AN INDEPENDENT VOICE FOR NURSING
Reflections of the Veterans Administration Puget Sound Health Care System Regional Nurse Practitioner Residency Forum Kameka Brown, PHD, RN, FNP-C, Anne Poppe, MN, Catherine P. Kaminetzky, MD, MPH, Joyce A. Wipf, MD, FACP, and Nancy Fugate Woods, PHD, RN, FAAN Kameka Brown, PHD, RN, FNP-C, is Chief Nurse for Primary Care Services, VA Northern California Health Care System, Seattle, WA and Clinical Assistant Professor, School of Nursing, University of Washington, Seattle, WA; Anne Poppe, MN, is Research Coordinator, Center of Excellence in Primary Care Education, VA Puget Sound Health Care System, Seattle, WA; Catherine P. Kaminetzky, MD, MPH, is Director of Education, VA Puget Sound Health Care System, Seattle, WA and Associate Professor, School of Medicine, University of Washington, Seattle, WA; Joyce A. Wipf, MD, FACP, is Physician Director, Center of Excellence in Primary Care Education, VA Puget Sound Health Care System, Seattle, WA and Professor, School of Medicine, University of Washington, Seattle, WA; and Nancy Fugate Woods, PHD, RN, FAAN, is Professor and Dean Emeritus, School of Nursing, University of Washington, Seattle, WA. Keywords Education, interprofessional education, professional issue, workforce Correspondence Kameka Brown, PHD, RN, FNP-C, Center of Excellence in Primary Care Education, VA Puget Sound Health Care System, 1660 S. Columbian Way S-123-COE, Seattle, WA E-mail: [email protected] The authors declare no conflict of interest. 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, the University of Washington, or any of the authors’ other employers or affiliations.
Brown
Poppe
PROBLEM. There is a proliferation of advanced practice residency programs. However, there is no uniform model of developing and evaluating program success. METHODS. An information forum was convened by Veterans Health Administration Puget Sound Health Care System’s Center for Primary Care Education on September 17, 2013, in Seattle, Washington, to explore critical aspects of residency models. The three objectives of this forum were to develop a shared understanding of key elements needed to support nurse practitioner residencies; define the unique needs of nurse practitioner trainees who are interested in applying for a residency; and examine the viability of designing a replicable nurse practitioner residency model benchmarking stakeholder best practices. FINDINGS. This article describes the organization of the forum and summarizes the presentations during the program. The companion article explores key recommendations from the forum related to future development of residency “toolkits” to aid in future evaluation and accreditation. CONCLUSION. As nurse practitioner residencies continue to develop and evolve, more is needed in the area of structure and alignment.
Kaminetzky
Wipf
70 Published 2015. This article is a U.S. Government work and is in the public domain in the USA. Nursing Forum Volume 51, No. 1, January-March 2016
Woods
Reflections Residencies
K. Brown et al. Introduction As many nurse practitioner (NP) stakeholders begin the process of considering initiating residencies and regulatory bodies determining key elements needed for accreditation, there is a need for consensus on key elements necessary for building a robust program. The Veterans Affairs Puget Sound Health Care System’s Center of Excellence in Primary Care Education (CoEPCE) convened a consensus-seeking invitational forum on September 17, 2013, in Seattle, WA. The three objectives of the forum were to: (a) develop a shared understanding of key elements needed to support local NP residencies; (b) define the unique needs of NP trainees who are interested in applying to local residencies; and (c) examine the viability of designing a replicable Doctorate of Nursing Practice (DNP) residency model benchmarking stakeholder best practices locally. This article is a summary reflection that describes the organization of the conference and summarizes presentations during the forum. The Center of Excellence in Primary Care Education The impetus for the Regional Nurse Practitioner Residency Forum was spearheaded by the VA Puget Sound Health Care System CoEPCE: to transform primary care education. Blending primary care training for NP students and physician residents integrates interprofessional learning and could include associated health professions such as pharmacy and mental health. The mission and goals of attendees at the forum included: (a) learning the skills needed for primary care team-based practice during training, and not predominantly afterward on the job; (b) providing longitudinal continuity experience for DNP trainees as well as enhancing collaboration, understanding, and respect for the unique roles and contributions of each profession, with development of exportable and sustainable curriculum; and (c) creating a comprehensive clinical training experience for DNP psychiatry mental health students to contribute to future work force needs for NP providers on mental health teams (Brown, Poppe, Kaminetzky, Wipf, & Woods, 2015).
