Are Residencies the Future of Nurse Practitioner Training?

Future of Nursing
Are Residencies the Future of Nurse Practitioner Training?
Residents Vivian Sha (left) and Beth Goldstein (center) consult with NP Tina Clark at Glide Health Services clinic in San Francisco (photos by Elisabeth Fall).

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.
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.
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.
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 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."
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