Are Residencies the Future of Nurse Practitioner Training?

January 2013Kate Darby Rauch

When Beth Goldstein finished her nurse practitioner training at UCSF a couple of years ago, the thought of seeing patients completely on her own made her a little jittery. She was licensed to provide primary care and confident in her skills. Yet the idea of a little more practice had tremendous appeal.

Soon Goldstein was immersed in exactly the kind of hands-on learning she craved, as one of the first nurse practitioner (NP) residents in a new UCSF-UCLA nurse practitioner residency partnership, with Glide Health Services clinic in San Francisco and the Union Rescue Mission clinic in Los Angeles. Monday through Friday, at Glide’s bustling clinic in San Francisco’s Tenderloin District, Goldstein peers into wheezing lungs, palpates swollen glands, orders blood tests and listens carefully to descriptions of pain, dizziness and a host of other complaints – all under the guidance of an experienced nurse practitioner mentor.

The partnership, which is winding up its inaugural year, is part of a small but growing movement to create formal primary care nurse practitioner residency programs, similar to those for physicians – essentially a layer of on-the-job training after formal schooling. The effort, which began at a Connecticut community clinic five years ago and is spreading nationally, is geared largely toward honing nurse practitioners for community care or frontline jobs serving populations that tend to be low-income, uninsured, homeless, mentally ill and/or substance abusing.

Primary care provider shortages in these challenging settings are well documented, and projected to grow.

“Our experience is that NP graduates are searching for this support as they transition to practice, and we have had a huge response from students across the country to our new program,” says UCSF nursing professor Pat Dennehy, who directs the partnership and the Glide clinic. Dennehy is also the primary investigator of the three-year federal Health Resources and Services Administration (HRSA) grant funding the program.

“And administrators in community health centers, employers, are searching for providers with the training and proven competence to work with these complex populations,” she says.

For Goldstein, who volunteered at the Glide community clinic for years, prompting her to switch careers from architecture to nursing, the residency is truly a dream come true.

“Even before I knew that residencies existed, I’d wished for such a thing, thinking it would be amazing for nurse practitioners,” she says. “It was a dream that it existed, and a dream that it worked out for me.”

A Primary Care Partnership Takes Hold

Launched in January 2012, the UCSF-UCLA nurse practitioner residency partnership, now ramping up for its second year, offers four one-year residencies to certified nurse practitioners, two at each community clinic. The UCSF and UCLA schools of nursing oversee the program – and the partnership clinics – but it’s open to nurse practitioners nationwide.

To be sure, many nurse practitioner programs, including the one at UCSF, specialize in the kind of “whole person” primary care that’s well suited for community clinics, where health is deeply intertwined with challenges in housing, food, money, employment and transportation. The UCSF adult nurse practitioner program, which Goldstein completed, includes clinical rotations in community care settings, which provide meaningful windows into the work but are considerably shorter than residencies.

But the community setting is demanding, even for those who are excellently prepared. The extra in-the-trenches learning of a residency not only solidifies skills, but also acts as a testing ground for future work experience, says JoAnne Saxe, a professor in UCSF’s School of Nursing and faculty advisor for the residency partnership.

“We want to be able to groom the next generation of nurse practitioners to be not only well-prepared clinicians, but well prepared to work in these types of clinical environments. We’re dedicated to caring for these populations, and we want to be able to ensure we have clinicians who have this passion, as well as preparation,” Saxe says.

Teaching Skills and Boosting Confidence

In the partnership program, preceptors work alongside the residents, case by case, reducing their direct involvement as the year progresses and the residents' skills strengthen. Though residents enter the program certified to practice primary care independently, the mission of the residency is to reinforce their knowledge in the context of the complexity of needs common to community clinics, said Karla Ballesteros, a resident preceptor at Glide.

“The role of the mentor changes as the level of confidence and expertise of the residents evolves,” she says. “By the time the residents complete their hours to obtain a furnishing license [to prescribe medicines], the preceptor is still available, but now the role is more of a colleague. By the end of the residency, residents need consultation only on very complicated patients.”

Vivian Sha with Glide Medical Assistant Darrin Brewer At Glide, as at other residency clinics, the training includes mastering the wraparound, or team, approach to care, with as-needed consultation with physicians, social workers, psychiatrists, dentists and pharmacists.

