannot be implemented without motivated, trained, and compensated preceptors; funding mechanisms to support residency implementation and expansion; accreditation for reimbursement; clinical training space; development of reliable and valid evaluation measures; and university affiliation. The focus group results add new knowledge to and support the existing literature regarding NP residencies. This is the first known study to gain consensus for standardization of residency program development and implementation. In addition, it is the only known study to propose ‘‘weighted’’ recommendations based on their impact and feasibly. Limitations of our study include use of a convenience sample of participants from our forum and predominately Western region participation. Another limitation was the small sample size. Thus, our results may not capture all recommendations for program standardization. NP residency programs are accelerating with recommendations for more parity in practice as providers. The first year after graduation is a critical time to ensure novice NPs are ushered into practice in an environment that both supports growth and stimulates professional development. Forum discussion and recommendations, guided by participant stakeholders from academia, practice, industry, and policy, will have strong influence on the future of the development and formation of NP residency programs. Nationwide standardization is the next step to ensuring that NP programs are
Nurse Educator
recognized as instrumental programs needed for the development of a well-prepared workforce of the future.
References 1. American Academy of Nurse Practitioners. All about NPs— historical timeline. Available at http://www.aanp.org/all-about-nps/ historical-timeline. Accessed September 14, 2014. 2. Brown S, Olshansky E. Becoming a primary care nurse practitioner: challenges of the initial year of practice. Nurse Pract. 1998; 23(7):46, 52-56, 58. 3. Goudreau KA, Ortman MI, Moore JD, Aldredge L. A nurse practitioner residency pilot program: a journey of learning. J Nurs Adm. 2011;41(9):382-387. 4. Hart AM, Macnee CL. How well are nurse practitioners prepared for practice: results of a 2004 questionnaire study. J Am Acad Nurse Pract. 2007;19(1):35-42. 5. Flinter M. From new nurse practitioner to primary care provider: bridging the transition through FQHC based residency training. Online J Issues Nurs. 2012;17(1):6. 6. American Association of College of Nursing. AACN position statement on the practice doctorate of nursing. 2004. Available at http://www.aacn.nche.edu/publications/position/DNP positionstatement.pdf. Accessed September 14, 2014. 7. Institute of Medicine of the National Academies. The future of nursing: leading the change, advancing health. 2010. Available at http://www.iom.edu/Reports/2010/The-future-of-nursingleading-change-advancing-health.aspx. Accessed August 10, 2014. 8. Flinter M. From New Nurse Practitioner to Primary Care Provider: A Multiple Case Study of New Nurse Practitioners Who Completed a Formal Post-graduate Residency Training Program [unpublished dissertation]. Storrs, CT: University of Connecticut; 2010. 9. Brown KL, Poppe AP, Kamietzky CA, Wipf JP, Woods NF. Reflections of the VA nurse practitioner residency forum. Nurs Forum. 2014. In press. 10. Rugen KW, Watts SA, Janson SA, et al. Veteran Affairs centers of excellence in primary care education: transforming nurse practitioner education. Nurs Outlook. 2013;62(2):78-84. 11. Gilman SC, Chokshi DA, Bowen JL, Rugen KR, Cox M. Connecting the dots: interprofessional health education and delivery system redesign at the Veteran Health Administration. Acad Med. 2014;89(8):1113-1116. 12. Zaptka SA, Conelius J, Edwards J, Meyer E, Brienza R. Pioneering a primary care adult nurse practitioner interprofessional fellowship. J Nurs Pract. 2014;10(6):378-386. 13. Brown KL, Poppe AP, Kamietzky CA, Wipf JP, Woods NF. Advancing post DNP Residency Experience: first year reflections. Clin Scholars Rev. 2014. In press. 14. American Academy of Nurse Practitioners. State practice environment. Available at http://www.aanp.org/legislation-regulation/ state-legislation-regulation/state-practice-environment. Accessed September 14, 2014.