Figure 1. Forum Invitees Versus Attendees
seven states (CA, CT, ID, IL, NC, OR, WA) and three distinct healthcare industries were represented, including education (university and college), workplace (healthcare system and community clinic), and regulatory (licensing and accreditation; Figure 1). An overarching goal for CoEPCE was to offer a balanced regional representation from each industry. Conference Organization The forum was funded by the Veterans Affairs Office of Academic Affiliations (OAA). Most invited participants had their institutions cover their expenses for traveling to the conference. In preparation for the meeting, the CoEPCE surveyed invited participants and stakeholders on aspects related to conference objectives. For each of the three objectives of the forum, plenary sessions consisted of invited presentations and discussions followed by smallgroup sessions in which participants drafted recommendations related to forum objectives and were guided by key small group questions. The following sections summarize the forum’s presentations and panel discussions, which highlighted issues and perspectives that were considered by participants in formulating recommendations. Making the Case for Nurse Practitioner Residencies
Invited Participants Of the 116 invited forum participants (not including the six participants from the CoEPCE staff),
Kameka Brown, PhD, MBA, FNP, Nurse Practitioner Director of CoEPCE Puget Sound Health Care System, opened the forum with a review of key factors impact71
Published 2015. This article is a U.S. Government work and is in the public domain in the USA. Nursing Forum Volume 51, No. 1, January-March 2016
Reflections Residencies ing NP practice over the last 50 years (AANP, 2013). Since their inception in the United States in the early 1960s, the development of NP training programs has been a reactive one. Most recently, Brown identified three factors that have led to changing practice patterns for contemporary NPs; growing complexity in health care (both aging population and technology advances), primary care provider shortage, and enacting of Patient Protection and Affordable Care Act (PPACA). Brown acknowledged that NP programs have continued to retool curricula to insure current knowledge; however, the community continues to outpace program restructuring (AANP, 2013). With the population living longer with more chronic conditions, the complexity of care increases. Additionally, the advent of new imaging and life-saving technology geometrically increases patient care needs. With recommendations from the Institute of Medicine (IOM, 2010), The Joint Commission (2005), and Benner, Leonard, and Shulman (2009), nursing education and practice recognize a need to extend preparation to include nursing residencies. These residencies serve as a transition to practice for novice practitioners focused on clinical skill development and role socialization needed to address the increased complexity of patient care and healthcare systems (Bahouth & Esposito-Herr, 2009). Brown discussed the CoEPCE initial DNP residency framework for graduates of a 3-year postbaccalaureate program, which included three essential dimensions: clinical practice, leadership, and scholarship. Continuity clinic assignment offers residents the opportunity to develop relationships with patients while specialty clinic rotations expose residents to critical specialties needed in primary care to manage complex patients. Leveraging practices from psychology and social work known as “clinical supervision,” residents present challenging and unique cases to their attending NP, which results in a mentored explanation of key practice implications. Finally, NP residents take the lead on shaping quality improvement and informing practice policy through the development of projects and/or manuscripts. CoEPCE All Site Review Kathryn Rugen, PhD, FNP, OAA Nurse Consultant, gave an overview of the goals and objectives of the CoEPCE as a national model in the Veterans Affairs (VA) for interprofessional clinical training for primary care provider trainees. Three levels of program impact are considered for implementation and exportability:
K. Brown et al. microsystem, mesosystem, and macrosystem. Microsystem represents the point of care or patient level of care and learning. Mesosystem encompasses the facility and academic program (e.g., university) engagement and redesign. The macrosystem is at the national health system level and the integration of financial and structure changes. Rugen highlighted the five locally developed CoEPCE sites: Boise, Cleveland, San Francisco, Seattle, and West Haven. She acknowledged their four shared educational domains: shared decision making, sustained relationships, interprofessional collaboration, and practice improvement. Each site has a collection of primary care focused trainees in the fields of medicine, nursing, psychology and pharmacy. A new component of the CoEPCE is the development of NP fellowship/ residency programs at each site. With a total of two dozen NP residents across five sites, an NP fellowship/ residency competency tool has been developed to track progress over the course of the 1 year NP fellowship/ residency. The results of this longitudinal multisite NP residency evaluation is currently being culled and analyzed for future dissemination. This tool has leveraged domains from the four CoEPCE core educational domains, the top primary care diagnoses seen in outpatient care at VA nationally, National Organization of Nurse Practitioner Faculties (NONPF) core Nurse Practitioner competencies (NONPF, 2012), National Center for Quality Assurance (2009) Patient-Centered Medical Home Standards, Core Competencies for Interprofessional Collaborative Practice sponsored by the Interprofessional Education Collaborative (Schmitt, Blue, Aschenbrener, & Viggiano, 2011), and American College of Graduate Medical Education (Accreditation Council for Graduate Medication Education, 2012). IOM Nursing Call to Act Nancy Fugate Woods, PhD, RN, Professor and Dean Emeritus, School of Nursing at the University of Washington, highlighted key aspects of the 2010 IOM The Future of Nursing recommendations (IOM, 2010). In her view, these recommendations were timely to the discussion of emerging NP residency programs. The initial charge of the IOM committee was to examine and produce recommendations that would lead to a more effective and efficient healthcare system. Woods identified key messages warranting operationalizing for nurses: practicing to the full extent of their education and training, achieving higher levels of education, and becoming
72 Published 2015. This article is a U.S. Government work and is in the public domain in the USA. Nursing Forum Volume 51, No. 1, January-March 2016
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K. Brown et al. full partners with physicians and other healthcare professionals in redesigning healthcare in the United States. With variability among states, removal of scope of practice barriers would reduce complexity by empowering advanced nursing practitioners with uniform licensure/scope of practice. Additionally, the inclusion of NP residencies provides an opportunity for extended training to prepare for the complex healthcare setting while mitigating the attrition commonly seen in the first 2 years of practice. To do this, Woods believes it is necessary to enact IOM recommendation #1, remove scope-of-practice barriers and recommendation #3, and implement nurse residency programs. With such recommendations being considered by Congress in an effort to expand Medicare/Medicaid coverage for nursing-led services, reimbursement is anticipated to become equal for equal services rendered. Designing a Nurse Practitioner Residency: Key Essentials Margaret Flinter, PhD, ARNP, FAAN, FAANP, Senior Vice President and Clinical Director of Community Health Center, Middleton, CT, presented the keynote address of the conference entitled “Training to Complexity; Training to a Model, Training for the Future.” She described several imperatives for NP residency design, including alignment between clinical preparation and patient complexity, and development of sustainable funding. As the site of the first NP residency in 2007, Flinter’s program incorporates a structure that includes precepted continuity clinics, specialty rotations, independent clinics, didactic education, and immersion in performance improvement and leadership development trainings. Based at a federally qualified health center, the underpinning of the residency is transition from novice to proficient practitioner through proactive clinical engagement. This includes morning huddles, panel management, and integrated team work. Additionally, each resident maintains a journal for qualitative self-reflection to assess personal practice improvement (Flinter, 2012). Flinter concluded her remarks by commenting that the future of NP residency programs should include the formation of a national consortium as a collective voice with health policy and national leadership. Additionally, Flinter is developing a book to aid others in the development of a residency program. Finally, linking key activities to funding opportunities such as
