There is a slow but growing movement toward nurse practitioner residency programs in the United States. Hospital- or community-based residency programs began a few years ago, but lack of funds, a sluggish government response and scant professional awareness seem to impede progress. As the country prepares for sweeping changes in healthcare reform we may see a shift in how nurse practitioners prepare for entry into the workforce.
At the heart of the issue is the present and projected shortage of primary healthcare providers. Currently, the number of physicians going into primary care is at an all-time low. The Health Resources and Services Administration reports that to meet a target of one provider for every 2,000 patients, an additional 17,722 primary care practitioners are already needed in shortage areas across the country.1
When the nation experienced a severe shortage of primary care providers in the 1960s the government went into action, turning 1965 into a pivotal year for both physicians and nurses. To address physician shortage, the federal government began to subsidize the training of new MDs in hospital based residency programs and sanctioned the nurse practitioner role to help relieve the burden of provider shortages. In addition, the role of physician assistant was proposed as another route to fast track providers into the workforce.2
Decades later, the government is again responding to a crisis in provider shortages. Nurse practitioner residency programs are now on the agenda for federal subsidization. The hope is that residencies will speed well trained nurse practitioners into needy targeted areas. An examination of the Affordable Health Care Act (ACA) reveals its impact on how primary care will be delivered and why advanced training of new nurse practitioners will be utilized to fill gaps in clinical care.
The Impact of Expanding Healthcare
A signature achievement of the ACA addresses the wide disparity in how Americans receive and access healthcare. The new laws may ensure that our country's poorest and most vulnerable will finally benefit from universal care. Beginning January 1, 2014, the expansion of Medicaid eligibility will include nonelderly citizens and people whose family income does not exceed 133% of the federal poverty level.3
However, changes with healthcare reform will add an estimated 32 million new people to the Medicaid program, while the latest data from the Association of American Medical Colleges projects an increased shortfall of more than 90,000 primary care physicians in 10 years.4 In addition, the number of baby boomers over the age 65 is projected to increase by 36% over the next decade.5
Demonstration Grants for NP Residency Programs
To fill the growing need in primary care, the ACA has earmarked monies for demonstration grants toward the development of NP residency programs. Nursing provisions from the ACA provide for family nurse practitioner residency training programs. A total of $253 million from the U.S. Health and Human Services Department has been stipulated to boost the national primary care workforce and includes the support of NP residency programs in Federally Qualified Health Centers (FQHCs).6 As a result, implications for entry practice as a nurse practitioner may shift, as we see an expansion of residency programs and fellowship options for the new graduate.
America's First Nurse Practitioner Residency
The concept of uniting nurse practitioner residency programs with FQHCs was first introduced in 2005 by Margaret Flinter, PhD, APRN, C-FNP, to address two main issues: the shortage in primary care clinicians and the stresses encountered by novice clinicians as they enter the workforce. She explains the burden experienced by the new graduate: "During this critical first year of practice, the new NP's development is largely tied to the skills and scope of a colleague whose primary responsibility is not mentorship, but his/her own practice, and who may or may not have the skill, patience, interest, and/or time to devote to intensive training and mentoring. This first year of experience is in contrast to the entry-to-practice physician who has completed a residency in a primary care specialty. The discrepancy in entry to practice risks placing the new NP in a mid-level, apprentice-type position from which it is very difficult to move to full professional status."7
Spearheaded by Flinter in 2007, Community Health Centers, Inc., in Conn., began offering the first residency training program for newly graduated family nurse practitioners. This community health center is designated a FQHC and as such is mandated to provide primary healthcare for diverse populations and must be staffed by clinicians specializing in family and primary care.8 Today, FQHCs are the healthcare providers for over 20 million Americans nationwide, and many new residency programs will be based in such care centers.9
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Current NP Residencies and Fellowships
At present, there is a small proliferation of diverse residencies and fellowships available to students and new graduates. These programs are based in the hospital as well as the community healthcare setting. While a fair number maintain a focus on family health and primary care, a recent search of the literature uncovered programs offering residencies or fellowships across a wide range of specialties, including critical care, dermatology, gastroenterology, psychiatry, pain and palliative care and cardiology. A sampling of current programs available across the nation is provided in the table accompanying this article.
