Opportunities and Challenges of Establishing a VA Residency

Changes in the nation's healthcare system, including an increasing aging population, an increase in individuals living with chronic illnesses, and changes in reimbursement policy, have contributed to the need for more providers, especially in medically underserved populations. The U.S. Department of Health and Human Services suggests that Nurse Practitioners (NP) can help fill this need (Hood et al., 2019). A Nurse Practitioner is an Advanced Practice Registered Nurse (APRN) with a master's or doctorate. The NP has advanced clinical training obtained through didactic and mandatory clinical courses beyond the initial professional Registered Nurse (RN) preparation with the clinical competency to provide care in primary, acute, and long-term healthcare settings. NPs are allowed to provide health care services to include but not limited to taking a history, performing physical/psychiatric exams, ordering labs and procedures, diagnosing and managing disease conditions, educating patients, and prescribing and coordinating referrals. State laws continue to impact the scope of practice and privileges granted to nurse practitioners. While some states allow NPs to practice independently without a physician’s supervision, others still mandate doctor’s supervision (American Association of Nurse Practitioners [AANP], n.d). (Author - provide reference for this, please - RY)

The Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, supports that the insight and skills gained by nurses over time contribute towards improving the quality and safety of patient care. To this end, the report emphasized establishing residency or fellowship programs to facilitate the transition from RN to NP practice for Advanced Practice Registered Nurses. Today, in the United States, more than 90 Nurse practitioner residency/fellowship programs have been established in various specialties and clinical settings in response to increasing healthcare needs. The Veterans Health Administration (VHA) is funding 59 of those programs in primary care and mental health nationwide. To ensure that the graduating nurse practitioners are well prepared for this role, the Commission on Collegiate Nursing Education (CCNE) and the National Nurse Practitioner Residency and Fellowship Training Consortium (NNPRFTC) established standards and competencies to be met by NP residency programs. These standards include professional development, leadership, organization enculturation, quality outcomes, mission/vision objectives, program eligibility, curriculum evaluation, and trainee services (Rugen et al., 2018).

Despite the continuous enhancement of graduate programs to better prepare nurse practitioners for practice, many new NPs report feeling underprepared for the initial role of patient care with inadequate diagnostic interpretation skills due to the complexity of the patients (Brown et al., 2015). They welcome the one-year post-graduate training as an opportunity to transition into practice in a supportive environment surrounded by experienced providers willing to mentor them as they make the transition. The one-year program allows residents to engage in mentored clinical time with a skilled provider willing to offer feedback on best clinical practices with a structured clinical rotation, specialty care clinical experience, and a classroom-based didactic component.

NP Residency Programs in the United States

The concept of residency programs arose to address the difficulties post-graduate NP were experiencing with role transition from RN to NP. The National Nurse Practitioner Residency and Fellowship Training Consortium (NNPRFTC) is “an informal group of early innovators and developers of a residency and fellowship training for new Nurse Practitioners, first in primary care and then in specialty care as well” (NNPRFTC, 2021). The purpose of this consortium was two-fold. Paramount was to provide more opportunities for fully credentialed novice NPs to participate in a postgraduate program to help hone skills and develop confidence as new providers. Additionally, there was a need to provide accreditation for these post-graduate training programs to ensure high standards and development of the novice NP. Consortium members posited that achieving these goals would “make a significant contribution to the profession of nursing and to the health and health care of the public” (NNPRFTC, 2021).

A residency program can apply for accreditation. To be accredited, it must meet and exceed the standards set by the accrediting board. This provides prospective applicants with the assurance that rigorous standards have been met. The NNPRFTC offers an extensive list of accredited programs and the process to become accredited by their organization. Moreover, The American Family Nurse Practitioner Association provides a smaller list of NP residencies. These include opportunities in acute care, cardiology, dermatology, emergency medicine, gastroenterology & hepatology, geriatrics, neuroscience, oncology, palliative care, pediatrics, primary care and family health, psychiatry, rural health, and surgery.

Currently, there are 156 accredited NP residency programs in the United States. California is the leader in the number of NP residency programs, with 19; Washington follows with 14; Massachusetts and New York have 13; and Texas has seven (NNPRFTC, 2021). The U.S. Department of Veterans Affairs Office of Academic Affiliation (VA OAA) increased the amount of NP residency programs throughout the United States in 2020, with plans to increase NP residency programs yearly. These programs are highly competitive and vary on the number of residents accepted into the 12-month program.