graduate medical education, she advocated Medicare reimbursement as a key element supporting the initiation and expansion of residency programs. Defining Elements of an Optimal Residency Program Pearls From Residency Leaders in Medicine, Pharmacy, and Psychology Three clinicians contributed to a panel discussion of residency designs. MaryAnn Overland, MD, Associate Program Director for Primary Care and Acting Instructor, University of Washington School of Medicine, noted the core values of the Internal Medicine residency: curiosity/discovery, community/ responsibility, and compassion/humanity. Rooted in a mission to develop the next generation of leaders in medicine, the medical residency design is an educationally based curriculum versus a service-based curriculum. While all first year physician residents (R1s) begin their residency experience similarly, their curriculum structure is adjusted based on the path they choose. Categorical or traditional track offers additional night medicine and electives. Primary Care track provides additional ambulatory and/or clinic without the night medicine. CoEPCE receives additional ambulatory care rotations in an interprofessional setting. From entry to graduation, the goal is to support the medicine resident in the transition from novice to proficient and finally expert/master in medical knowledge and patient care. Steve McCutcheon, PhD, Director of VA Puget Sound’s Psychology Internship and Residency program, emphasized the importance of customer satisfaction when executing a psychology residency program. In defining the customer, McCutcheon delineated six key consumers a residency program must consider to be deemed effective; the resident, faculty, administration, community agencies, patients, and other professions (American Psychology Association Internship Accreditation, 2013). While the natural inclination is to assume the patient or the resident, McCutcheon noted the interplay of all of these consumers is critical to the success of a psychology residency program as each adds value to a program’s success and richness. Of unique interest is the inclusion of administration in the success of a residency. Administration support can propel a psychology residency and expand the program’s reach to more 73
Published 2015. This article is a U.S. Government work and is in the public domain in the USA. Nursing Forum Volume 51, No. 1, January-March 2016
Reflections Residencies community agencies and patients for residents to connect with more interprofessional partners to clinical leverage. Administration becomes a unique cog in the wheel of residency benchmarking beyond patient-centric design and innovative teaching curricula. Joyce Wipf, MD, Professor of Medicine, and Physician Director of CoEPCE, presented Pharmacy Program details. Wipf noted that the close integration of pharmacy has afforded her a keen awareness of the pharmacy residency program matrix. The purpose of the residency is to prepare pharmacists to face the challenges of contemporary care with broad and in-depth evidence-based drug therapy knowledge and advanced pharmaceutical care practice skills. The yearlong residency includes clinical rotations in acute patient care, ambulatory care, drug information, and pharmacy practice management (Accreditation Council for Pharmacy Education, 2007). Six educational outcomes guide the CoEPCE pharmacy residency program: maintain and improve medication use process, provide evidence-based and patient centered medication therapy with interdisciplinary team, exercise leadership and practice management skills, execute project management skills, provide medication and practice education and training, and utilize medication informatics. To achieve residency certification, all residency objectives must be completed along with the submission of a manuscript for publication. A DNP Resident’s Perspective Adeline Wakeman, DNP, ARNP, DNP Resident, reflected on her motivations for seeking a residency. Driven by a desire to provide high-quality, competent, and efficient patient care, Wakeman sought residency experiences as an opportunity to bolster her clinical skills to care for her patients. With a positive experience in an RN residency program, Wakeman saw that the NP residency offered mentorship, specialty clinical experiences, research opportunities, and professional development. Reflecting on her first few months, Wakeman acknowledged that the time has been both exhausting and exhilarating. The balance of clinical practice, research/quality improvement, leadership/ teaching, and professional development is dichotomous to the experience if she would have entered directly into practice. She closed her presentation by acknowledging her structured mentoring team and critical gaps residencies bridge. Residencies offer a
K. Brown et al. transition to practice, improve patient care skills, and reduce attrition through increased job satisfaction. Measuring Success and Creating Sustainability Barbara Trehearne, PhD, RN, Vice President for Nursing and Primary Care, Group Health Cooperative (GHC), described the opportunities and challenges for NPs in a reformed environment. With the enactment of PPACA as law, states are authorized to establish healthcare teams and support patient-centered medical homes and accountable care organizations (ACOs). To be effective in a medical home or ACO, care must be cost effective and evidence based within the healthcare team. Healthcare reform legislation impacts NPs uniquely with the emphasis on full recognition and full utilization of NPs as primary care providers in healthcare systems and in medical homes. Additionally, increasing funding to develop nurse managed clinics and closing the gap of a looming nursing shortage further emphasizes the key role of NPs. Finally, policies to reengineer reimbursement for true costs of care and allow NPs to certify home healthcare services are all hot topics within new legislation. Trehearne described the initial redesign of GHC medical home integration. With the model encompassing five core primary care functions (comprehensive, patient centered, coordinated, accessible, and quality and safety), Trehearne quickly noted challenges with the initial design (1.0) and retooled to their current model (2.0). Within this 2.0 model, NPs are moving to equal parity as their physician counterparts. The patient panel mix is based on DxCG (diagnosis code group) scoring for risk adjustment, with NPs caring for a panel of patients that is smaller than the number of patients in physicians’ panels (Iglehart, 2011). Trehearne acknowledged that challenges still persist within the new model. Lack of both clarity and scope of practice for NPs continues to occur for the clinical staff. Global workforce shortages of primary care providers, physicians, and NPs prevent a full scale implementation of the 2.0 model reducing effectiveness and full penetration. Finally, reimbursement limitation and unknown costs containment related to NP care continues to impede full scale expansion. Forum Outcomes After each of the two series of plenary sessions at the September 2013 Regional Nurse Practitioner Resi-
74 Published 2015. This article is a U.S. Government work and is in the public domain in the USA. Nursing Forum Volume 51, No. 1, January-March 2016
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K. Brown et al. dency Forum, participants divided into eight groups (seven members per group) for the purpose of drafting forum recommendations. The forum planning team selected three attendees as discussion facilitators and two CoEPCE staff members as recorders; these individuals were briefed on the purpose and process of the work groups. Forum planners chose the topics for the workgroups discussions based on the forum objectives and the results of the preconference surveys. Participants were asked to formulate conclusions or “findings” based on specific issues assigned to group. For example, one group was asked to identify “key components needed to establish a successful nurse practitioner residency.” Work groups convened twice—first for formulating residency then for sustainability issues. Based on their findings, the groups compiled recommendations for considerations at each session. The conference edited these drafts, striving for clarity and minimal redundancy, and prepared the final set of recommendations. Forum Conference Recommendations One hundred and fifty-two recommendations were formulated during the two round table discussions. 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 healthcare institutions. Eighty-five recommendations related to critical aspects needed to build an NP residency and 67 recommendations related to sustaining and key measures for residency programs. Each recommendation was rated on the following scale: 1. 2. 3. 4. 5.
