As the US health care system responds to the expansion of health insurance coverage, the aging population, and increasingly complex care, many stakeholders are concerned that the demand for health care services may exceed supply (National Center for Health Workforce Analysis, 2013). The expected increase in demand for primary care and the uncertainties associated with payment and delivery reforms have energized policymakers to address how to ensure the primary care workforce can respond to the health needs of all US individuals (Buerhaus, Skinner, Auerbach, & Staiger, 2017). Although the size and impact of the primary care shortage is uncertain, this demand creates opportunity for nurse practitioners (NPs) to provide primary care, particularly in rural areas and for vulnerable populations.
Equally important is the concern about the ability to deliver high-quality, value-based, and safe patient care. Innovative care and financing models, such as Primary Care Payment Models, Accountable Care Organizations, and Patient-Centered Medical Homes, were designed to address the challenges facing the US health care system through an increasing focus on quality improvement, the development of innovative team-based care models, and holding health care providers accountable for the total health of populations (Damberg et al., 2014; Edwards, Bitton, Hong, & Landon, 2014).
The ever-increasing numbers of new graduate NPs who have completed a practice doctorate program are poised to meet these challenges. The additional skill set acquired in the educational preparation of a NP, with a practice doctorate, focuses on quality improvement, team leadership, interprofessional collaboration, translation of evidence into practice, and innovation of care delivery models. This additional time and practice prepares NPs to participate and lead innovative team-based care models. Until more NPs are prepared with these competencies, postgraduate NP residency/fellowship programs have emerged as an additional support for new graduate NPs to transition to practice, with supervision from experienced mentors.
Background and significance
Increased production of nurse practitioners
One promising approach to achieve new models of effective health care delivery and to increase access to care is to increase production and make optimal use of the growing NP workforce. Schools of nursing have responded by significantly increasing program size, as well as the number of graduates from these programs (Salsberg, 2015). The NP workforce has nearly doubled since 2007, and currently, more than 270,000 NPs are licensed in the United States (American Association of Nurse Practitioners [AANP], 2019). An additional 26,000 NPs graduated from programs in the 2016-2017 academic year, an increase of 9% from the previous academic year (AANP, 2019). The NP workforce is projected to increase by 93% between 2013 and 2025 (National Center for Health Workforce Analysis, 2016). Other projections indicate that the NP workforce is expected to double in the next 15 years (Auerbach, 2012).
An estimated 87% of new NP graduates have been trained in primary care, and nearly two of three new NPs will graduate from family NP programs (AANP, 2019; Buerhaus, Desroches, Dittus, & Donelan, 2015). Concurrently, recent studies propose that more NPs are practicing in specialty areas (Martsolf et al., 2018; Ray, Martsolf, Mehrotra, & Barnett, 2017). This growing interest in specialty care is occurring at the same time as the Advance Practice Registered Nurse (APRN) Consensus Model is gaining momentum to update state regulations to reach full scope of practice authority for NPs to match the level of their education, preparation, and educational training (National Council of the State Boards of Nursing [NCSBN], 2019). This expanded regulation to achieve autonomous practice authority allows NPs to practice without supervision or formal collaboration agreements with physicians (Barnes et al., 2017; Buerhaus et al., 2015; Gadbois, Miller, Tyler, & Intrator, 2015). The variability of state scope of practice regulations and Medicaid reimbursement rates may limit efficient distribution of NPs (Barnes et al., 2017). The American Academy of Nursing (AAN) issued a position statement in November 2017 in favor of removing all practice restrictions on APRNs, allowing them to practice independently and to the full extent of their education, training, and experience (Bosse, 2017). This statement agreed with the NCSBN, National Academies of Sciences, American Association of Retired Persons (AARP), American Hospital Association, Federal Trade Commission, and others on this NP scope of practice issue.
These trends suggest that, as the number of NPs entering practice increases and legislation changes, NPs will function more autonomously, and their responsibilities will increase in complexity and importance. Educators, regulators, and employers are seeking the best way to prepare the new graduate NP to transition to practice in primary care, as well as in specialty practices, with full scope of practice and autonomy. Employer-based postgraduate NP residency/fellowship programs have emerged as one means to address this issue.