In an interview with Dr. Jill MacPherson (2021), she indicated the VA currently has 25 Psychiatric Mental Health NP residencies and 34 Primary Care NP residencies throughout the United States. The VA started the residency program to meet the increased complexity of the Veterans' overall health needs and to care for those who served. The program accepts practice-ready Nurse Practitioners from various specialties and supports them through a one-year residency training. It is a competency-based curriculum that was designed on an 80/20 model. 80% of the training time focuses on advancing the residents' clinical skills, while 20% aims to increase their clinical knowledge, assessment, and diagnostics skills while concentrating on veteran-centric topics. According to the VA OAA, the Nurse Residency Expansion Initiative Program Announcement Return on Investment Study (ROI) of its nursing residency programs was conducted in 2016. It indicated a substantial positive payoff for the investment across all VA OAA nursing residency programs.

Transitioning to the NP Role

For some, the transition from RN to NP can be difficult, and understanding the role of the transition of the newly graduated NP entering practice is essential (Benner, 1984; Murray et al., 2019). Using Benner's novice-to-expert transition model can facilitate understanding new graduate NPs' transition process. A beginner's stressors during the transition phase, such as the fear of making mistakes and the need for constant validation, are common occurrences. Murray et al. (2019) postulated that new nurses go through several stages as they continue their experience. The same holds for NPs as they advance through these stages. As NPs gain clinical experience, they develop problem-solving skills and significantly increase confidence as they progress to an expert role. The NP residents in the initial phase begin to feel shocked and overwhelmed. To assist the residents initially, they may be assigned to a smaller patient panel and have protected time for learning and discussing cases with the assigned mentor. As NP residents' comfort level is reached and confidence increases, they advance their ability to see more patients in the clinic.

Several nurse researchers have identified concerns and challenges related to NP role transition (Mounayar & Cox, 2021). Brown & Olshansky (1998), were the first to identify new graduates who go through several stages of development as they enter NP practice. Brown and Olshansky explained the first stage identified was “laying the foundation” (recuperating from school, negotiating the bureaucracy, looking for a job, and worrying). The second theme was "launching" (feeling real, getting through the day, battling time, and confronting anxiety). The third theme was "meeting the challenge" (increasing competence, gaining confidence, and acknowledging system problems). The last theme was "broadening the perspective" (developing system savvy, affirming oneself, and upping the ante). NPs reflect as they face each challenge and integrate these changes into their lives until they become competent and confident. NPs’ self-confidence increases as they become more comfortable with their role and perceive themselves as legitimate providers. Brown and Olshansky further discussed that at the end of the first year, NPs had a better perspective of their earlier experience, were able to acknowledge the progress, and had a better understanding of their role as a provider. Similarly, Horberg et al. (2019) posited that nurses experience an actual transition period as they go through different stages to acquire a new professional identity, embrace the change, and adapt to their new role. The adjustment in professional identity can “impact self-confidence, impair the development of the new role, and influence decisions to remain in the job and the profession within the first year of clinical practice for new NPs” (Twine, 2017, p. 56).

NP graduates face challenges in their role identity and relationships due to demands in rapid role assimilation and the need for clinical expertise (Dillon et al. 2016). Sargent and Olmedo (2013) (Author - Sargent needs a reference - RY) also described the first year of transition as complex, as novice NPs found themselves unprepared for their new role, worsened by high demands from an employer, lack of support from team members, and unavailability of experienced NPs to mentor. These factors increase anxiety, leading to job dissatisfaction. Faraz (2016) discussed internal and external obstacles that new NP faces during the transition to practice. Internal factors such as feeling inadequate and uncertain about primary NP education resulted in a loss of self-confidence to take a new role. External factors such as interprofessional conflict and non-acceptance of the NP role stemmed from a need for more understanding from physicians' colleagues. Variances regarding the expectations of the role have caused frustration, insecurity, and isolation among new NPs. Lastly, Jones et al. (2014) described how NP graduates felt unprepared to care for older adults with complex health needs. In this study, NPs reported the differences in their role as providers. They harbored feelings of inadequacy and uncertainty without adequate time to transition to practice.

