Supporting the professional transition of nurse practitioners (NPs); oddly, this is a topic of much controversy.
Residency programs, or post-graduate education programs, are a topic of debate in healthcare. NP residency programs are increasing in number based on the recommendation of the Institute of Medicine (now called the National Academy of Medicine). The topic of NP residencies is layered and complex. Some people feel these residencies should be mandated for new NP graduates, while others feel they are unnecessary. The first NP residency program was developed in 2007 and since then more have popped up around the United States.
Advocates of NP residency programs cite the National Academy of Medicine’s recommendation for these programs, new graduate NP’s interest in these programs, and increasing patient complexity as reasons to support these residency programs. Individuals in this camp believe that additional training after graduation from an MSN program is needed to hone skills and that new grads do not have the knowledge needed to safely provide patient care. This seems reasonable enough at first glance. Let’s look at the viewpoint of opponents of NP residency programs before digging deeper.
The most outspoken opponents of nurse residency programs include the NP Roundtable which is a collaborative of various national NP organizations that represent the interests of nearly 300,000 NPs in the U.S. The NP Roundtable discussed postgraduate education in May 2014 and voiced that NPs are competent providers at graduation and do not require additional training. The NP Roundtable expressed that postgraduate education may inhibit NPs from working in underserved and rural areas that do not have the funds to provide expensive postgraduate education to new NPs. In addition to the expense of residency programs, other concerns are the potential barrier to independent practice and consumer access to healthcare with mandated residencies for NPs. The NP Roundtable also felt that a focus on requiring additional training after completing the MSN program for NPs would suggest to the public that new NP graduates lack competency, which is not supported by current research.
In fact, it turns out that NPs and physicians provide comparable care despite training differences. Systematic reviews and meta-analyses show that NPs provide safe, effective patient care with patient outcomes similar to those produced by physicians (Martinez-Gonzalez et al., 2014; Stanik-Hutt et al., 2013; Horrocks et al.,2002).
One study that was conducted in 2002, before the introduction of NP residencies, conducted a randomized control trial comparing NPs and physicians providing patient care in a primary care setting. The study found no differences in prescriptions, return consultations, or referrals. The study also found that in some ways, quality of care was rated by patients as better for NPs than physicians (Horrocks et al., 2002). The authors of this study concluded that increasing availability of NPs in primary care is likely to lead to high levels of patient satisfaction and high-quality care. Another systematic review study supports these findings, showing that patient outcomes of NP-provided care are equivalent to those of physicians (Stanik-Hutt et al., 2013). These studies seem to demonstrate that gaining competency is not a reason for mandating NP residencies. Clearly, an NP residency does not keep an NP from practicing, but it would delay their full entrance into more autonomous practice.
I wonder if there are some feelings among other specialists in healthcare that the room is getting too crowded, so to speak. Physicians do go to school much longer than NPs. Maybe there are feelings that because NPs did not go through the same training as physicians that safety and quality cannot be maintained at the same standard (even though the research shows otherwise). Or maybe there are thoughts that physician value may be lessened in some way by having more providers available to provide patient care. If there can be a limit to the scope of NP practice through residency programs and other legal measures, then the value of the scarce physician remains high. If this is the case, I think that vying for value by limiting the number of other providers misses the point. We need to be producing quality patient care and increasing access, not limiting it.
It’s clear that a new NP grad does not have all the experience he or she could possibly have, how could they with a shorter span of training? But do they need significant extra training that limits their earning potential (because NP residencies pay NPs less than an average NP job)? I’m not so sure. Patient outcomes and research over the past several decades have shown that NPs provide comparable quality, safety and effectiveness of care. Residencies do offer support in the transition to practice with honing clinical skills and confidence along the way, but is that worth a $20,000 + pay cut for the yearlong residency program? I’m not sure it is. I think there are other ways a new NP grad can learn skills and confidence to be a force to be reckoned with when it comes to providing safe, quality and effective patient care.
I think the right answer to NP postgraduate education lies somewhere in between the advocates for NP residencies and opponents of it. While NPs do not require more training from a competency-perspective, they don’t have the support needed to smoothly transition from graduation into practice. I don’t think the solution lies in requiring NP residency programs but by addressing confidence and self-doubt.
The real question is how to support new NP grads transitioning into practice. There should not be concern over whether another specialty is “losing” value because another specialty of providers is entering it. There should not be concern about increasing access to care for patients with the introduction of more NPs either. The concern should be about making sure the new NP grad feels supported. The subjective feeling of support, diminishing doubt, and increasing confidence. This needs to be the focus.
Providing this support occurs by reaffirming a new NP’s skills, encouraging their ability to learn and utilize resources, and reminding them of their true value in the healthcare space. Research shows NPs have good patient outcomes, but new NP grads doubt this. The transition into practice is filled with doubt and anxiety. We need to support them and build confidence. This doesn’t need to happen through residency programs where thousands of dollars are spent in the process.
Instead, NPs need to be intentional about setting themselves up for success. This includes contract negotiation after a job is offered that includes a slow “ramp up” period and opportunities to meet with a collaborating provider (MD, APRN) weekly that is built into the NP’s schedule. This would become protected time that cannot be spent seeing patients but instead meeting with a collaborator to discuss difficult patient cases. If this cannot be negotiated in a job contract, find an experienced clinician to do private supervision with. This is little known among NPs for some reason but common in medicine. You can pay an experienced clinician to meet with regularly to do consultation with for case reviews and med management. This is invaluable. I doubt the private consultation will cost you the $20,000 or more you could be losing by doing a residency program.
This really is a controversial topic and I’m presenting a side of the argument that is likely biased, as I am an NP (surprise, surprise), but I thought it should be considered with creative ways to “have it all”. Have the salary you desire and deserve as a successful graduate of advanced practice, have the support you create that is set up during your contract negotiation, and have ongoing educational support and mentorship through a collaborating provider from your job or found on your own. You can have a lucrative career and get the support you need. You just need to be creative about how you go about doing this. Gaining confidence and support does not need to come from some expensive residency program. You have what you need as a new grad to provide quality, safe patient care. We just need to build in some support networks along the way.
References:
Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. Br Med J, 819-823. DOI: 10.1136/bmj.324.7341.819
Martinez-Gonzalez, N., Djalali S., Tandjung, R., Huber-Geismann, F., Markun, S., Wensing, M., & Rosemann R. (2014). Substitution of physicians by nurses in primary care: A systematic review and meta-analysis. BMC Health Services Research. DOI: 10.1186/1472-6963-14-214
Stanik-Hutt, J., Newhouse, R. P., White, K. M., Johantgen, M., Bass, E. B., Zangaro, G., Wilson, R., Fountain, L., Steinwachs, D. M., Heindel, L. & Weiner, J. P. (2013). The quality and effectiveness of care provided by nurse practitioners. The Journal for Nurse Practitioners. DOI:https://doi.org/10.1016/j.nurpra.2013.07.004