Emergence of nurse practitioner residency/fellowship programs
Currently, there are a number of ways to assist NPs to transition to practice to meet these challenges. A growing number of employer-based postgraduate programs, called NP residencies or fellowships, have emerged in the last decade in both acute care and community-based primary care settings. Postgraduate NP residency/fellowship programs are a relatively new phenomenon across the country and lack standardization in definition, organization, management, and structure (Kesten, El-Banna, & Blakely, 2019; Martsolf, Nguyen, Freund, & Poghosyan, 2017). These postgraduate NP residency/fellowship programs provide education and clinical training for NPs beyond their formal graduate education. Currently, fellowships are not required for licensure into practice and the National Organization of Nurse Practitioner Faculties (NONPF) released a statement that there should be no post-licensure requirement such as a residency (NONPF, 2019).
A previous study collected data about the number, length, geographic location, specialty areas, admission requirements, and organizations overseeing the postgraduate NP residency/fellowship programs (Martsolf et al., 2017). This study accessed online program descriptions to collect their data and provided a foundational database of programs. Recently, the authors uncovered that the growing number of discoverable programs had reached 88 and successfully surveyed 41 program directors (Kesten et al., 2019). However, there is a dearth of literature regarding the facilitators, barriers, benefits, and funding of implementing postgraduate NP residency/fellowship programs.
The key success characteristics of postgraduate NP residency/fellowship programs include communication with preceptors, mentoring consistency, building evaluation components to quantify program results, and identifying key stakeholders and funding sources to support implementation and sustainability of the programs (Brown, Poppe, Kaminetzky, Wipf, & Woods, 2016; Goudreau et al., 2011; Kells, Dunn, Melchiono, & Burke, 2015; Rugen et al., 2014; Sciacca & Reville, 2016). In a recent survey, Faraz (2019) found that facilitators of NP transition to practice include mentorship, social support, job satisfaction, and work-life balance. Many of these results, however, are based on single case studies. Therefore, policymakers, educators, employers, and NPs all have a limited understanding of postgraduate NP residency/fellowship programs.
The purpose of this study was to conduct an in-depth exploration of postgraduate NP residency/fellowship programs in the United States, as perceived by program directors, to gain an understanding of the facilitators, barriers, benefits, and funding to develop and implement these programs.
Methods
After Institutional Review Board approval for this study was obtained, a survey was sent to all postgraduate NP residency/fellowship programs directors in the United States. Forty-nine program directors (56% response rate) started the survey and 41 programs directors completed the study survey from November 2018 to February 2019.
Although no validated questionnaires suitable for this study were identified, a survey tool was developed to obtain information on NP residency/fellowship: (1) facilitators and barriers to program development and implementation and (2) funding and perceived benefits by program directors of these programs. Four doctoral-prepared colleagues familiar with postgraduate NP residency/fellowship programs reviewed the survey for content and face validity; another four colleagues pilot tested the tool, including two program directors. An invitation to participate in the study was sent to program directors and included a link to an online survey. Recipients were instructed to forward the invitation to an appropriate designee, if needed. A $50 gift card incentive was offered. Data were collected from November 2018 to February 2019.
Data analyses
Data were analyzed using IBM Statistical Package for the Social Sciences (SPSS) Statistics, version 25. Meticulous data collection and sampling were used to prevent error. A sample of 41 surveys were analyzed, after exclusion of eight incomplete surveys. Descriptive statistics included a calculation of mean, SD, percentage, and ranges for all study variables, as needed, to describe and provide summations of postgraduate NP residency/fellowship programs' facilitators, barriers, funding, and benefits. Data were screened and inspected for outliers such as extreme scores. Each outlier was detected for each variable by running the frequencies and the frequency distribution tables of extreme values of individual data elements within the data set. This screening procedure resulted in examining all study variables; however, outliers could not be attributed to any single program. There were some values that indicated an error in the data entry such as a typo, and they were removed from the data before calculating summary statistics or making inferences.