Low impact/low feasibility. Low impact/high feasibility. High impact/low feasibility. High impact/high feasibility. No opinion.
Impact was defined as the effect that a recommendation would have, if implemented, on creating a structured residency program for the first set of recommendations. 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 sense of importance as well as ease of implementation. A recommendation of “low impact/low feasibility” would offer no true consideration in comparison with a recommendation of “high impact/high feasibility.” CoEPCE staff members did not participate in the polling. Of the 53 participants, 16 were from VA, 15 from university settings, 14 from medical centers, and 8 from certifying bodies and/or policy. Recommendations for Formulating a Nurse Practitioner Residency Among the 85 recommendations related to formulating an NP residency program design, 26 were rated “high impact/high feasibility.” Notably, considerable overlap existed in the role of the NP resident during the program with leadership; interprofessional and collaborative practice being ranked highest in nine items. Six recommendations were included in the lower ranked items and crossed all areas of residency program design. The inclusion of specialty care rotation, exploring teaching styles to develop optimal workplace learning scenarios, stakeholder agencies to support residencies, and equal liability insurance were among the items viewed as having both lower urgency and lower potential on NP residency formulation. Recommendations for Key Outcomes and Cost Measures to Sustainability Among the 152 recommendations related to key outcomes and cost measures for sustainability, 18 measures were rated “high impact/high feasibility.” Measuring the fiscal benefits of NP residencies yielded almost unanimous responses with facile implementation and widespread reach. Seven recommendations were rated “low impact/ low feasibility.” In response to “What might be some positive benefits from having an NP residency program?”, dimensions related to leadership, financial savings, panel size, and cultural change were seen as having limited overall influences and limited achievability. Forum Outcomes Throughout the forum, attendees were offered opportunities for spontaneous reflection and collabo75
Published 2015. This article is a U.S. Government work and is in the public domain in the USA. Nursing Forum Volume 51, No. 1, January-March 2016
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K. Brown et al.
ration. It was through these connections that a synthesis of ideas emerged. Attendees generated a list of key must haves, a toolkit of sorts, for the development of a nurse practice residency program. The following toolkit is based on attendee responses:
Acknowledgments. A grant from the Office of Academic Affiliations supported the forum rental space and conference materials. Center of Excellence in Primary Care Education staff provided excellent staff support in the organization and conduct of this forum.
• • • •
References
Interprofessional training design Leadership/policy component Quality improvement and scholarship dimension Hone diagnostic and special skill readiness (e.g., EKG reading, etc.) • Dedicated mentorship and role development Participants collectively agreed that such programs cannot be implemented without the following: • Motivated, trained, and compensated preceptors • Funding mechanism to support residency implantation and expansion • Accreditation for reimbursement • Clinical training space • Development of reliable and valid evaluation measures • University affiliation Conference Closing Kameka Brown, PhD, FNP, and Joyce Wipf, MD, CoEPCE Directors, closed the forum by thanking participants, speakers, grantors, and Center staff and by commenting on how CoEPCE will use the feedback from the forum to develop additional regional workshops. Both CoECPE Directors postulated that the forum had the potential to shape larger residency practice and design. Wipf saw the need for greater interprofessional collaboration to insure that clinicians leverage the best of each respective clinical skills training. Brown explored the exciting time in nursing and the need for rigor and quantitative analysis to insure that residency practice is anchored in evidence based practice that is measurable and replicable. Conclusion This September 2013 invitational conference explored a variety of aspects related to NP residency programs. Forum discussions 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.
Accreditation Council for Graduate Medication Education. (2012). Accreditation Council for Graduate Medication Education Residency Program Guidelines. Retrieved from http://www.acgme.org/acgmeweb/tabid/83/Programand InstitutionalGuidelines.aspx Accreditation Council for Pharmacy Education. (2007). Accreditation standards for continuing pharmacy education. Retrieved February 17, 2015, from https://www.acpe -accredit.org/standards/default.asp American Association of Nurse Practitioners. (2013). Historical timeline. Retrieved February 17, 2015, from http:// www.aanp.org/all-about-nps/historical-timeline American Psychology Association Internship Accreditation. (2013). Understanding APA accreditation. Retrieved February 17, 2015, from http://www.apa.org/ed/accreditation/ about/index.aspx Bahouth, M., & Esposito-Herr, M. (2009). Orientation program for hospital based nurse practitioners. AACN Advanced Critical Care, 20(1), 82–90. Benner, P., Leonard, V., & Shulman, L. S. (2009). Educating nurses: A call for radical transformation. New York: Wiley. Brown, K., Poppe, A., Kaminetzky, C., Wipf, J., & Woods, N. F. (2015). Recommendations for nurse practitioner residencies. Nurse Educator, 6(2), 10–13. Flinter, M. (2012). From new nurse practitioner to primary care provider: Bridge the transition through FQHC based residency training. Online Journal of Issues in Nursing, 17(1), 1–9. Iglehart, J. (2011). The uncertain future of medicare and graduate medical education. New England Journal of Medicine, 365, 1340–1345. Institute of Medicine. (2010). The future of nursing: Leading the change, advancing health. Retrieved February 17, 2015, from https://www.iom.edu/Reports/2010/The-Future -of-Nursing-Leading-Change-Advancing-Health.aspx The Joint Commission. (2005). Health care at the crossroads: Strategies for addressing the evolving nursing crisis. Retrieved from http://www.jointcommission.org/assets/ 1/18/health_care_at_the_crossroads.pdf National Center for Quality Assurance. (2009). Patient centered medical home recognitions. Retrieved February 17, 2015, from http://www.ncqa.org/Programs/Recognition/ Practices/PatientCenteredMedicalHomePCMH.aspx National Organization of Nurse Practitioner Faculties. (2012). Core competencies for nurse practitioners. Retrieved February 17, 2015, from http://www.nonpf.org/general/ custom.asp?page=14 Schmitt, M., Blue, A., Aschenbrener, C., & Viggiano T. (2011). Core competencies for interprofessional collaborative practice: Reforming health care by transforming health professional education. Academic Medicine, 86(11), 1351.
