The 2010 Institute of Medicine report The Future of Nursing: Leading Change, Advancing Health recommends residency programs for nurses in three specific areas: (1) after completing one of the three educational paths (baccalaureate, associate degree, or hospital diploma programs) that lead to eligibility for registration, (2) following the completion of an advanced practice degree program (i.e., a postgraduate program), or (3) when changing practice areas.1 The report calls for state boards of nursing to support residency completion, for federal agencies such as Health and Human Services to redirect funding from hospital diploma programs to residency programs in rural and critical access areas, and for other agencies such as the Health Resources and Services Administration and the Center for Medicare and Medicaid Services (CMS) to fund development and implementation of residencies across all practice settings.1 The rationale for this very ambitious recommendation rests in the need to improve nurse retention, to expand nursing competencies (defined as “integrated enactment of knowledge, skills, and values/attitudes that define the domains of work of a particular health profession applied in specific care contexts”2), and to improve patient outcomes across all settings and levels of practicing nurses.
Residencies: A New Practice in Nursing
Postgraduate residency training for physicians is a long-standing tradition—not so for nurses. Until the early 1970s, hospitals used nursing students who were working in the hospital’s diploma programs as an institutional workforce in lieu of hiring an adequate number of nurses who had already earned their diplomas. This traditional training constituted, in a sense, a three-year residency for the nurses. Diploma nurses exited their hospital-based programs with the ability to function immediately in an acute care setting—performing procedures, understanding institutional culture, and quickly easing into floor management. Training and experiences of this type suited hospitals of the 1950s and 1960s that were geared toward normal deliveries and uncomplicated surgical cases. But as obstetrics, treatments, and patients grew more complicated—and as the population aged and chronic disease proliferated—a different type of nurse and nursing education became necessary.3 Transitioning nursing education into colleges and universities meant forfeiting the long hours of “service” that had been part of the diploma programs for, instead, better-educated nurses who had the critical thinking skills required by changing patient demographics.
Today’s nurses provide safe, effective care with excellent patient outcomes. Providers, however, must allow new nurses or those who change practice sites adequate time to transition into practice, to achieve efficiency, to gain role satisfaction, and to be able to manage a typical patient load. Researchers have documented the effectiveness of nurse residencies for postbaccalaureate nurses in providing these professionals with an increased sense of confidence and with the additional skills necessary to move quickly into higher-level competencies, while at the same time decreasing costs to employers through reduced turnover. These postbaccalaureate residencies, typically provided in acute care hospitals where most general nurses are employed, are part of a growing private industry and have demonstrated cost-effectiveness and excellent patient care outcomes.4
The situation is different for postgraduate advanced practice nurses—that is, nurse practitioners (NPs), nurse anesthetists, clinical specialist nurses, and nurse midwives—who, through program accreditation, rigorous certification exams, and competency-based standards, graduate with the skills and knowledge needed to achieve licensure. The safety and high quality of care provided by NPs (the primary focus of our Commentary) have been extensively documented across multiple settings, and little evidence suggests that a residency requirement through regulatory channels is needed to develop these providers’ clinical skills.5
Research indicates that NPs provide excellent care without postgraduate training; however, other factors require consideration. Until the last decade, most nurses who would eventually become NPs first practiced as general nurses, typically for a few years in acute care institutions, before entering NP training programs. After completing their NP programs, they directly entered into practice, using their practice experience as their clinical foundation; the NP program provided additional skills and knowledge. This pathway was appropriate as the NP role built upon the general nursing role and nurses' prior experiences. But—as happens with all clinical practice roles—the clinical context changed over time and place, and in turn, influenced the provider role. Patients today are more complicated, and nurses have transitioned quickly from practicing in acute care institutions to primary care settings, where different types of skills are needed. Nurses are also entering NP programs without clinical experience after their baccalaureate programs. These factors contribute to a climate in which a postgraduate residency could be an important component of an NP’s successful transition to practice, could positively influence the quality and safety of care, and could support provider satisfaction and efficiency.
In this issue of Academic Medicine, Meyer and colleagues6 suggest that some NPs are receptive to and interested in such transition-to-practice programs. A growing number of postgraduate residencies for NPs have emerged in the last decade in, specifically, community-based primary care settings. The most well-known example is Connecticut’s Community Health Center Inc. (CCHC) residency program.7 Started in 2007 by NP Margaret Flinter, the program was developed to support NPs’ transitions into practice at community health centers and federally qualified health centers (FQHCs). Flinter believed that high patient complexity and population-based issues complicated care provision in these settings and that new NPs needed support to develop efficient and effective population-based practice management. On the basis of evidence that a team-based, patient-centered model of care that used electronic health records was particularly effective in these sites and populations, she developed the residency program to provide NPs with the experience of working as members and leaders of provider teams.7
The CCHC has evaluated its training program in terms of provider outcomes and found that the program improves practitioner confidence, strengthens NP role identity, and enhances management skills.7 But, the nursing community still lacks specific data on the direct impact of residency programs on patient outcomes across all health professions. Most of the research on postgraduate residency programs for nurses tends to examine (as Flinter’s research did) the program’s impact on the provider, and much of it draws indirect assumptions that a more satisfied and better-functioning provider positively influences patient care. That may indeed be the case, but more research is needed to demonstrate patient outcomes before policy decisions are made concerning need and requirement.