Results
Figure 1 represents the locations of all 88 NP residency/fellowship programs from 32 states that were surveyed. Of the 88 program directors or their designees who were contacted, 49 program directors (56% response rate) responded. Only the 41 completed surveys were used in this study. The results are presented in the major categories of the survey: program demographics, facilitators and barriers to program implementation, benefits of the programs, and sources of funding.
Program demographics
Postgraduate NP residency/fellowship programs are named with a range of terminology. Forty-four percent referred to the program as a NP Residency, whereas 51% used the term NP Fellowship. Only 5% used alternate terms to describe their programs such as postgraduate NP or Advanced Practice Nursing (APN) training. The majority of the programs (85.4%) indicated that they were 12-18 months in length; however, the typical length was 12 months. The mean length of program existence was 4.8 years (SD = 2.69), whereas the oldest NP residency/fellowship program located in the study survey was initiated more than 12 years ago. The NP residency/fellowship programs were relatively small in size with a maximum cohort size of 20 (mean = 4.31, SD = 4.20).
Facilitators and barriers to program implementation
From the program director perspective at the employment site, there are numerous facilitators to implement NP residency programs ranging from physician and administrative support to a demand for program and competitive compensation program (Table 1). The perceived barriers to NP residency/fellowship programs are also shown in Table 2. Less than half of the program directors indicated that the burden and workload of the preceptor and the cost of program implementation were barriers for their programs. Only 11% of the programs selected the lack of qualified preceptors as a barrier, which was the least selected barrier to implement programs.
Benefits of the programs
The most benefits to organizations that offered postgraduate NP residency/fellowship programs are shown in Table 3. Benefits to NP resident/fellows include salary, insurance, vacation, and tuition benefits. Salary for NP resident/fellows ranged from $50,000 to $98,000/year, with the mean salary of $69,301/year (SD = 10,307). Other benefits provided to NP residents/fellows were health care insurance (97.6%), liability insurance (90.2%), life insurance (80.5%), and other (34.1%), including paid time off, vision, dental, retirement, tuition benefits, and vacation. Seventy-eight percent of NP programs indicated that they did not require contract time after program completion but 66.98% of the programs hired their NP resident/fellow graduates and 80% assisted them with job placement.
Evaluation feedback during the NP residency/fellowship program is another benefit to the new graduate NP as they transition to practice. Programs used two-to-five different ways to evaluate their NP residents/fellows. All programs used the preceptor/mentor feedback along with other evaluation methods, such as self-assessment (95.1%), skills demonstration (92.7%), peer review (53.7%), and knowledge examination (36.6%). These data showed that there is a need for between 1 and 10 preceptors, with an average of five preceptors for each NP resident. Also, lack of incentives for preceptors appeared to be of moderate concern.
Funding sources for programs
Nearly half of the programs (46%) received no source of funding and only 10% of programs receive two sources of funding to implement the program. Major sources of reportable funding were from organization billing (15%), Veterans Administration Centers of Excellence in Primary Care Ed (10%), and Medicare/Medicaid (4.9%).
Discussion
Program directors reported a number of facilitators to program implementation while citing few barriers, which may explain why the programs are gaining momentum. Overwhelming support from physicians and administration for program implementation outweigh the small percentage of those program directors that cited barriers. Although increased workload and burden on preceptors is a fairly common cited barrier to program implementation, a lack of qualified preceptors was not cited by program directors. This is surprising to nurse educators because a lack of preceptors is one of the biggest challenges in providing graduate nursing clinical education. In this study, it was reported that NP residents/fellows have a large ratio of preceptors to NP residents from 1-to-10, with an average of five preceptors for each resident/fellow. Although preceptors can provide valuable mentoring and evaluation feedback, the highest percentage of evaluation feedback was reported in the form of self-evaluation. Self-evaluation is the least labor-intensive task for preceptors, whereas concern is often raised about the potential for decreased productivity of preceptors while mentoring.