“The critical-thinking skills you develop from this year of residency are priceless. It’s something you have to go through. You can’t teach it in lectures,” says Vivian Sha, the second inaugural resident at Glide. “It really teaches you how to think on your feet.”

Sha completed a nurse practitioner master’s degree program at Boston College in 2011, after working as a hospital RN for a year and a half. She commended her training, saying it included “extensive” clinical rotations. But still, Sha said, she didn’t feel comfortable jumping into a busy clinic holding the reins as a primary practitioner.

“I came out of my NP training feeling fairly unprepared,” Sha says. “One of the biggest things I’ve learned is to be more assertive; the program builds self-confidence. As a nurse, you’re taking a lot of orders and carrying them out efficiently. As an NP, you are the one giving orders. That role switch doesn’t always come easily.”

Thinking long-term for your patients, planning and monitoring follow-up care, is a highlight of the residency, Sha says. This can include teaching someone without a bathroom, kitchen or phone how to change a dressing, eat nutritiously on a tight budget or return for a critical appointment. “You have to be creative and thoughtful to provide comprehensive care,” Sha says.

The Origins of NP Residencies

The UCSF-UCLA partnership is modeled after the first nurse practitioner residency program in the country, started in 2007 at the Community Health Center, Inc., of Connecticut by Margaret Flinter.

Flinter, who launched the program in response to the escalating complexity of patient needs at community clinics, is consulting with the UC partnership as part of a collaboration of a dozen organizations that have or will soon have residency programs. Almost all are at federally qualified community clinics, which means they receive federal funding to provide comprehensive primary care to underserved populations, either on a sliding scale or for free.

It’s difficult to know how many other residency opportunities exist, as their number isn’t centrally tracked. The UCSF School of Nursing, for example, is overseeing another new nurse practitioner residency program at San Francisco VA Medical Center. In that program, however, the NP residents are known as fellows, and there is some debate about the proper term to use.

Community clinics serve 20 million patients today, and this is “projected to grow to 40 million over the next 20 years,” Flinter says. “And there’s no question that patients in these centers have very complex needs.”

Flinter – along with her UCSF colleagues Dennehy, Saxe and Karen Hill, who manages the Glide clinic – hope the nurse practitioner residency concept grows. There’s new urgency, they agree, as more people become insured under the Affordable Care Act (ACA), and nurse practitioners prepare to respond to the short supply of primary care providers.

Hope for Growth in the Future

But according to Flinter, this will happen only if secure funding is identified. Money is needed to pay for preceptors, resident stipends and administrative costs.

“There’s huge momentum in terms of the interest in the residency programs. There needs to be a sustainable path forward to meet the need,” she says.

Meanwhile, she calls the residencies a “slow-growing trend.”

If nurse practitioner residencies take hold, one inevitable question is whether they should be required, as they are for doctors.

Goldstein acknowledges that the requirement issue is tricky. “I absolutely recommend it to someone whose life can accommodate an additional year of training,” she says. But she also notes that residents currently earn stipends that are considerably less than even a starting salary, so it can be a tough call.

“I was eager to have the opportunity to practice under my own license, but with support and preceptorship – the way that medical residents do – before becoming completely independent,” she continues. “But I think many of my classmates felt ready to start working on their own as soon as they graduated.”

Dennehy believes NP residencies will evolve with the profession. “As NPs are called to provide primary care roles in the community, the residency experience will become the norm.”



This has always been the answer, and should be available in all subspecialities, much more useful than a DNP degree.

Completely agree!

Completely agree!

I agree as well. I am currently writing a proposal to start a fellowship program at my hospital as I prepare for graduation. Thank you for this valuable information.

I am wondering how your proposal went? I am working on the same for my facility and would appreciate some input/advice/recommendations.

How did the proposals go? My NP research project is about NP residencies and I am going to propose starting a NP residency program at my facility. Please email Thank you ! !

And how has that gone so far?

It seems like malpractice to let nurses who don't have nearly the degree of training that physicians do could practice without a residency!

I appreciate doctors, but the way it is now, many of them are making more mistakes than ever in practice. The patient population are the ones who are suffering, and nursing is tempered for patient care, which in some ways give them an edge on the health care industry in the future.