Current Standards Meet Clinical Expectations of Excellence
Current standards of practice allow nurse practitioners to function as licensed providers of care without additional education; NPs receive clinical training as part of their educational programs. It is certainly true that time and experience have shown that fully trained, certified and licensed NPs are safe and effective practitioners without residencies. Research has also shown that NPs enjoy enormous patient satisfaction and stellar safety records.10 In addition, there is no study as yet demonstrating that nurse practitioners will perform better after a 1-year residency program.
There is no doubt that advanced education benefits nurse practitioners and smooths transition to practice. As Flinter proposed, an NP trained in a residency program may experience greater job satisfaction and increased professional status. The expectation that well trained NPs will more easily fill gaps in the provider shortage seems logical. At issue then is what the future may hold for entry-level practitioners as residencies and fellowships continue expanding across the nation. According to a 2011 report by The Institute of Medicine (IOM), residency programs should expand quickly: "State boards of nursing, accrediting bodies, the federal government, and health care organizations should take actions to support nurses' completion of a transition-to-practice program (nurse residency) after they have completed a prelicensure or advanced practice degree program or when they are transitioning into new clinical practice areas."11
Implications for Practice
Thus, the question of whether all nurse practitioners should undergo a 1- to t2-year residency program may be an issue the profession will need to face sooner rather than later. As nurse residency programs continue to expand, employers may elect to hire nurse practitioners who have undergone residency training or received fellowship education over the new graduate without advanced training.
An additional burden may be placed on new graduates, as the American Association of Colleges of Nursing has recommended that all nurse practitioners obtain DNP degrees by 2015, effectively adding another 2 to 3 years of education over a 1- to 2-year residency requirement.12 The current cost of educating a nurse practitioner is considerably less than the cost of educating a physician. In terms of cost and efficiency, it is estimated that between 3 and 12 nurse practitioners can be educated for the price of educating 1 physician, and more quickly.13 It follows that commensurate costs and time considerations will need to figure into the equation of educating and incentivizing clinicians to fill present and projected shortages.
Looking to the Future
As nurse practitioner residencies grow in number and popularity, it will be of clinical interest and significance to conduct timely research studies that examine the effectiveness of the programs. However, it will also be critical to view the movement's impact on how prospective nurse practitioners and new graduates consider employment options and alternate pathways to practice. Similarly, we will need to examine how future employers will critique the prospective clinician's entry to practice credentials and experience, when it comes time to hire the new graduate.
Karyn Lee Boyar is a family nurse practitioner who is a clinical instructor at the New York University College of Nursing and a student in the DNP program at Pace University in New York.
1. Carrier E, et al. Matching supply to demand: Addressing the U.S. primary care workforce shortage. NIHCR policy analysis no. 7. www.nihcr.org/PCP_Workforce.html.
2. MEDEX Northwest Division of Physician Assistant Studies. Physician assistant training programs. www.washington.edu/medicine/som/depts/medex/whoweare/whatisapa.htm.
3. Sommers BD, Rosenbaum S. Issues in health reform: How changes in eligibility may move millions back and forth between Medicaid and insurance exchanges. Health Aff. 2011;30(2):228-236.
4. Alberti M. Warnings of doctor shortage go unheeded. www.remappingdebate.org/article/warnings-doctor-shortage-go-unheeded.
5. Administration on Aging. A Profile of Older Americans: 2009. www.aoa.gov/aoaroot/aging_statistics/profile/2009/docs/2009profile_508.pdf.
6. US Department of Health and Human Services. HHS awards $320 million to expand primary care workforce. www.hhs.gov/news/press/2010pres/09/20100927e.html.
7. Flinter M. Residency programs for primary care nurse practitioners in federally qualified health centers: A service perspective. Online J Issues Nurs. 2005;10(3)6.
8. Community Health Centers, Inc. Our Model of Care. http://www.npresidency.com/.
9. U.S. Department of Health and Human Services. The Affordable Care Act and health centers. http://bphc.hrsa.gov/about/healthcenterfactsheet.pdf.
10. Newhouse RP, et al. Advanced practice nurse outcomes 1990-2008: A systematic review. Nurs Econ. 2011;29(5):230-250.
11. The Institute of Medicine. The Future of Nursing Report. (2011). http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx.
12. American Association of Colleges of Nursing. DNP Roadmap Task Force Report. http://www.aacn.nche.edu/dnp/roadmapreport.pdf.
13. Fairman JA, et al. Broadening the scope of nursing practice. New Engl J Med. 2011;364(3);193-196.