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Nurse Educator Vol. 40, No. 3, pp. 148-151 Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Recommendations for Nurse Practitioner Residency Programs Kameka Brown, PhD, MBA, MS, FNP & Anne Poppe, MS, RN & Catherine Kaminetzky, MD, MPH Joyce Wipf, MD & Nancy Fugate Woods, PhD, RN, FAAN The purpose of this study was to identify and prioritize critical aspects needed in the design and execution of new nurse practitioner (NP) residency programs. Subjects answered a series of questions on formulating residency programs and on key outcomes and cost measures related to their sustainability. These results serve as potential guideposts for future work in NP residency standardization and sustainability development. Keywords: graduate nursing education; nurse practitioner program; nursing practitioner residency; residencies
T
he role of nurse practitioners (NPs) continues to evolve and bridge critical health care gaps. Similar to the national call in the late 1960s, present-day NPs are viewed as a viable resource to fill primary care shortages across the country.1,2 However, today’s patients are much more complex than the patients of yesteryear. With a number of factors impacting patient complexity, staggering growth in the aging population, more patients in sub–acute care treated in outpatient settings, and technological advances, NPs are managing patient populations not envisioned in the original design of advanced practice programs.3 Graduate nursing programs have enhanced program offerings to better prepare NPs for practice, yet many NPs report feeling underprepared for the complex patients faced in the ambulatory setting.4 Nurse practitioner residencies offer an additional year of mentored training following completion of both graduate studies and licensure. Many novice NPs view this transition-to-practice Author Affiliations: Nurse Practitioner and Director (Dr Brown), Evaluation Coordinator (Ms Poppe), and Physician Director (Dr Wipf), Center of Excellence in Primary Care Education, and Director of Education (Dr Kaminetzky), VA Puget Sound Health Care System, Seattle, Washington; Clinical and Assistant Professor (Dr Brown), Professor and Dean Emeritus (Dr Woods), and Clinical Instructor (Ms Poppe), School of Nursing, and Assistant Professor (Dr Kaminetzky), and Professor (Dr Wipf), School of Medicine, University of Washington, Seattle. Dr Brown is now an Associate Chief Nurse for Primary Care - Northern California VA. This study was funded by a grant from Veteran Affairs Office of Academic Affiliations. The views presented in this article are the authors’ own and do not necessarily reflect the views or opinions of the Department of Veterans Affairs, the Veterans Health Administration, or any of the authors’ employers or affiliations. The authors declare no conflicts of interest. Correspondence: Dr Brown, 1660 S Columbian Way, S-123-COE, Seattle, WA 98108 ([email protected]). Accepted for publication: October 15, 2014 Published ahead of print: December 10, 2014 DOI: 10.1097/NNE.0000000000000117
148
year as a welcomed opportunity to ease into clinical practice with a supportive network of mentors available to offer motivation and instill clinical wisdom. Since the inception of the first residency in 2007, nearly 3 dozen residencies operate throughout the United States.5 However; a standardized framework for these programs does not yet exist.
Review of the Literature Contemporary NPs have experienced numerous changes in the advanced practice role. Graduate nursing programs expanded course offerings and clinical time to mirror the patient changes, extending the number of credits of many master’s programs with some equivalent with doctorate-level requirements. In 2004, the American Association of Colleges of Nursing issued a position statement adding DNP as the terminal degree for all NPs.6 This signaled an acknowledgement that additional time is needed for advanced practice preparation. The Institute of Medicine recommendations call for the implementation of nurse residency programs to transition new NPs into clinical practice areas, foster clinical readiness in critical access areas of need, and promote retention and leadership skills.7 Novice NPs were entering the workplace reporting underpreparation in much needed diagnostic interpretation skills. The role anxiety related to transition as a novice provider was high for many NPs who were unable to identify role models or workplace social networks for support.3 Such adjustment issues mitigate primary care provider shortages with new NP attrition. Recognized this problem, the Community Health Clinic of Connecticut designed a program to usher NPs into the novice provider role in a supportive environment.8 Akin to nursing residency programs, NP residencies provide mentored clinical time for residents to have dedicated discussion time with a more senior provider on how to manage patients.