76 Published 2015. This article is a U.S. Government work and is in the public domain in the USA. Nursing Forum Volume 51, No. 1, January-March 2016
Reflections of the Veterans Administration Puget Sound Health Care System Regional Nurse Practitioner Residency Forum Kameka Brown, PHD, RN, FNP-C, Anne Poppe, MN, Catherine P. Kaminetzky, MD, MPH, Joyce A. Wipf, MD, FACP, and Nancy Fugate Woods, PHD, RN, FAAN Kameka Brown, PHD, RN, FNP-C, is Chief Nurse for Primary Care Services, VA Northern California Health Care System, Seattle, WA and Clinical Assistant Professor, School of Nursing, University of Washington, Seattle, WA; Anne Poppe, MN, is Research Coordinator, Center of Excellence in Primary Care Education, VA Puget Sound Health Care System, Seattle, WA; Catherine P. Kaminetzky, MD, MPH, is Director of Education, VA Puget Sound Health Care System, Seattle, WA and Associate Professor, School of Medicine, University of Washington, Seattle, WA; Joyce A. Wipf, MD, FACP, is Physician Director, Center of Excellence in Primary Care Education, VA Puget Sound Health Care System, Seattle, WA and Professor, School of Medicine, University of Washington, Seattle, WA; and Nancy Fugate Woods, PHD, RN, FAAN, is Professor and Dean Emeritus, School of Nursing, University of Washington, Seattle, WA. Keywords Education, interprofessional education, professional issue, workforce Correspondence Kameka Brown, PHD, RN, FNP-C, Center of Excellence in Primary Care Education, VA Puget Sound Health Care System, 1660 S. Columbian Way S-123-COE, Seattle, WA E-mail: [email protected] The authors declare no conflict of interest. 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, the University of Washington, or any of the authors’ other employers or affiliations.
Brown
Poppe
PROBLEM. There is a proliferation of advanced practice residency programs. However, there is no uniform model of developing and evaluating program success. METHODS. An information forum was convened by Veterans Health Administration Puget Sound Health Care System’s Center for Primary Care Education on September 17, 2013, in Seattle, Washington, to explore critical aspects of residency models. The three objectives of this forum were to develop a shared understanding of key elements needed to support nurse practitioner residencies; define the unique needs of nurse practitioner trainees who are interested in applying for a residency; and examine the viability of designing a replicable nurse practitioner residency model benchmarking stakeholder best practices. FINDINGS. This article describes the organization of the forum and summarizes the presentations during the program. The companion article explores key recommendations from the forum related to future development of residency “toolkits” to aid in future evaluation and accreditation. CONCLUSION. As nurse practitioner residencies continue to develop and evolve, more is needed in the area of structure and alignment.
Kaminetzky
Wipf
70 Published 2015. This article is a U.S. Government work and is in the public domain in the USA. Nursing Forum Volume 51, No. 1, January-March 2016
Woods
Reflections Residencies
K. Brown et al. Introduction As many nurse practitioner (NP) stakeholders begin the process of considering initiating residencies and regulatory bodies determining key elements needed for accreditation, there is a need for consensus on key elements necessary for building a robust program. The Veterans Affairs Puget Sound Health Care System’s Center of Excellence in Primary Care Education (CoEPCE) convened a consensus-seeking invitational forum on September 17, 2013, in Seattle, WA. The three objectives of the forum were to: (a) develop a shared understanding of key elements needed to support local NP residencies; (b) define the unique needs of NP trainees who are interested in applying to local residencies; and (c) examine the viability of designing a replicable Doctorate of Nursing Practice (DNP) residency model benchmarking stakeholder best practices locally. This article is a summary reflection that describes the organization of the conference and summarizes presentations during the forum. The Center of Excellence in Primary Care Education The impetus for the Regional Nurse Practitioner Residency Forum was spearheaded by the VA Puget Sound Health Care System CoEPCE: to transform primary care education. Blending primary care training for NP students and physician residents integrates interprofessional learning and could include associated health professions such as pharmacy and mental health. The mission and goals of attendees at the forum included: (a) learning the skills needed for primary care team-based practice during training, and not predominantly afterward on the job; (b) providing longitudinal continuity experience for DNP trainees as well as enhancing collaboration, understanding, and respect for the unique roles and contributions of each profession, with development of exportable and sustainable curriculum; and (c) creating a comprehensive clinical training experience for DNP psychiatry mental health students to contribute to future work force needs for NP providers on mental health teams (Brown, Poppe, Kaminetzky, Wipf, & Woods, 2015).