You forget that many nurses have been practicing for years prior to going to nurse practitioner school. This alone gives them a foot up over physcians to be ready to practice out of school with out residency. That being said, I am considering an emergency critical care residency because I want the experience I didn't get as a Family Nurse Practitioner student.

If that's the case, you may want to consider post-Master's acute care cert. Some states consider critical care/emergency care (not talking about urgent care type services in ERs) outside the scope of FNPs. In my state, FNPs can't even admit to hospitals.

Editor's Note: This is an important topic. Please weigh in and let us know how you feel about the need for these residencies.

I have never had a problem with this. I have already stated that new grad PA's are able to hit the ground running and are at a greater advantage than NP's. Glad you are finally accepting what an NP has been telling you all along. As you see, I ain't so dumb as you thought I was.

Yet there are 3 times the PA RESIDENCIES s there are from NPs...because new grad PAs need specialty training just like NPs

A 1 year residency should be a staple component of a DNP program- a 4 year program for BSN-DNP students and 3 year for post MS students. The last year should be a residency, thus giving true value to the DNP. I am quite pleased to see such a residency available and look forward to it becoming standard for all advance practice nurse training in the future. -Sylwia Beben, BSN,MS, DNP-FNP student.

I wholeheartedly​ agree. My masters program had clinical rotations that included one semester rotation of adult primary care! I was in the surgical clearance department at the VA. I watched my presceptor and interviewed three patients. My speciality is psych. The department head was a master's prepared nurse counselor. A Psych NP attended the classes but didn't lecture. The psych NP program didn't require a thorough Adult primary care rotation. It is important to have a residency program. We did not have a stable practice setting to gain the needed competencies. The program was competing with the medical residents for clinical placements. NP clinical placements were the left overs. I had to move between six practice settings to get the number of clinical hours needed to graduate. I was discouraged from sitting for the board certification. I didn't even know which accreditation body offered the certification test. It wasn't until I applied for a staff position at a hospital that I saw how inadequate my preparation was. With the help of a psychiatrist that worked the same shift. I learned to dictate, what collateral information was and how to use it to form a preliminary chief complaint. I learned to dictate, perform a thorough psychiatric evaluation and a risk assessment. I also learned to formulate a plan for treatment and orders. I learned how to do inpatient rounds and discharge plans. I did not receive any of this training until six years after graduation! I took my specialty boards and passed them eight years after graduation.

Residency programs need to be implemented for NP students, this is invaluable experience. Some larger Universities offer Master Entry Programs in Nursing(MEPN)where an individual can get their RN degree and move directly into an NP program without RN experience. It is not the book smarts that they lack, it is the years of experience dealing with patients and making life and death decisions independently. They have never had to deal with a dying patient, or the family and friends of that dying patient. They have never called or run a code in an emergency, and they have never learned the experience of how to talk with the doctors, nurses, aides and all the axillary staff when it comes to a patient's outcomes. To gain the respect, confidence and skills required all NP programs should have extended residency programs.

Residencies should be available in specialty areas such as nephrology, critical care, and emergency medicine as well as the primary care setting.

I think this residency program is a great idea. I am a women's health NP student and feel I may need more training after graduation. I think NP's should have a residency program for all specialties just like doctors. It will only increase the safety for our patients and improve health care over all.

Totally agree with a residency program-after I graduated, I had the very basics of what I needed to practice and that was NOT ENOUGH. The most I've learned is when I have mentored with my collaborating physicians-like a residency would.

I have practiced as an RN for twenty years prior to starting FNP school and I will have completed the program in one more week. I believe that residency programs would be beneficial and I would like to find one in North or South Carolina! It is worth the investment to continue my training as an FNP as a resident, to increase self confidence and transitioning into the role.