What’s in a name?
Postgraduate residencies for nurses are not without controversy. One major issue is their label: Should they be called residencies or fellowships? Assigning labels is a process wrought with politics that conveys the power of naming something. One possible label, residency, is a term typically associated in health care with medicine, and it signifies the period of postgraduate training required for licensure and specialization. Some physicians maintain that the term “residency” should be exclusive to medicine.8
Many nurses favor the term fellowship because they believe that an NP, who can obtain certification and licensure immediately after completing his or her clinical training program, is more qualified than a medical resident (NPs gain their specialization competencies through their clinical education programs). Unlike a residency which is a requirement, fellowship training is an option for specialization.
Finally, the American Association of Nurse Practitioners and other NP organizations have used the phrase “transition to practice” as an umbrella term to describe postgraduate training programs. It does not assume regulatory control, entail mandatory requirements, or imply that the NP is not immediately competent to provide care.
Who will pay?
A second issue is program funding. If offered, should the programs be federally funded through means similar to the Direct and Indirect Medical Education payments that Medicare uses to help support medical residencies and fellowships? Some postgraduate NP residency programs are federally funded through institutions such as the U.S. Department of Veterans Affairs or the Nurse Education, Practice, Quality and Retention program. The Affordable Care Act (ACA) has also funded a CMS Graduate Nurse Education Demonstration project in an effort to train more NPs in primary care. The original language in the ACA included funding for primary care nurse residencies, but that provision has remained unfunded. None of the current federal funding is assured in the long term, and many programs remain self-funded. The uncertainty of federal funding and the current need for private funding renders larger-scale implementation, quality control, and standardization difficult.
To mandate or not to mandate?
A third issue is the danger of mandatory or required programs. If NPs are eligible to obtain both certification in their population focus areas and state licensure once they complete their clinical training program, why are residencies needed? Although a great deal of evidence shows that NPs are safe and effective providers, some evidence also indicates that many new NPs are not confident in their ability to take on the NP role or to manage growing patient loads. Many new NPs, as described by Meyer and colleagues,6 welcome and seek the support of a well-established, interdisciplinary, and patient-focused program that provides the role modeling and socialization they need and want.
A Solution and Why Residencies Matter
We believe an excellent option would be a network of local, consistently funded, multidisciplinary team residencies including nurses, physicians, pharmacists, social workers, and others who would help socialize one another to working in a team and practicing in a primary care setting.
As more and more Americans gain health insurance and begin to seek out health care providers, primary care NPs will be essential to meet demand. Providing almost 20% of primary care in the United States, NPs are already a critical part of the primary care workforce.9 And, although many of the newly insured are young and healthy, much of the population seeking primary care is more complex, chronically ill, and older.9 Patients using FQHCs may also be affected by many downstream factors such as family fragility, poverty, malnutrition, and discrimination, creating a patient care environment in which teams of providers are well situated to address patients’ issues.
NPs may need transition-to-practice support, but they do not need additional regulatory hurdles to practice. Without data supporting the need for a required residency, mandating such programs through state regulation becomes an unwelcome means of attempting to control NPs in practice. Institutions offering postgraduate transition-to-care programs for NPs will be attractive employers. These programs should support new NPs or those transitioning to new areas of practice, provide them with the opportunity to gain valuable management skills, help them formalize their identity as NPs, and affirm their confidence as they take on their new roles. Multidisciplinary programs, such as the Connecticut VA Fellowship program,6 provide added value for patients and providers alike and can serve as models for programs in many types of institutions and primary care settings.
1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. 2011 Washington, DC National Academies Press
2. Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. May 2011 Washington, DC Interprofessional Education Collaborative http://www.aacn.nche.edu/leading-initiatives/IPECReport.pdf
. Accessed September 30, 2014
3. Fairman JA Making Room in the Clinic: Nurse Practitioners and the Evolution of American Health Care. 2008 New Brunswick, NJ Rutgers University Press
4. Goode CJ, Lynn MR, McElroy D, Bednash GD, Murray B. Lessons learned from 10 years of research on a post-baccalaureate nurse residency program. J Nurs Adm. 2013;43:73–79
5. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Sys Rev.. 2005;18
6. Meyer EM, Zapatka S, Brienza RS. The development of professional identity and the formation of teams in the Veterans Affairs Connecticut Healthcare System's Center of Excellence in Primary Care Education program (CoEPCE). Acad Med. 2015;90:802–809
7. Flinter M. From new nurse practitioner to primary care provider: Bridging the transition through FQHC-based residency training. Online J Issues Nurs. 2012;17 doi: 10.3912/OJIN.Vol17No01PPT04. Accessed June 10, 2014
8. Patton RM, Stierle LJ. Letter to David M. Lichtman, MD, Re: American Medical Association House of Delegates Resolution 303 (A-08) protection of the titles “Doctor,” “Resident” and “Residency.” June 11, 2008. http://www.nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/2008PR/AMALetterTitles.pdf
. Accessed September 30, 2014
9. Dower C, O’Neil E The Synthesis Project: New Insights From Research Results. Primary Care Health Workforce in the United States. July 2011 Princeton, NJ Robert Wood Johnson Foundation Research synthesis report no. 22. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf402104/subassets/rwjf402104_1
. Accessed September 30, 2014