Private sector influences are the major driving force behind APRN residency/fellowship programs. As I have discussed in prior blog posts, the first APRN residency program was developed in 2007 by Dr. Margaret Flinter and colleagues at the Community Health Centers, Inc. (CHC). Due to the success of their program, several other APRN residencies were started and have expanded to include various subspecialties. As of 2016, 38 APRN residency programs exist throughout the United States (http://www.nursepractitionerschools.com/blog/np-fellowship-residency-programs). Residencies exist in areas of primary care and family health; geriatrics; pediatrics; palliative care; neuroscience; dermatology; oncology; cardiology; emergency medicine; psychiatry; acute care; surgery; and gastroenterology and hepatology.
The primary funding for these residencies comes from the organization itself usually through organizational “buy in.” When I interviewed Dr. Flinter at the beginning of this blog, she said the most important factor in these programs being successful is that the organization places importance on the program and believes in the goals that are trying to be achieved (personal correspondence). We see this with any organizational change, there must be buy in in order for the change to occur.
Some would argue that these programs are expensive to start and places more financial burdens on the organization. The question then becomes, are these programs advantageous to the organization?
Carolina’s Heath Care System (CHS) is one of the largest APRN residency/fellowship programs in the country with approximately 70 fellows admitted each year with 20 distinct specialty tracts (Taylor, Broyhill, Burris, & Wilcox, 2017). Several positive organizational outcomes seen by CHS with the implementation of its’ APRN fellowship program include:
- Retention of APRNs in the organization once the residency is complete
- Decrease costs to the organization due to lower turnover rates
- Increased productivity and revenue due to fewer provider vacancies
- Increases to patient access which results in improved patient satisfaction
- Reduction in readmission rates
- Revenue obtained through APRN billing as the APRNs are fully credentialed and privileged at the start of the fellowship
(Taylor, Broyhill, Burris, & Wilcox, 2017)
Other positive outcomes that have resulted that are not directly monetary in nature but can lead to long-term financial gains to the organization include:
- Improved APRN job satisfaction making them less likely to leave the organization
- Improved confidence in abilities and skills
- Decreases in job burnout
- Improved collaboration between members of the healthcare team
- Better integration of new APRN into the system progressing them into leadership, committee involvement, and overall improved engagement in the organization. (Taylor, Broyhill, Burris, & Wilcox, 2017; Simone, McComiskey, & Anderson, 2016)
As with anything in healthcare, APRN residencies/fellowships are not without their expenses. Providing education, training, preceptor support, and salaries for APRNs pursuing extra training is an expense that organizations have to be willing to undertake. More creative private sector funding solutions are needed along with creative government funding discussed in the last blog to help make these programs a success. As shown above, there are positive outcomes that can result for organizations who undertake these programs but there must be organizational buy in and support for these programs. Without that, APRN residencies/fellowship programs will continue to remain an important but unsupportive postgraduate education opportunity.
Current APRN residencies/fellowship programs across the US
References:
Simone, S., McComiskey, C.A., & Andersen, B. (2016). Integrating nurse practitioners into intensive care units. Critical Care Nurse, 36(6):59-69. doi:http://dx.doi.org/10.4037/ccn2016360
Taylor, D.A., Broyhill, B.S., Burris, A.M., & Wilcox, M.A. (2017). A strategic approach fordeveloping and advanced practice workforce. Nursing Administration Quarterly, 41(1):11-19. doi:10.1097/NAQ.0000000000000198
Advanced Practice Registered Nurse Fellowship programs 
Brittany Broyhill was a classmate of mine at Vanderbilt. We both went through the same ACNP program and she has managed to implement an incredible residency program at CHS. They have put an extraordinary amount of work into building the shining example for what fellowship programs can be.
However, I think the CHS example and the call for more fellowship programs highlights a bigger need amongst large health systems. Where do advanced practice providers belong in the heirarchy? Should they report to nursing? To physicians? To administrators? Carolinas Health has succeeded in building an exceptional program because they have a centralized advanced practice voice and strategy! CHS developed a direct line to executive leadership for APRNs and because of that, they were able to drive this fellowship forward. As we have pushed forward with calls for full practice authority, many of our hospital/health system employed colleagues have remained in limbo. There has not been a push to have APRNs reporting to APRNs, and in most health systems that idea remains foreign.
Registered nurse transition to practice programs succeed and are able to be successfully developed because there is a chief nurse on the executive team. Similarly with residency developments. But again, where does advanced practice belong? Without that unified, leading voice, I fear attempts to develop fellowship programs at most centers will fall flat.
For those of us lucky enough to have a voice, I am ridiculously grateful for the roadmap CHS has provided towards developing post-graduate training programs!