I believe they have a couple in the Carolinas

I am all for residency program. Many NPs that i've spoken w/says they feel 'unprepared'-'study over the weekend' while practicing NP at a clinic,

I think overall NP curriculum has to be changed and focusing of more clinical training. I have been working in the Internal Medicine department for 15 years. It took me a minimum of five years to start feeling comfortable with the practice. I realized that the knowledge I acquired during the FNP school is not adequate. I landed at the first job at the VA hospital, and it is very hard. In order to work in a large medical group as a new grad was a nightmares. I wasn't prepared and have to sink and swim to survive. I almost quit on the second month after getting the job. It's a joke to cramp up all the classes in a short period of time in NP school and be ready to practice medicine. In order for a new NP to be able to work in any areas of medicine, the NP education should focus more in clinical aspect instead of nursing theory because the truth is we are practicing medicine and not nursing. Many years of bedside nursing experiences gave us a very basic foundation in taking care the patient; we are receiving the doctor orders. Becoming NP is totally different since we now are not receiving the order any more. How could we be confident to practice INDEPENDENTLY with a year or year and a half learning what doctors learn in four years. The medical doctor residents are mentoring by the attending which NP did not receive that special treatment. I support 110% to include the NP residency program for new grad. and should be a MUST in the DNP program to help advancing the clinical knowledge and skills. It is time to revamping the NP education if we are dying to call ourselves "Independent practitioner."

Reading all these comments I finally why physician are more intelligent than nurses: They started with basic math and went to medical school. I you add all the years of BSN, MSN, and DNP plus work experience it is a lifetime. It only takes 6 years to become a physician.

The NP who posted Apr 09, I agree with you totally as a soon to be NP graduate who has been around residents and meds students throughout my career. Our training is weak compared to theirs. Wake up academia types!

I am SO glad to see this discussion! Health care has changed dramatically but the logical step of extending the education to include comprehensive residencies has not. Clinical rotations in primary care were an education in the' pressures on providers to produce revenue and pay based on performance. While academics provided the foundations of care, the process involved in practicing was not provided in any depth. Clinicals were good environments to test the waters briefly but too limited. NP s need exposure to primary care over much longer periods with providers specified as attendings to be available to only the residents. MDs and NPs. are providers therefore the residency should be modeled the same. allow the NP a safety net prior to practicing independently. It is clearly setting the NP in a stressful environment.

OMG...where was this when I graduated from my NNP program at UCSF. If UCSF continues with residemcies for NPs, I may get a post masters in FNP...broadening my scope may also mean more employment opportunities.

I am excited to see this kind of program, but as the number of NP students increase, I wonder if this model can be expanded to include NP students as well as graduates. The paucity of preceptors who can provide a quality mentorship to students is terrible, and the fact that there is no training, or quality control for preceptors, leads to disparate experiences for our students. I am searching for funding opportunities that might make some sense to change this antiquated system. Anyone out there that can help??? Please contact

I live in Colorado and there is a requirement of 1800 hours for prescriptive authority. Where does this all fall in. 1800 hrs, then residency? Just wondering. Thank you

Does anyone know where a good source is to finding the applications for these residencies? I am interested but have spent countless hours trying to find them with little luck- midwest/ohio looking for primary care or Veterans Affairs

I am a Primary Care Adult Geri NP-c, I have 8 years of critical care inpatient experience as a RN. I am a extremely confident RN and I credit a huge part of that confidence to my new grad RN program-I was not alone as a RN for over 4 months. I am entering a DNP program in the fall but I still would like something that gives more clinical experience. I have applied countless times to the VA;they just had a new graduate program start up at the VA in Long Beach. I cant get through to anyone in HR! I want to be the best provider possible and a NP residency is the only way to transition in my opinion. Any info please contact me at 310-850-2414.

In my opinion , Over NP curricum should focus more in depth on medical base science and good amount of NP clinical training Along with At least one year residency program

I would love to have had a residency program - I was and still am very envious of physician residencies and the opportunities for learning this affords. In Texas all NP programs are required to provide at minimum 600 hours of supervised clinical training. This is similar to PAs. Our graduate course work takes over 2 years, not the one year mentioned in this article. I am finishing a post masters program and have completed another 500 hours in this specialty, along with a year of didactic study. If I could do another year as a resident I would gladly take it, however, at this point I am in my 4th year of graduate school, which is the same amount of graduate course work as a physician. I am exhausted, working a fulltime position as an NP and fulltime in graduate school with 20 to 30 hours a week of unpaid clinical internship. But, to have a paid residency, would afford those we hope to help and the providers a huge benefit.

Most nurse practitioners have many years of experience before deciding to pursue the education to become a nurse practitioner. This is a significant distinction between those in this occupation and the profession of physician assistant, who frequently move straight into chase of an advanced education right after completing an undergraduate degree.