Additionally, the increasing complexity of patient healthcare and the rapidly changing healthcare environment are challenges that can overwhelm new NPs during a transition period. Addressing the challenges that new NPs experience during difficult transitions is essential. Flinter (2011) concluded a “structured, formal residency training program would be the approach most likely to support the transition from new NP to competent primary care provider” (Background). NP residency programs have been the trend in the past decade and can be the critical solution to facilitate a successful transition (Park & Faraz, 2021).

Benefits of Residency Programs

The NP residency program’s primary goal is to assist novice NPs in transitioning to practice successfully and was implemented as a response to the proposed goals of the Institute of Medicine (IOM). The IOM calls for healthcare organizations to support the transition into practice programs such as the NP residency to address retention and recruitment issues, expand competency, improve patient outcomes, and improve access to care (IOM, 2010) (Author - Your reference lists 2010 here, but 2011 in the reference list. Which is it so that we can correct it - RY). Implementing the 2010 Patient Protection and Affordable Care Act (ACA) transformed the healthcare delivery system in the United States. The ACA emphasizes the preventive health services model of care. However, the current shortage of primary care providers may limit patients' access to care. The Institute of Medicine (IOM, 2010), The Future of Nursing: Leading Change, Advancing Health, reports the potential for NPs to provide quality care and address patient health concerns. Thompson (2019) posits the demand for primary care continues to rise, and NPs have the potential to contribute to healthcare provision as part of the ACA transformation of the healthcare system. The Future of Nursing 2020-2030 recommendations have been updated to embrace the significance of preparing novice NPs to foster a culture of health and equitable society through residency programs (Mounayar & Cox, 2021). To achieve this vision, well-prepared NPs in educational, clinical, and research settings are necessary. Nurse practitioner residency programs aid in achieving this vision.

To address the challenges of the first year of practice, NP residency can bridge the gap between didactic learning and real-world clinical practice, providing clinical training for NPs beyond their formal graduate education. Residency programs offer additional postgraduate experience to newly graduated NPs, including hands-on training and mentorship, mitigate risks, and facilitate role transition. The residency period, including a classroom-based or didactics curriculum, enables more robust clinical knowledge (Mackay et al., 2018).

Findings from several studies support the positive impact of NP residency programs during the NP’s transition to practice. According to Wiltse and Fairman (2015), NP residency programs support and allow residents to develop time management skills, improve self-confidence, and establish their identities as they take on new responsibilities. Hart & Flinter (2015) also identified that NP residents had gained superior skills in interprofessional teamwork, an increased understanding of community health, and improved confidence in their abilities to provide safe, quality primary care.

According to Kesten & El-Banna (2020), "the most benefits to organizations that offered postgraduate NP residency/fellowship programs are increased competence and skill proficiency, increased confidence, recruitment and retention, improved communication and collaboration in a team, enhanced clinical judgment, improved socialization to the NP role, increased job satisfaction, and improved patient safety” (p. 5). These findings are consistent with previous research by Zapatka et al. (2015); having a structured experience as NPs transition to practice may provide greater confidence in skills and job satisfaction, thus potentially improving recruitment and retention, which is vital considering the high costs of filling NP positions.

With these considerations in mind, several successful NP residency models have been developed. Painter, Sebach, and Maxwell (2020) discussed how a residency program in an extensive, community-based academic medical center health system in the mid-Atlantic region inaugurated the first residency class, organization support, and outcomes of the program. There was an overall high satisfaction rate from residents, faculty, and stakeholders. Painter, Sebach, and Maxwell further noted that the residents and participants would recommend the NP residency to others (2020). The most important outcomes were the recruitment and retention of the NP residents, which reduced turnover and costs associated with hiring a new employee (Painter, Sebach & Maxwell, 2020). MacKay et al. (2015) described the success of an NP residency in retail health clinics, the goal of which was to support novice NPs in transitioning to practice. MacKay et al. claimed, "The feedback revealed that NP residency programs could provide the clinical, business, and preceptor support needed to transition into a successful NP while reducing turnover and improving retention" (p. 157).