Figure 1. Forum Invitees Versus Attendees
seven states (CA, CT, ID, IL, NC, OR, WA) and three distinct healthcare industries were represented, including education (university and college), workplace (healthcare system and community clinic), and regulatory (licensing and accreditation; Figure 1). An overarching goal for CoEPCE was to offer a balanced regional representation from each industry. Conference Organization The forum was funded by the Veterans Affairs Office of Academic Affiliations (OAA). Most invited participants had their institutions cover their expenses for traveling to the conference. In preparation for the meeting, the CoEPCE surveyed invited participants and stakeholders on aspects related to conference objectives. For each of the three objectives of the forum, plenary sessions consisted of invited presentations and discussions followed by smallgroup sessions in which participants drafted recommendations related to forum objectives and were guided by key small group questions. The following sections summarize the forum’s presentations and panel discussions, which highlighted issues and perspectives that were considered by participants in formulating recommendations. Making the Case for Nurse Practitioner Residencies
Invited Participants Of the 116 invited forum participants (not including the six participants from the CoEPCE staff),
Kameka Brown, PhD, MBA, FNP, Nurse Practitioner Director of CoEPCE Puget Sound Health Care System, opened the forum with a review of key factors impact71
Published 2015. This article is a U.S. Government work and is in the public domain in the USA. Nursing Forum Volume 51, No. 1, January-March 2016
Reflections Residencies ing NP practice over the last 50 years (AANP, 2013). Since their inception in the United States in the early 1960s, the development of NP training programs has been a reactive one. Most recently, Brown identified three factors that have led to changing practice patterns for contemporary NPs; growing complexity in health care (both aging population and technology advances), primary care provider shortage, and enacting of Patient Protection and Affordable Care Act (PPACA). Brown acknowledged that NP programs have continued to retool curricula to insure current knowledge; however, the community continues to outpace program restructuring (AANP, 2013). With the population living longer with more chronic conditions, the complexity of care increases. Additionally, the advent of new imaging and life-saving technology geometrically increases patient care needs. With recommendations from the Institute of Medicine (IOM, 2010), The Joint Commission (2005), and Benner, Leonard, and Shulman (2009), nursing education and practice recognize a need to extend preparation to include nursing residencies. These residencies serve as a transition to practice for novice practitioners focused on clinical skill development and role socialization needed to address the increased complexity of patient care and healthcare systems (Bahouth & Esposito-Herr, 2009). Brown discussed the CoEPCE initial DNP residency framework for graduates of a 3-year postbaccalaureate program, which included three essential dimensions: clinical practice, leadership, and scholarship. Continuity clinic assignment offers residents the opportunity to develop relationships with patients while specialty clinic rotations expose residents to critical specialties needed in primary care to manage complex patients. Leveraging practices from psychology and social work known as “clinical supervision,” residents present challenging and unique cases to their attending NP, which results in a mentored explanation of key practice implications. Finally, NP residents take the lead on shaping quality improvement and informing practice policy through the development of projects and/or manuscripts. CoEPCE All Site Review Kathryn Rugen, PhD, FNP, OAA Nurse Consultant, gave an overview of the goals and objectives of the CoEPCE as a national model in the Veterans Affairs (VA) for interprofessional clinical training for primary care provider trainees. Three levels of program impact are considered for implementation and exportability:
K. Brown et al. microsystem, mesosystem, and macrosystem. Microsystem represents the point of care or patient level of care and learning. Mesosystem encompasses the facility and academic program (e.g., university) engagement and redesign. The macrosystem is at the national health system level and the integration of financial and structure changes. Rugen highlighted the five locally developed CoEPCE sites: Boise, Cleveland, San Francisco, Seattle, and West Haven. She acknowledged their four shared educational domains: shared decision making, sustained relationships, interprofessional collaboration, and practice improvement. Each site has a collection of primary care focused trainees in the fields of medicine, nursing, psychology and pharmacy. A new component of the CoEPCE is the development of NP fellowship/ residency programs at each site. With a total of two dozen NP residents across five sites, an NP fellowship/ residency competency tool has been developed to track progress over the course of the 1 year NP fellowship/ residency. The results of this longitudinal multisite NP residency evaluation is currently being culled and analyzed for future dissemination. This tool has leveraged domains from the four CoEPCE core educational domains, the top primary care diagnoses seen in outpatient care at VA nationally, National Organization of Nurse Practitioner Faculties (NONPF) core Nurse Practitioner competencies (NONPF, 2012), National Center for Quality Assurance (2009) Patient-Centered Medical Home Standards, Core Competencies for Interprofessional Collaborative Practice sponsored by the Interprofessional Education Collaborative (Schmitt, Blue, Aschenbrener, & Viggiano, 2011), and American College of Graduate Medical Education (Accreditation Council for Graduate Medication Education, 2012). IOM Nursing Call to Act Nancy Fugate Woods, PhD, RN, Professor and Dean Emeritus, School of Nursing at the University of Washington, highlighted key aspects of the 2010 IOM The Future of Nursing recommendations (IOM, 2010). In her view, these recommendations were timely to the discussion of emerging NP residency programs. The initial charge of the IOM committee was to examine and produce recommendations that would lead to a more effective and efficient healthcare system. Woods identified key messages warranting operationalizing for nurses: practicing to the full extent of their education and training, achieving higher levels of education, and becoming
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K. Brown et al. full partners with physicians and other healthcare professionals in redesigning healthcare in the United States. With variability among states, removal of scope of practice barriers would reduce complexity by empowering advanced nursing practitioners with uniform licensure/scope of practice. Additionally, the inclusion of NP residencies provides an opportunity for extended training to prepare for the complex healthcare setting while mitigating the attrition commonly seen in the first 2 years of practice. To do this, Woods believes it is necessary to enact IOM recommendation #1, remove scope-of-practice barriers and recommendation #3, and implement nurse residency programs. With such recommendations being considered by Congress in an effort to expand Medicare/Medicaid coverage for nursing-led services, reimbursement is anticipated to become equal for equal services rendered. Designing a Nurse Practitioner Residency: Key Essentials Margaret Flinter, PhD, ARNP, FAAN, FAANP, Senior Vice President and Clinical Director of Community Health Center, Middleton, CT, presented the keynote address of the conference entitled “Training to Complexity; Training to a Model, Training for the Future.” She described several imperatives for NP residency design, including alignment between clinical preparation and patient complexity, and development of sustainable funding. As the site of the first NP residency in 2007, Flinter’s program incorporates a structure that includes precepted continuity clinics, specialty rotations, independent clinics, didactic education, and immersion in performance improvement and leadership development trainings. Based at a federally qualified health center, the underpinning of the residency is transition from novice to proficient practitioner through proactive clinical engagement. This includes morning huddles, panel management, and integrated team work. Additionally, each resident maintains a journal for qualitative self-reflection to assess personal practice improvement (Flinter, 2012). Flinter concluded her remarks by commenting that the future of NP residency programs should include the formation of a national consortium as a collective voice with health policy and national leadership. Additionally, Flinter is developing a book to aid others in the development of a residency program. Finally, linking key activities to funding opportunities such as