Volume 40 & Number 3 & May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Nurse Educator
In addition, programs universally offer continuity clinic sessions, specialty care clinics, and a didactic component. Continuity clinic sessions offer residents the opportunity to manage a group of patients and develop patient relationships across the yearlong experience. Specialty care exposure enhances resident preparation by focusing on a disease process and management. Specialty care areas with high referral wait times and limited practitioners are often featured in the residency program as many of these patients need to be managed by their primary care provider while awaiting specialty care appointments. Typical specialties include cardiology, endocrinology, orthopedics, dermatology, mental health, and women’s health.9 Variability exists between programs based on the availability of specialists to support residents. Finally, most residencies include didactic learning sessions, providing residents with case-based and classroomstyle learning in disease management and clinical conferences. Topic areas are general, such as chronic eye disorders, and focused, such as preventive care in persons with human immunodeficiency virus. All topics are a means to provide additional knowledge to enhance patient care. The level of didactic instruction is based on the program’s underpinning as a primarily clinical institution (eg, community clinic) versus a teaching institution (eg, academic medical facility). The spawning network of NP residency programs has not yielded consensus on the critical elements of a residency program that will lead to the most effective design. In addition, there is lack of consensus regarding financial and quality measures needed to make the business case for implementing an NP residency.
Center of Excellence in Primary Care Education In 2010, Veterans Affairs (VA) competitively selected 5 Centers of Excellence in Primary Care Education (CoEPCEs) to serve as training centers for team-based approaches to patient care in the VA’s Patient-Aligned Care Teams (medical home) model. VA Puget Sound Health Care System CoEPCE, in Seattle, Washington, works to advance education of interdisciplinary teams and develop clinical leaders including medicine residents, NP trainees, pharmacy residents, and psychology interns.10 Interprofessional primary care leaders are educated to deliver patient-centered care, transform delivery of health care services, and improve health outcomes through a collaborative team approach. A central focus of the Seattle CoEPCE is to develop skills needed for collaborative primary care practice during training. The CoEPCE curriculum incorporates both direct patient clinical experiences and interprofessional interactive seminars with longitudinal themes including team building, panel management, and multidisciplinary hands-on clinical sessions leveraging the unique training skills of each profession and melding together to reduce silos and promote communication.11 All 5 CoEPCE sites offer NP residency programs, with West Haven CoEPCE being the first post–master’s degree in 2011 and Seattle CoEPCE as the first post-DNP in 2013.12,13 Shortly after embarking on this endeavor, Seattle CoEPCE leadership sought to better understand the key elements of residency design needed for a successful and thriving proNurse Educator
gram. Thus, the purpose of this study was to explore essential elements of NP residencies offered by a varied audience of nursing stakeholders. Establishing consensus for developing programs to consider when initiating the residency development is the final outcome.
Methods This study involved the administration of written questionnaires and focus group discussions. The written questionnaires were developed by 1 of the authors and were reviewed for content validity and formatting by the CoEPCE team as well as 1 external expert RN researcher. The final questionnaires were divided into 2 main themes: (1) formulating an NP residency program and key outcomes and (2) cost measures for sustainability. With the exception of demographic information, each theme was bracketed into 3 major headings with 3 questions, each totaling 9 items for each theme (or 18 items); items were rated using a 5-point Likert scale. Specifically, the questionnaires contained items related to building a framework for a residency, resources needed to support residents and program implementation, characteristics of a successful resident, costs impacting sustainability, and fiscal benefits of a residency program. Participant demographic information included education level, current occupation, facility affiliation, and current NP residency status. The questionnaires were administered to attendees at a regional NP residency forum in September 2013 in Seattle, Washington. Prior to the forum, a digital survey was e-mailed to all invitees (n = 116) to identify their goals for the forum and was used as a registration method. Official registered participant count from this meeting was 53. At the beginning of the day, the CoEPCE team announced that the purpose of the forum was to produce and disseminate a toolkit that would inform development of future NP residencies. Participants addressed formulating an NP residency program during the morning sessions (a total of 9 questions) and key outcomes and cost measures for sustainability (a total of 9 questions) in the afternoon. Participants were placed into 7 groups. For both the morning and afternoon sessions, there were at least 2 groups to address each theme.
Analysis For the purposes of this forum, a recommendation was defined as a statement of action or need (related to a topic assigned to a work group) that should be assessed by specific parties such as health care institutions. Each recommendation was rated on the following scale: (1) low impact/low feasibility, (2) low impact/high feasibility, (3) high impact/low feasibility, (4) high impact/high feasibility, or (5) no opinion. For the first set of recommendations, impact was defined as the effect that a recommendation would have, if implemented, on creating a structured residency program. For the second set of recommendations, impact was defined as the effect the recommendation would have, if implemented, on quantitatively capturing and sustaining a viable residency program. For all recommendations, feasibility was defined as the ease of implementing a recommendation, considering time and resources. The rating scale was designed to offer a Volume 40 & Number 3 & May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
149
sense of importance as well as ease of implementation. A recommendation of low impact/low feasibility, for example, would have no importance in comparison to a recommendation of high impact/high feasibility.