The Department of Veterans Administration (VA) Residency

The Department of Veterans Administration (VA) has started residency programs to aid new NPs transition to practice through the VA Office of Academic Affiliations (OAA). A Nurse Practitioner Residency (NPR) program is one of VA’s premier education and training programs designed as a bridge from academic to clinical practice to develop competent and confident Nurse Practitioners. The unique VA OAA NPR residency program immerses the participants in interprofessional learning environments in which NP residents work collaboratively with physicians, psychology, pharmacy, social work, and other health professions residents. According to the OAA, the NP residency program is a competency-based curriculum  using an 80/20 model “with 80 percent of the training time focused on  the advancement of clinical skills and 20 percent on the enhancement of clinical knowledge, focusing on Veteran-centric topics and principles of assessment, diagnostics, and treatment of complex clinical cases that incorporate the bio-psycho-social aspects of the whole person and evidence-based practice”. The development of leadership skills involves a variety of mentoring activities. Some examples include interprofessional team conferences, medical center committees, and mentoring in specialty areas of expertise. A central hallmark of the program is that residents are deeply engaged in evidence-based practice and system redesign projects during their training at the various VA medical centers, providing opportunities for scholarly presentations and publications. According to the VA Office of Academic Affiliations (OAA), self-assessments and faculty assessments at regular intervals reveal positive outcomes identified by the OAA.

From the OAA website, previous graduates from VA residency programs conveyed their experiences and cited several benefits. Several spoke about how the residency allowed them to discover a passion for a specialized field, such as substance abuse disorders, which they would desire to enter after they graduated from the residency program. Several appreciated working closely with highly regarded and experienced providers who greatly influenced their practice. Many found the experience allowed them to bridge the knowledge and confidence gap between being a student and a full-time provider. The VA continues to grow this program by developing new opportunities within the VA system for VISNs (AUTHOR: PLEASE EXPLAIN THE ABBREVIATION) that do not have residency programs.

Even though The Institute of Medicine recommended the establishment of residency programs for advanced practice nursing graduates, the evidence about such program effectiveness is limited (Rugen et al. 2018). Rugen et al. (2018) examined NP residents who have completed the VA Centers of Excellence in Primary Care Education (VA CoEPCE) 12-month NP residency program. Results indicated VA CoEPCE NP residents "demonstrated readiness for independent practice in all seven competency domains (Clinical competency, Interprofessional team collaboration, Patient-centered care, Shared decision-making, Sustained relationship, Quality improvement/population management) and significant improvement by self and mentor ratings. While more research is needed in this area, this points to a beginning understanding of how residencies impact NP transition to practice.

Challenges of Establishing a VA Residency

The NP residency program at the South Texas Veterans Health Care System (STVHCS) was piloted on August 31, 2020, under the VA Office of Academic Affiliations (OAA) Nurse Practitioner Residency (NPR) program. Since the program was in its first year, most providers, specifically faculty, house staff, and even nurses, were unfamiliar with it and needed clarification about its relevance to the STVHCS. Due to the unfamiliarity of the new program, several challenges were identified.

There was confusion about the role of an NP resident versus an NP student. There were times when NP residents were incorrectly introduced to patients and/or families, physicians, and nursing staff as students instead of fully licensed independent practitioners, per the Texas Board of Nursing. This led to an adjustment period of defining the role of the NP resident and the difference from an NP student. This improved as the rotations continued and mentors became more aware.

The NP Resident is not technically considered a VA employee or a medical resident but a contract employee, confusing the Human Resources department and the credentialing department. Initially, it needed to be clarified how clinical documentation and notes were to be signed and reviewed by the preceptor. This varied among rotation sites and preceptors. Despite having prescriptive authority from the state, NP residents went several weeks without being allowed to prescribe medications. Preceptors were then required to refill or prescribe medications for the resident, which led to preceptors questioning the role of the NP resident vs a student.

At times, more workspace and exam rooms were needed for the residents to examine their patients and document findings. While spending time in specialty rotations was beneficial, it was unknown exactly how much time would be needed in each specialty rotation, such as cardiology, women’s health, neurology, nephrology, wound care, and palliative care. The residents sometimes spent more extended periods in specialty than needed and more time away from their primary care or mental health focus.