I have heard this many times before, mainly from nurses: NPs have been RNs for years; PAs begin their graduate education right out of undergraduate studies. However, the truth seems to be far more ambiguous, as an increasing number of RNs begin their NP education after only a year or two of nursing practice. Moreover, most PA programs require health care experience before entry (some, quite a significant amount), and PAs complete 2000 clinical hours as part of their program, as opposed to 500-700 for most NPs. I write this as someone without a foot firmly in either camp yet. I'll be starting a second degree BSN program in the fall, and later, after working at least a few years as a full-time RN, will apply to PA, MSN, and/or DNP programs. I find the enhanced clinical component of PA programs very, very attractive. That said, I would be quite interested in MSN or DNP programs if they included a residency. From what I've seen of curricula and heard from graduates, practice-oriented graduate nursing programs simply *have* to include more basic science and clinical experience to meet the needs of patients and produce confident clinicians. I'm very interested in the ideas of experienced practitioners on this topic.

i hate to write on a blog about this because i feel that i am undervaluing the past 3 years i spent in an NP program, but i am sorely disappointed by how few clinical hours NPs are required to have and how cursory our medical training is. when i first heard about the DNP, i thought "oh that's great" and then i learned that it didn't involve more clinical training but added research methods and qi. i don't understand what kind of anachronistic dinosaurs were in charge of this because if they actually listened to NP students on how NP programs could be improved, they would have an overwhelming majority reporting the need for more clinical training. i am hard pressed to believe that any NP student has ever said "you know, i really feel my quality improvement education is lacking" when struggling with differentials on a complex patient. i'm sorry to rant, but as someone who is about to graduate, the need for residency is glaring. i just don't understand how this issue is not being addressed. what exactly is the policy that is keeping NPs down?

I agree. I have been a nurse practitioner for 15 years and 15 years ago I knew there was a need for more clinical training in the NP program and especially a need for a NP residency program to bridge between graduate school and independent practice. I felt ill prepared as a new NP and I had 14 years of bedside nursing experience before my graduate training.

I agree with every word I have read. I have been a nurse for 35yrs most of them in the ED. I was a trauma leader. I decided to go back to school for my FNP, recently graduated. I feel so unprepared the first day I work in a urgent care was a nightmare. I was learning a new emr, the other providers had routine orders under their names, my dea number had not been applied to e-script and to top it all off I had a MD who kept reminding me I needed to hurry and he make a comment that I looked up "everything" per him. When I left there my confidence was rock bottom. I think a residency program is a great idea.

I also agree with the underlying sentiment from all the postings. I am a 30 year ICU/CCU veteran with a double Masters, adult gero NP and DNP, who still feels overwhelmed in the primary care setting. I also hold a hospitalist NP position which is a bit easier, but even that is challenging. Physicians are bombarded with basics in a structured learning environment and then learn to compile all that basic information into something that makes sense. I am also constantly being told to move faster, stop reading and just memorize everything. I was reminded early on that physicians don't receive an "orientation" to their job. I am lucky that my chief medical officer has taken the time to provide the extra training necessary for me to perform effectively and safely. I think a residency program is an excellent idea.

Nice to see NPs who are practicing repeating the same line as physicians to hold back future NPs. NPs are not internists or specialists. There is no future role for NPs as specialists. In fact, NPs may just be the temporary solution to the shortage of physicians. Regardless of how you shuffle the DNP program it will never amount to an MD degree. New physicians are as stressed and confused as new NPs, the only difference is that they have the support of their peers unlike NPs.

It would be great if someone could offer a link of current, nationwide NP residency/fellowship program. One would think that AANP or similar organization would offer such. No such luck; No interest.