Results A total of 52 questionnaires were completed and used in the analysis (a response rate of 98%). The sample consisted of 96% (n = 51) women; 37% had a master’s degree in nursing. Respondents selected all occupant characteristics that best described their current role and were able to select more than 1 option. Most participants were currently practicing (26%) in a teaching medical center (33%) as a certified NP (24%). The majority of attendees participating in the forum planned to develop a residency (44%). Participants resided in states largely on the West Coast of the United States (89%). Of those states represented, 50% have independent practice authority for advanced practice nurses. Twenty-five percent of states represented have the most limiting scope of practice for advanced practice nurses.14 Characteristics of forum participants clustered around common themes. The majority of participants (70%) represented clinical practice settings in comparison to education, policy, or professional organizations. While 36% of participants reported having an existing residency program, 56% of participants were currently designing or had plans to develop a residency program in the future. One hundred fifty-two recommendations were formulated during the 2 roundtable discussions. Eight-five recommendations related to critical aspects needed to build an NP residency, and 67 recommendations related to sustaining and key measures for residency programs. The Table provides an example of participant responses and ratings for each theme.
Recommendations for Formulating an NP Residency Program Participants found high potential and impact in the formulation of a residency program. Nearly 30% of recommendations were considered high impact/high feasibility; these were items participants viewed that could be enacted with relative ease and lead to maximum impact. Such recommendations included developing a stronger evaluation component to the program. The highest-ranked recommendations were the need for programs that included leadership component, were interprofessional in nature, and demonstrated a collaborative practice. Participants acknowledged that some recommendations would be challenging to adopt as a standard for all residency programs across sites. This included inclusion of specialty care rotations, identifying agencies to support the residencies, and equal liability insurance to that of physician counterparts. Seven percent of recommendations were rated as low impact/low feasibility. Recommendations for Key Outcomes and Cost Measures Related to Sustainability Of more than 150 recommendations, 11% were viewed as simple to implement and yielding the measurable clinical and cost outcomes to promote sustainability. These included increasing the number of patients seen by residents, clinical quality measures such as emergency use and readmission rate and burnout surveys at time intervals during residency. The NP providing critical care was noted as having low impact/high feasibility, indicating a recommendation would be easy to initiate (high feasibility) but would yield little benefit (low impact) to residency program standardization. Participants conceived the areas of site leadership, financial savings, assigned patient load, and cultural change as
Table. Recommendations for NP Residency Programs Formulating an NP Residency Program Building a framework Development of strong evaluation component to quantity program results Inclusion of specialty care clinical rotations Resources and support Program tailored to individual’s experience and interest Identify key stakeholders to support residency implementation (community, legislature, private vendors, private insurers, providers) Identify external funding sources to support residency and preceptor salary Description of a successful NP resident Commitment as care provider to clinical skills mastery Developing awareness of role as team member on clinical team Equal contributor to quality improvement and clinical practice enhancement Key Outcomes and Cost Measures for Sustainability Desired outcomes Increase in number of patients seen Retention of mentors and trainees Impact measures Burnout survey Readmission rate Decrease in productivity Costs and benefits Staff recruitment—pipeline of already trained NPs NP to provide critical care Saving orientation costs
H/H L/L H/L L/L H/L H/H H/H L/L H/H H/L H/H H/H H/L H/L L/L H/H
Abbreviations: H/H, high impact/high feasibility; H/L, high impact/low feasibility; L/H, low impact/high feasibility; L/L, low impact/low feasibility.
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being the most challenging to standardize and overcome in residency program design. Four percent of participants viewed these aspects as having low feasibility and low impact in overall program design.