graduate medical education, she advocated Medicare reimbursement as a key element supporting the initiation and expansion of residency programs. Defining Elements of an Optimal Residency Program Pearls From Residency Leaders in Medicine, Pharmacy, and Psychology Three clinicians contributed to a panel discussion of residency designs. MaryAnn Overland, MD, Associate Program Director for Primary Care and Acting Instructor, University of Washington School of Medicine, noted the core values of the Internal Medicine residency: curiosity/discovery, community/ responsibility, and compassion/humanity. Rooted in a mission to develop the next generation of leaders in medicine, the medical residency design is an educationally based curriculum versus a service-based curriculum. While all first year physician residents (R1s) begin their residency experience similarly, their curriculum structure is adjusted based on the path they choose. Categorical or traditional track offers additional night medicine and electives. Primary Care track provides additional ambulatory and/or clinic without the night medicine. CoEPCE receives additional ambulatory care rotations in an interprofessional setting. From entry to graduation, the goal is to support the medicine resident in the transition from novice to proficient and finally expert/master in medical knowledge and patient care. Steve McCutcheon, PhD, Director of VA Puget Sound’s Psychology Internship and Residency program, emphasized the importance of customer satisfaction when executing a psychology residency program. In defining the customer, McCutcheon delineated six key consumers a residency program must consider to be deemed effective; the resident, faculty, administration, community agencies, patients, and other professions (American Psychology Association Internship Accreditation, 2013). While the natural inclination is to assume the patient or the resident, McCutcheon noted the interplay of all of these consumers is critical to the success of a psychology residency program as each adds value to a program’s success and richness. Of unique interest is the inclusion of administration in the success of a residency. Administration support can propel a psychology residency and expand the program’s reach to more 73
Published 2015. This article is a U.S. Government work and is in the public domain in the USA. Nursing Forum Volume 51, No. 1, January-March 2016
Reflections Residencies community agencies and patients for residents to connect with more interprofessional partners to clinical leverage. Administration becomes a unique cog in the wheel of residency benchmarking beyond patient-centric design and innovative teaching curricula. Joyce Wipf, MD, Professor of Medicine, and Physician Director of CoEPCE, presented Pharmacy Program details. Wipf noted that the close integration of pharmacy has afforded her a keen awareness of the pharmacy residency program matrix. The purpose of the residency is to prepare pharmacists to face the challenges of contemporary care with broad and in-depth evidence-based drug therapy knowledge and advanced pharmaceutical care practice skills. The yearlong residency includes clinical rotations in acute patient care, ambulatory care, drug information, and pharmacy practice management (Accreditation Council for Pharmacy Education, 2007). Six educational outcomes guide the CoEPCE pharmacy residency program: maintain and improve medication use process, provide evidence-based and patient centered medication therapy with interdisciplinary team, exercise leadership and practice management skills, execute project management skills, provide medication and practice education and training, and utilize medication informatics. To achieve residency certification, all residency objectives must be completed along with the submission of a manuscript for publication. A DNP Resident’s Perspective Adeline Wakeman, DNP, ARNP, DNP Resident, reflected on her motivations for seeking a residency. Driven by a desire to provide high-quality, competent, and efficient patient care, Wakeman sought residency experiences as an opportunity to bolster her clinical skills to care for her patients. With a positive experience in an RN residency program, Wakeman saw that the NP residency offered mentorship, specialty clinical experiences, research opportunities, and professional development. Reflecting on her first few months, Wakeman acknowledged that the time has been both exhausting and exhilarating. The balance of clinical practice, research/quality improvement, leadership/ teaching, and professional development is dichotomous to the experience if she would have entered directly into practice. She closed her presentation by acknowledging her structured mentoring team and critical gaps residencies bridge. Residencies offer a
K. Brown et al. transition to practice, improve patient care skills, and reduce attrition through increased job satisfaction. Measuring Success and Creating Sustainability Barbara Trehearne, PhD, RN, Vice President for Nursing and Primary Care, Group Health Cooperative (GHC), described the opportunities and challenges for NPs in a reformed environment. With the enactment of PPACA as law, states are authorized to establish healthcare teams and support patient-centered medical homes and accountable care organizations (ACOs). To be effective in a medical home or ACO, care must be cost effective and evidence based within the healthcare team. Healthcare reform legislation impacts NPs uniquely with the emphasis on full recognition and full utilization of NPs as primary care providers in healthcare systems and in medical homes. Additionally, increasing funding to develop nurse managed clinics and closing the gap of a looming nursing shortage further emphasizes the key role of NPs. Finally, policies to reengineer reimbursement for true costs of care and allow NPs to certify home healthcare services are all hot topics within new legislation. Trehearne described the initial redesign of GHC medical home integration. With the model encompassing five core primary care functions (comprehensive, patient centered, coordinated, accessible, and quality and safety), Trehearne quickly noted challenges with the initial design (1.0) and retooled to their current model (2.0). Within this 2.0 model, NPs are moving to equal parity as their physician counterparts. The patient panel mix is based on DxCG (diagnosis code group) scoring for risk adjustment, with NPs caring for a panel of patients that is smaller than the number of patients in physicians’ panels (Iglehart, 2011). Trehearne acknowledged that challenges still persist within the new model. Lack of both clarity and scope of practice for NPs continues to occur for the clinical staff. Global workforce shortages of primary care providers, physicians, and NPs prevent a full scale implementation of the 2.0 model reducing effectiveness and full penetration. Finally, reimbursement limitation and unknown costs containment related to NP care continues to impede full scale expansion. Forum Outcomes After each of the two series of plenary sessions at the September 2013 Regional Nurse Practitioner Resi-
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K. Brown et al. dency Forum, participants divided into eight groups (seven members per group) for the purpose of drafting forum recommendations. The forum planning team selected three attendees as discussion facilitators and two CoEPCE staff members as recorders; these individuals were briefed on the purpose and process of the work groups. Forum planners chose the topics for the workgroups discussions based on the forum objectives and the results of the preconference surveys. Participants were asked to formulate conclusions or “findings” based on specific issues assigned to group. For example, one group was asked to identify “key components needed to establish a successful nurse practitioner residency.” Work groups convened twice—first for formulating residency then for sustainability issues. Based on their findings, the groups compiled recommendations for considerations at each session. The conference edited these drafts, striving for clarity and minimal redundancy, and prepared the final set of recommendations. Forum Conference Recommendations One hundred and fifty-two recommendations were formulated during the two round table discussions. 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 healthcare institutions. Eighty-five recommendations related to critical aspects needed to build an NP residency and 67 recommendations related to sustaining and key measures for residency programs. Each recommendation was rated on the following scale: 1. 2. 3. 4. 5.