Employers reported many benefits to developing and implementing postgraduate NP residency/fellowship programs. Our findings reinforce that the number of postgraduate NP residency/fellowship programs has grown across the United States since the first studies demonstrated increased recruitment and retention of new graduate NPs, thus reducing turnover (Bush & Lowery, 2016; Owens, 2019). Retaining NPs in primary care is incentive for implementing employer-based NP residency/fellowship programs. Whereas the most prominent benefit that program directors reported was increased competence and skill proficiency of the NP while citing no uniform or standard set of competencies and skills. This is consistent with previous research by Klein and Lugo (2018) and Kesten et al. (2019) who found that 62.5% of postgraduate NP training programs do not practice competency-based evaluation. This is a clear opportunity for improvement because the development of evidence-based competency assessment and evaluation tools would help quantify outcomes and establish success standards (Hodges, et al., 2019; Kesten et al., 2019). Thus, a standardized curriculum, consistency in preceptor mentorship, competency-driven assessment and evaluation, and meaningful feedback are highly recommended to improve the quality outcomes for all NP residency/fellowship programs.
A lack of funding sources for postgraduate NP residency/fellowship programs surfaces as a primary concern when thinking about sustainability of these programs. Our physician colleagues benefit from medical residencies that are required, with funding for clinical medical faculty time, resident salary, and standard curricula that leads to board certification and competency in a specialization (Sargent & Olmedo, 2013). Our study supports the findings of MacKay, Glynn, McVey, and Rissmiller (2018) that a lack of federal funding for postgraduate NP residency/fellowship programs and their associated costs, including salary, benefits, administrative costs, and possible reduced productivity of the preceptor need to be taken into consideration. In 2011, the Institute of Medicine (IOM) recommended that the Center for Medicaid and Medicare Services (CMS) and Health Resource & Services Administration (HRSA) support continued growth and sustainability of NP residency/fellowship programs. Previously, Graduate Nurse Education (GNE) Demonstration projects, which were funded by CMS, enabled the implementation of NP residency/fellowship programs. The same holds true for the Veterans Administration (VA) federally funded programs (Rugen et al., 2014; Wiltse Nicely et al., 2012). Innovative funding of NP residencies/fellowships is needed to explore diverse funding stream sources such as health systems to receive a return on investment on the NP workforce. Additionally, increased access, directly and indirectly, to graduate medical education funds would be optimal and equitable. Federal funding remains uncertain; therefore, the need for private funding should be explored. A future plan to incorporate a mentored practice immersion experience of NP residency/fellowship programs into academic practice doctorate programs is recommended by means of an academic-practice partnership.
Limitations
Postgraduate NP residency/fellowship programs that were not discoverable were not included in our database and therefore not able to be surveyed. Program directors perspectives were captured as they were surveyed. Further survey of the NP residency/fellowship program graduates is needed. The descriptive statistics do not enable the conclusions to be generalized beyond the population studied.
Conclusion
Overwhelmingly, the program directors indicated that NP recruitment and retention were benefits to organizations implementing NP residency/fellowship programs. The vast majority indicated that physician support and administrative support were facilitators to program implementation. Less than half of program directors were able to identify barriers to implementation. The large number of facilitators and benefits in combination with very few barriers to develop and implement NP residency/fellowship programs creates a climate to support a growing surge in these programs. Organizations that offer NP residency/fellowship programs in partnership with academic partners and that are accredited will be attractive employers to new graduate NPs. Ultimately, if NP residency/fellowship programs are deemed beneficial, legislative initiatives to fund these programs needs to be explored. This study serves to provide data that will inform regulators, educators, and employers about the emerging industry of postgraduate NP residency/training programs and inform decision makers about the facilitators, barriers, benefits, and funding of programs.
Acknowledgements The authors wish to acknowledge The George Washington University School of Nursing for funding this study and Grant Martsolf for his consultation during the instrument development and design of the study.
References