Residency during COVID-19

The emergence of the Coronavirus-19 (COVID-19) pandemic has affected the sense of normalcy within our professional and personal lives. The unintended consequence of the unprecedented challenges brought by the COVID-19 pandemic in 2020 was experienced by almost all residency programs in the medical and nursing fields. Social distancing and stay-at-home guidelines explicitly affected the NP residency, limiting face-to-face practice. These mandatory restrictions, in turn, affected the NP residency at the STVHCS. Swift adjustments and changes in balancing learning needs and reducing the risk of exposure to COVID-19 were necessary. A new avenue of learning, such as virtual meetings using Microsoft Teams, was one platform that was adopted at the VHA to replace the traditional in-person meeting format. Although this virtual learning system would not provide the much-needed clinic or hospital environment experience, it was a practical, innovative solution to fill the educational gap while focusing on the safety of the NP residents. The CDC COVID-19 prevention measures, specifically wearing PPE, social distancing, and avoiding group gatherings, were shown to reduce exposure. These activities required immediate action and called for rapid changes in the NP residency training, but the NP residents quickly adapted to the changing learning environment. To limit patient traffic in office spaces and waiting room congestion, the conversion of patients' in-person visits to virtual platforms was implemented to provide continued access to care. Patient's in-person visits, which were the residents' primary sources of hands-on learning, were severely disrupted.

Lessons Learned

Several recommendations and improvement opportunities were discovered due to the challenges of a new program and overall challenging year (Table 1). To consider undertaking a nurse practitioner residency program, candidates must realize the many and varied sacrifices associated with the choice and be confident in their program choice. Unfortunately, a negative aspect of nurse practitioner residency programs is the need for uniformity in learning modules, making choosing the most effective residency program more difficult for new NPs. In 2013, a forum was held by the Veterans Health Administration Puget Sound Health Care System's Center for Primary Care Education in Seattle, Washington, to discuss "critical aspects of residency models" (Brown, Poppe, Kaminetzky, et al., 2016). (Author - your reference here shows 2016, but your reference list shows 2015. Which is the correct year? - RY) The three objectives of this forum were to "develop a shared understanding of key elements needed to support nurse practitioner residencies… define the unique needs of nurse practitioner trainees who are interested in applying for a residency…examine the viability of designing a replicable nurse practitioner residency model benchmarking stakeholder best practice”. A uniform learning module could be the basis for research and policy initiatives to strengthen residencies and improve outcomes.

Table 1. Challenges and Recommendations

Conclusion

Developing NP residencies is difficult but essential to our NP workforce. We explored the literature surrounding the difficulty in role transition for new NPs, highlighting the importance of support and mentoring as a critical component of the first year. NP residency programs ease NP role transition, and the VHA NP residency graduates reported feeling more competent and confident after the program. Implementing the STVHCS’s first NP residency program is not without challenges. Unprecedented challenges brought by COVID-19 and challenges specifically experienced by postgraduate NPs during rotations can be alleviated with changes to the program. Lessons learned from this project may aid others who wish to develop an NP residency. Further research is needed to evaluate residency effectiveness concerning clinical competence, confidence, professional autonomy, job retention, and patient outcomes.

Authors

Erica Coronado, MSN, APRN, FNP-C
Email: Erica.Coronado@va.gov

Erica Coronado is an Advance Practice Registered Nurse working for South Texas Veterans Healthcare System. She is the primary care provider for the Orange Team at the Kerrville VA Clinic. In addition to her primary care panel, she directs a Battlefield Acupuncture Clinic to manage acute and chronic pain. She has worked for 22 years in nursing, in the Emergency Department (adult and pediatric), Intensive Care Unit, and Nursing Education. She obtained her MSN with a post-master’s FNP from the University of Texas at El Paso. She completed an additional year of training with the STVHCS primary care NP residency program.

Ifeoma Nkemakolam, MSN, PMHNP-BC
Email: Ifeoma.Nkemakolam@va.gov

Ifeoma Nkemakolam is a Psychiatric Mental Health Nurse Practitioner in the South Texas Veterans Healthcare System, where she directs Balconies Height Outpatient Clinic for Mental Health and Battlefield Acupuncture Clinic for Battlefield Acupuncture, an Integrative complementary treatment for pain management. She obtained her Master of Science in Nursing from the University of Texas Health Science Center, San Antonio.

Tess De Jesus MSN, AGACNP, ASC-BC
Email: Tess.DeJesus@va.gov

Tess De Jesus is an Adult-Geriatric Acute Care APRN. She completed her Nurse Practitioner Residency at South Texas Veterans Healthcare System. She treats veterans with neurological disorders at the South Texas Veterans Healthcare System. With more than 30 years of combined nursing experience in the emergency department, intensive care unit, and care coordination, she places a high value on optimizing patient care outcomes across the continuum of care.