Low impact/low feasibility. Low impact/high feasibility. High impact/low feasibility. High impact/high feasibility. No opinion.
Impact was defined as the effect that a recommendation would have, if implemented, on creating a structured residency program for the first set of recommendations. 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 sense of importance as well as ease of implementation. A recommendation of “low impact/low feasibility” would offer no true consideration in comparison with a recommendation of “high impact/high feasibility.” CoEPCE staff members did not participate in the polling. Of the 53 participants, 16 were from VA, 15 from university settings, 14 from medical centers, and 8 from certifying bodies and/or policy. Recommendations for Formulating a Nurse Practitioner Residency Among the 85 recommendations related to formulating an NP residency program design, 26 were rated “high impact/high feasibility.” Notably, considerable overlap existed in the role of the NP resident during the program with leadership; interprofessional and collaborative practice being ranked highest in nine items. Six recommendations were included in the lower ranked items and crossed all areas of residency program design. The inclusion of specialty care rotation, exploring teaching styles to develop optimal workplace learning scenarios, stakeholder agencies to support residencies, and equal liability insurance were among the items viewed as having both lower urgency and lower potential on NP residency formulation. Recommendations for Key Outcomes and Cost Measures to Sustainability Among the 152 recommendations related to key outcomes and cost measures for sustainability, 18 measures were rated “high impact/high feasibility.” Measuring the fiscal benefits of NP residencies yielded almost unanimous responses with facile implementation and widespread reach. Seven recommendations were rated “low impact/ low feasibility.” In response to “What might be some positive benefits from having an NP residency program?”, dimensions related to leadership, financial savings, panel size, and cultural change were seen as having limited overall influences and limited achievability. Forum Outcomes Throughout the forum, attendees were offered opportunities for spontaneous reflection and collabo75
Published 2015. This article is a U.S. Government work and is in the public domain in the USA. Nursing Forum Volume 51, No. 1, January-March 2016
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ration. It was through these connections that a synthesis of ideas emerged. Attendees generated a list of key must haves, a toolkit of sorts, for the development of a nurse practice residency program. The following toolkit is based on attendee responses:
Acknowledgments. A grant from the Office of Academic Affiliations supported the forum rental space and conference materials. Center of Excellence in Primary Care Education staff provided excellent staff support in the organization and conduct of this forum.
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References
Interprofessional training design Leadership/policy component Quality improvement and scholarship dimension Hone diagnostic and special skill readiness (e.g., EKG reading, etc.) • Dedicated mentorship and role development Participants collectively agreed that such programs cannot be implemented without the following: • Motivated, trained, and compensated preceptors • Funding mechanism to support residency implantation and expansion • Accreditation for reimbursement • Clinical training space • Development of reliable and valid evaluation measures • University affiliation Conference Closing Kameka Brown, PhD, FNP, and Joyce Wipf, MD, CoEPCE Directors, closed the forum by thanking participants, speakers, grantors, and Center staff and by commenting on how CoEPCE will use the feedback from the forum to develop additional regional workshops. Both CoECPE Directors postulated that the forum had the potential to shape larger residency practice and design. Wipf saw the need for greater interprofessional collaboration to insure that clinicians leverage the best of each respective clinical skills training. Brown explored the exciting time in nursing and the need for rigor and quantitative analysis to insure that residency practice is anchored in evidence based practice that is measurable and replicable. Conclusion This September 2013 invitational conference explored a variety of aspects related to NP residency programs. Forum discussions 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.
Accreditation Council for Graduate Medication Education. (2012). Accreditation Council for Graduate Medication Education Residency Program Guidelines. Retrieved from http://www.acgme.org/acgmeweb/tabid/83/Programand InstitutionalGuidelines.aspx Accreditation Council for Pharmacy Education. (2007). Accreditation standards for continuing pharmacy education. Retrieved February 17, 2015, from https://www.acpe -accredit.org/standards/default.asp American Association of Nurse Practitioners. (2013). Historical timeline. Retrieved February 17, 2015, from http:// www.aanp.org/all-about-nps/historical-timeline American Psychology Association Internship Accreditation. (2013). Understanding APA accreditation. Retrieved February 17, 2015, from http://www.apa.org/ed/accreditation/ about/index.aspx Bahouth, M., & Esposito-Herr, M. (2009). Orientation program for hospital based nurse practitioners. AACN Advanced Critical Care, 20(1), 82–90. Benner, P., Leonard, V., & Shulman, L. S. (2009). Educating nurses: A call for radical transformation. New York: Wiley. Brown, K., Poppe, A., Kaminetzky, C., Wipf, J., & Woods, N. F. (2015). Recommendations for nurse practitioner residencies. Nurse Educator, 6(2), 10–13. Flinter, M. (2012). From new nurse practitioner to primary care provider: Bridge the transition through FQHC based residency training. Online Journal of Issues in Nursing, 17(1), 1–9. Iglehart, J. (2011). The uncertain future of medicare and graduate medical education. New England Journal of Medicine, 365, 1340–1345. Institute of Medicine. (2010). The future of nursing: Leading the change, advancing health. Retrieved February 17, 2015, from https://www.iom.edu/Reports/2010/The-Future -of-Nursing-Leading-Change-Advancing-Health.aspx The Joint Commission. (2005). Health care at the crossroads: Strategies for addressing the evolving nursing crisis. Retrieved from http://www.jointcommission.org/assets/ 1/18/health_care_at_the_crossroads.pdf National Center for Quality Assurance. (2009). Patient centered medical home recognitions. Retrieved February 17, 2015, from http://www.ncqa.org/Programs/Recognition/ Practices/PatientCenteredMedicalHomePCMH.aspx National Organization of Nurse Practitioner Faculties. (2012). Core competencies for nurse practitioners. Retrieved February 17, 2015, from http://www.nonpf.org/general/ custom.asp?page=14 Schmitt, M., Blue, A., Aschenbrener, C., & Viggiano T. (2011). Core competencies for interprofessional collaborative practice: Reforming health care by transforming health professional education. Academic Medicine, 86(11), 1351.
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