In 2011, the Institute of Medicine's (IOM) "The Future of Nursing: Leading Change, Advancing Health" report recommended that State Boards of Nursing, the government, and accrediting bodies support nurses' completion of residency programs. This recommendation included nurses graduating from prelicensure programs, nurses transitioning to new clinical practice areas, and nurses graduating from advanced practice degree programs. Nurse residency programs have been shown to improve retention, confidence, nurse satisfaction, and overall competence. According to the IOM (2015) report, "Assessing Progress on the Institute of Medicine Report The Future of Nursing," there are differing needs for advanced practice registered nurses (APRN) from non-advanced practice nurses.
Although RN residencies transition new graduates to their first clinical setting, APRN fellowships are focused more on professionalism and independence. These programs help new APRNs find preceptors, attain needed practice skills, and have demonstrated success in improving competence. The IOM (2015) report states that APRN fellowships operate in various healthcare setting, such as clinics, Department of Veteran Affairs primary care centers, acute care hospitals, and federally qualified health centers. Cosme and Pokorny (2017) state that there are two distinct models for APRN fellowships: one is where the new APRN is trained in a specialty area, such as critical care or cardiac care, and the other is where the APRN is prepared to work in one specific organization. Length of time of orientation will be dependent upon the model and the required competencies the APRN must master. To ensure APRN fellowship quality, the American Nurses Credentialing Center (ANCC) established fellowship standards through its Practice Transition Accreditation Program. In order to attain APRN fellowship accreditation, the program must include an organizational orientation, practice-based experience, and supplemental activities to promote nursing professional development.
In 2014, Dr. Kaleen Cullen, APRN-BC, was asked by the Peak Vista leadership to develop a postlicensure fellowship for new family nurse practitioners. She was hired, in 2015, as the program director. Peak Vista is located in Colorado's Pikes Peak and East Central Plains regions and serves the community through 26 outpatient centers. The Peak Vista APRN Fellowship has hired their third cohort for the year-long fellowship. Dr. Cullen was asked to share her organization's journey in creating an APRN fellowship and the challenges in attaining ANCC program accreditation.
PEAK VISTA'S JOURNEY
Peak Vista is a federally qualified health center in central Colorado, and they care for approximately 90,000 mostly low-income families. Dr. Cullen shared that their patients are wonderful people with complex healthcare needs. They noticed that new nurse practitioners struggled with confidence, time management, and prioritization skills needed to care for their patients. At the same time, organizational leadership recognized that nurse practitioners are part of the answer to improving patient access to care. Peak Vista decided to create a program to help new APRNs transition from academia to clinical practice.
Postgraduate APRN fellowships have been recommended by the Future of Nursing Report (IOM, 2011) as a tactic to seamlessly transition recently graduated APRNs to the clinical setting. The Peak Vista Primary Care Fellowship combines precepted interdisciplinary clinical immersion; relevant postgraduate didactic; and self-directed, population management, quality improvement activities. A unique feature of the fellowship is that it is housed in a stand-alone fellowship clinic and offers interdisciplinary team-based care.
The Peak Vista APRN Fellowship is philosophically oriented around Benner's Novice to Expert Model, Bandura's Theory of Self-Efficacy, and Mesirow's Theory of Transformative Learning. Self-evaluated and preceptor-evaluated competencies are derived from the National Organization of Nurse Practitioner Faculties (2014) core and family population-focused competencies. Under the guidance of a preceptor, the fellows gradually increase the number and complexity of patients seen. Then, specialties on women's health and pediatric rotations add to experiential foundations in family practice. The fellowship provides a safe and nurturing environment for fellows to mature in their new role, so they may better care for the community. Each year, Dr. Cullen's team selects applicants to infuse the fellowship with diversity in culture, education, nursing philosophy, and experience. Because they are passionate and committed to what they do, they choose fellows who bring their own passion and commitment to Peak Vista. Currently, 80% of the fellows remain at Peak Vista in family practice after the fellowship. This is possibly because of the strong leadership and board support for the program. The fellows are salaried Peak Vista employees for the full-time, year-long program, and they may be eligible to apply for a provider position as the end of their fellowship.
Challenges along the way included organizational culture change to embrace training and education in what had always been a patient-centered clinical setting. Shortly after the fellowship enrolled the first cohort of APRNs, Peak Vista also accepted its first class of residents for the Doctor of Osteopathy class of medicine. The shift from pure clinical activities to educational activities was disruptive for the organization. However, they continued to work to integrate education/clinical training in a way that met everyone's needs.
The goals of the fellowship are as follows:
1. Increase access to quality health care for communities by assisting recently graduated APRNs to transition seamlessly to the practice setting.
2. Nurture the confidence and competence of transitioning APRNs in the primary care setting, thereby improving APRN and employer satisfaction.
3. Improve APRN retention in the primary care setting.
4. Immerse APRNs in a collaborative and interdisciplinary model of primary care and vulnerable populations care consistent with the recommendations of the IOM.
5. Facilitate professional development and life-long learning through continued population-focused interdisciplinary education and quality assessment/improvement appropriate to the primary care setting.
6. Provide mandated hours of precepted, prescriptive, practice experience as required by the Colorado Board of Nursing and Department of Regulatory Agencies.
It was important for Peak Vista, as an organization, to demonstrate to their community and their fellows a commitment to quality by working toward accreditation for the fellowship. This year, they were honored to have earned accreditation from the ANCC Practice Transition Accreditation Program. More important to Peak Vista than this accomplishment has been what the organization learned along the way to improve the program. Dr. Cullen's practical advice to new program leaders is to slow down and use the accreditation process for program improvement. Dr. Cullen and her team found out, "it isn't a sprint, it's a marathon."
Both the Nursing Professional Development: Scope & Standards of Practice, 3rd Edition (Harper & Maloney, 2016) and the Core Curriculum for Nursing Professional Development, 5th Edition outline the role of the nursing professional development (NPD) practitioner as a partner for practice transitions (Harper & Maloney, 2016). In many healthcare organizations, it is the NPD practitioner who is responsible for nurses transitioning to new areas, and they are responsible for ensuring that competency and safety standards are met. Practice transitions include moving the newly licensed nurse into their first clinical position, helping the experienced nurse transition to a new specialty, or ensuring a smooth transition for APRNs to competent providers. The NPD practitioner can attain knowledge about practice transition programs by studying successful programs and by becoming aware of practice transition accreditation standards.
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