Conclusions Our results indicate that there is continuing need for NP residency program standardization. With a focus largely on primary care NP residency programs, the survey suggests recommendations that can be implemented in both clinic and teaching hospital settings nationwide. Furthermore, the results provide new program aspects that will produce little effect so as to avoid common pitfalls from established programs. The final list of ‘‘must haves’’ agreed on by participants included (1) interprofessional training, (2) leadership/ policy component, (3) quality improvement and scholarship dimension, (4) diagnostic skill honing and special skill readiness (eg, electrocardiogram readings), and (5) dedicated mentorship and role development. Participants collectively agreed that NP residency programs cannot be implemented without motivated, trained, and compensated preceptors; funding mechanisms to support residency implementation and expansion; accreditation for reimbursement; clinical training space; development of reliable and valid evaluation measures; and university affiliation. The focus group results add new knowledge to and support the existing literature regarding NP residencies. This is the first known study to gain consensus for standardization of residency program development and implementation. In addition, it is the only known study to propose ‘‘weighted’’ recommendations based on their impact and feasibly. Limitations of our study include use of a convenience sample of participants from our forum and predominately Western region participation. Another limitation was the small sample size. Thus, our results may not capture all recommendations for program standardization. NP residency programs are accelerating with recommendations for more parity in practice as providers. The first year after graduation is a critical time to ensure novice NPs are ushered into practice in an environment that both supports growth and stimulates professional development. Forum discussion and recommendations, guided by participant stakeholders from academia, practice, industry, and policy, will have strong influence on the future of the development and formation of NP residency programs. Nationwide standardization is the next step to ensuring that NP programs are
Nurse Educator
recognized as instrumental programs needed for the development of a well-prepared workforce of the future.
References 1. American Academy of Nurse Practitioners. All about NPs— historical timeline. Available at http://www.aanp.org/all-about-nps/ historical-timeline. Accessed September 14, 2014. 2. Brown S, Olshansky E. Becoming a primary care nurse practitioner: challenges of the initial year of practice. Nurse Pract. 1998; 23(7):46, 52-56, 58. 3. Goudreau KA, Ortman MI, Moore JD, Aldredge L. A nurse practitioner residency pilot program: a journey of learning. J Nurs Adm. 2011;41(9):382-387. 4. Hart AM, Macnee CL. How well are nurse practitioners prepared for practice: results of a 2004 questionnaire study. J Am Acad Nurse Pract. 2007;19(1):35-42. 5. Flinter M. From new nurse practitioner to primary care provider: bridging the transition through FQHC based residency training. Online J Issues Nurs. 2012;17(1):6. 6. American Association of College of Nursing. AACN position statement on the practice doctorate of nursing. 2004. Available at http://www.aacn.nche.edu/publications/position/DNP positionstatement.pdf. Accessed September 14, 2014. 7. Institute of Medicine of the National Academies. The future of nursing: leading the change, advancing health. 2010. Available at http://www.iom.edu/Reports/2010/The-future-of-nursingleading-change-advancing-health.aspx. Accessed August 10, 2014. 8. Flinter M. From New Nurse Practitioner to Primary Care Provider: A Multiple Case Study of New Nurse Practitioners Who Completed a Formal Post-graduate Residency Training Program [unpublished dissertation]. Storrs, CT: University of Connecticut; 2010. 9. Brown KL, Poppe AP, Kamietzky CA, Wipf JP, Woods NF. Reflections of the VA nurse practitioner residency forum. Nurs Forum. 2014. In press. 10. Rugen KW, Watts SA, Janson SA, et al. Veteran Affairs centers of excellence in primary care education: transforming nurse practitioner education. Nurs Outlook. 2013;62(2):78-84. 11. Gilman SC, Chokshi DA, Bowen JL, Rugen KR, Cox M. Connecting the dots: interprofessional health education and delivery system redesign at the Veteran Health Administration. Acad Med. 2014;89(8):1113-1116. 12. Zaptka SA, Conelius J, Edwards J, Meyer E, Brienza R. Pioneering a primary care adult nurse practitioner interprofessional fellowship. J Nurs Pract. 2014;10(6):378-386. 13. Brown KL, Poppe AP, Kamietzky CA, Wipf JP, Woods NF. Advancing post DNP Residency Experience: first year reflections. Clin Scholars Rev. 2014. In press. 14. American Academy of Nurse Practitioners. State practice environment. Available at http://www.aanp.org/legislation-regulation/ state-legislation-regulation/state-practice-environment. Accessed September 14, 2014.
Volume 40 & Number 3 & May/June 2015
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