Currently a BSN-DNP student, second year of training with 3 years of nursing experience prior to beginning my DNP program. @Jan 28, there is a difference between the DNP and MD degrees and the research on outcomes have not been able to demonstrate any constant deficiencies in outcomes for safety and care quality. The problem with this comparison is that we have not been able to clearly determine what minimum amount of training is needed to begin safe clinical practice. There is a threshold for education and training where more training may increase quality but the effects can be situational and occasionally minimal (think dose response curve). MD's & many PA programs do typically have more clinical hours than the average NP program (varies for PA but can be verified for most regions). The MD residencies and second year of PA programs are great for providing students the knowledge skills they need to confidently transition into autonomous practice (or “collaborative”). In regard to out of the gate preparation, the use of an NP residency is something that I would personally want and believe that it has a place in bolstering NPs clinical abilities. The evidence on this student’s confidence and anecdotal reports of improved clinical proficiency is in favor of a residency. The challenge is in the logistics of providing a residency program to every NP and ensuring that it is high quality and not a waste of time. However (returning to the DNP-MD discussion), the purpose of the DNP is not to increase clinical experience and its value is a separate argument. The IOM’s report: Future of Nursing called for nurses to do more than just clinical positions. As the largest profession in health care there is a great potential to use nurses’ numbers and training in other roles within the health care environment. The DNP program is designed to fill some of those varied roles in addition to providing more clinicians. I believe that most NPs entering practice would agree that they could use more clinical hours regardless of MS or DNP. We need to find a way to balance the political (turf war), financial (decr pay for NP residents vs prev exp RN pay), and logistical (lack of infrastructure to support residency) challenges to accommodate an NP residency plan.

I believe the solution has to be decided by two major decision making entities who are responsible for curriculum development for NPs and certifying bodies. There has to be standardized requirements for all APRNs just as Medical Doctors if we are to fill the void of Primary Care Providers. Certifying bodies must require proof of at least 6 month post graduation residency to sit for certification exam.

There are very few NP residency positions available relative to the number of graduating NPs. They cost money to run, and Congress does not a lot of spare funds. The AMA has managed to increase the funding for medical residencies, but the bills for NP residencies have languished. If we want NP residencies we are going to have to advocate for it politically.

There has been a demonstration project called Graduate Nursing Education (GNE) which has provided funds to hospitals in five locations to train NPs. Linda Aiken RN PhD provided a summary presentation on the Hill - see ppt: . The demonstration projects are happening, the evidence is mounting for Federal support for NP training and then residency training. This is going to be a heavy lift and we need to lift together to get this done and funded.

I am currently in my last year of my FNP program. I will start practicums in December and should finish next August. I just recently learned of the residency/fellowship programs that some hospitals offer. I plan to apply to two when I finish. The problem is that the ED fellowship at the one facility only accepts 4 students a year. The other program has multiple specialty fellowships that each take 2 per year. I have been an RN for 15 years, have a family, and have continued to work full time while attending school. One of the issues with FNP education right now is that we are not eligible for the same loans that MD and DO students are, such as cost of living, relocation, etc. The fellowships typically pay a stipend amount in the ballpark of 40000/yr with the usual perks of CME budget, uniforms, lab coats, credentialing, etc. This is lower than what I make as an RN. I want to do a fellowship in Emergency Medicine and Palliative care. In order to swing this at a stipend amount, NP's need to have the same access to educational loans and grants as medical students. I do believe that this should be a requirement of the Nurse practitioner program, but I also believe they need to make it financially feasible and doable.

It's very disturbing that some of this big teaching hospitals are not even hiring board certify nps . Adult nps , do they now throw licenses away or what ? So sad you paid so much money for the education and time spent for the education. Now we're talking about residency . Why is it that any formal education in nursing has to be tied to something or watered down . Medical curriculum is not changing . It's okay to tailor programs to patients needs and the changing world . Basic education is the same for these programs.

After 10 years of working as an RN, I decided to pursue my Psychiatric NP. For 3 years while I was in school, I worked as an RN at a Community Mental Health Clinic. Understand that such clinics typically pay their RN's at least a third less than a normal RN position. In 2003, I was making 30k, just for reference. Yes it was a sacrifice, but during that time I did very extensive self preparation. Far beyond the requirements of school. Every night I came home, and looked up what I saw at work that day. I wanted to be ready when the time came, and I could see school was not preparing me. We were doing stupid classes about nursing theory. These classes should be a felony. I can honestly say it worked. But it involved extensive self preparation. No one is going to spoon feed it to you. And it involved financial sacrifice, probably 50,000 in salary over 3 years. Worth every penny. When the time came, I was ready. Not that there wasn't more to learn at my first job, but I had the basics

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