Taylor, D.A., Broyhill, B.S., Burris, A.M., & Wilcox, M.A. (2017). A strategic approach for developing and advanced practice workforce. Nursing Administration Quarterly, 41(1):11-19. doi:10.1097/NAQ.0000000000000198
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I think it is great to have residency programs for APRNs. This can allow them to get specialty experience in the field of interest. I understand the issues related to such programs in terms of cost. On one hand, if APRNs go through a residency program and remain working for the organization, then the employer would benefit from the additional cost of the program. However, if there is high turnover among APRNs after the residency program finishes, there won’t be any value to the organization. One of the beneficial aspects of medical residency programs from an organizational standpoint is that residents are not paid high salaries and organizations like Medicare provide funding (AAMC). In contrast to medical residency programs, it doesn’t appear that APRN residencies have lower salaries. However, considering the growth in number of APRN programs, organizations must realize the value or they wouldn’t continue.
American Association of Medical Colleges (nd). Medicare direct graduate medical education payments. Retrieved from https://www.aamc.org/advocacy/gme/71152/gme_gme0001.html
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I absolutely love not only your topic but passion to tackle this problem that APNs are facing. I remember years ago being a newly graduated BSN starting my career in the newborn intensive care unit and my hospital had a nurse residency program that all new grads were a part of for their first year. For the NICU nurses, we had the hospital-wide residency once a month but also had a NICU specific class that was also once a month but for only four months. It was frustrating for all of the NICU nurses sitting in the hospital-wide class learning about bariatric lift devices and rapid response teams when none of that applied to us. It was good information two years later when I started floating to other units but as a new grad trying to learn the basics of being a nurse “in real life” it was difficult. Now, fast forward and I’m about to begin my career as a NNP, I see many options (or mostly lack of options) for residency programs for APNs. And I agree with you completely that it is a multi-faceted problem. First being the organization buy in to see the value of the expense and time and also understanding where APNs “fit it.”
As I began my job search for after graduation the differences in how organizations viewed NNPs (or any advanced practice nurse) became part of a deciding factor. Many grouped them into the “nurse” category while many grouped them into the “physician/professional” category. I still remember thinking to myself, “wait, I AM a nurse and very proud of that but I am also advanced practice.” I have also found it interesting in listening to people talk about their opinions about their place in their own advance practice profession. Some are almost offended when they think you’re talking about them being “just a nurse” while others are offended when someone thinks they are trying to “be a physician” and many are somewhere in the middle of the two extremes. As the profession grows and evolves it will be interesting to see how it progresses but I can understand the uncertainty of organizations on how to properly identify the advanced practice nurse when it seems that we as a group haven’t even fully identified our place.
Going back to my job search process, it was sometimes clear where the different organizations (I looked at 7) placed the advanced practice nurse while others it wasn’t clear and difficult to understand the hierarchy. However, during my visit to Children’s Medical Center and UT Southwestern I was in complete awe and excitement for the passion and dedication to not only the patients but nurses, advanced practice nurses, resident physicians, fellows, and attending physicians. They are in the process of developing an advanced practice residency program and want it to be very similar in opportunities as the resident physician program (1). I will be interested to see how that develops especially seeing other programs that are already established in the many differences between them also. Specifically speaking to the NNP population, Meier and Staebler (2014) wrote in their workforce survey about the gap in education and support many NNPs are feeling/experiencing especially in certain geographical areas and specifically within the higher acuity NICUs. Unfortunately, that is leading the majority of the NNPs gravitating toward the lower acuity units where they won’t be using their skills to their fullest potential but they will feel more supported with less responsibility. The downside is the specialized, higher acuity areas are experiencing higher shortages which, in turn, requires experiences NNPs to work more and train new incoming NNPs less. It becomes a vicious cycle.
I see this as not just a challenging time in our profession, but also a very exciting time!! All of us coming through have the ability to make a large impact and use our skill set to the fullest potential. My question and challenge to all of us, including myself, is if your organization doesn’t have a residency program, help create one!!! We all have the knowledge and ability to make it happen and as you very eloquently pointed out, there are challenges but opportunities to make this healthcare problem a solution. Great job and I hope you continue your work and passion.
1. Childrenshealth (nd). Residency programs. Retrieved from: https://www.childrens.com/for-healthcare-professionals/education-training/residency-programs
2. Meier, S. & Staebler, S. (2014). 2014 Neonatal nurse practitioner workforce survey: Executive summary. National Association of Neonatal Nurse Practitioners. Retrieved from: http://nann.org/uploads/Membership/NNP_Workforce_Survey_Executive_Summary-FINAL_01-13-15.pdf
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