10/16/2018. Advanced Practice Provider Fellowships in Emergency & Urgent Care Medicine. Why are the beneficial? Objectives
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1 Advanced Practice Provider Fellowships in Emergency & Urgent Care Medicine Why are the beneficial? Heidi Springer, MSN, FNP-C, CCRN UR Medicine, Strong Memorial Hospital Department of Emergency Medicine Objectives 1) Improve understanding of reasoning for developing an Advanced Practice Provider Fellowship program 2) Improve understanding of the differences between a traditional new graduate Advanced Practice Provider orientation and an Advanced Practice Provider Fellowship program 3) Improve understanding of the goals of an Advanced Practice Provider Fellowship program 4) Describe the improvements and benefits that the Advanced Practice Provider Fellowship program has brought to UR Medicine Strong Memorial Hospital s Emergency Medicine Department 2 History of Advanced Practice Fellowship Programs 1 st Nurse Practitioner (NP) Residency program started in 2007 at Federally Qualified Health Centers (FQHC) in CT by Margaret Flinter, PhD, FNP-BC, FAANP Now there are estimated to be >30 programs in the US 1 st Physician Assistant (PA) post graduate program started in 1971 at Montefiore Medical Center Now there are estimated to be >80 programs in the US Current programs vary from Primary Care, Internal Medicine, Pediatrics, Emergency Medicine, Critical Care, Cardiology, Surgery, Oncology, OB/GYN, Orthopedics, ENT, Urology, Pediatrics, Psychiatry and Urgent Care Medicine (Hussaini, et al. 2016) (Pasquini, 2017) 3 1
2 AANP Position Statement on Post-Graduate Training Programs There are >222,000 Nurse Practitioners (NPs) licensed in the US today AANP s position: NPs are integral in meeting the growing demands on the health care system and are trained to provide safe, high quality care from the point of graduation Post-graduate opportunities may provide NPs with additional management techniques, but these programs are not necessary for successful entry into professional practice Residency is not the optimal term for description it suggests that the postgraduate program is a requirement. Preference is to use the term Fellowship which suggests optional postgraduate training opportunity (Twine, 2018) (AANP, 2014) 4 Institute of Medicine The Future of Nursing: Focus on Education Recommending an increase in the number of NP Fellowships as one of the several initiatives to advance nursing practice National Nurse Practitioner Residency and Fellowship Training Consortium (NNPRFTC) established in 2010 to set standards and program expectations In 1988, the American Association of Physician Assistants (AAPA) developed the Association of Post-graduate PA Programs (APPAP) to set standards and program consistency (IOM, 2010) (Hussaini, 2016) 5 The Discussion Begins The discussion first started for NPs in 2004 How well are NPs prepared for practice after NP program? Survey was given to 562 NPs with an average of 11 years of experience at 2 large national NP conferences NONPF and Annual NP Symposium 10%--perceived they were very well prepared for practice 38%--perceived they were generally well prepared for practice 51%--perceived they were only somewhat or minimally prepared (Hart, 2007) 6 2
3 NPs Perceptions on NP education Most prepared Health assessment Differential diagnoses Pathophysiology Pharmacology Health teaching Clinical management of acute disease (Hart, 2007) Least prepared Coding/Billing Complimentary/Alternative medicine Mental health management EKG interpretation X-ray interpretation Procedural proficiency Suturing Splinting/Casting 7 Are NPs interested in them? Survey asked about interest in post-graduate Residency programs: 87%--definitely/possibly would have been interested 77%--definitely/possibly would have been interested even if very low salary 42%--definitely/possibly would have been interested even if had to relocate to participate (Hart, 2007) 8 Recommendations for NP education improvement Survey asked about recommendations for further education: More emphasis on anatomy and pathophysiology Increase clinically relevant content and experiences during clinical rotations More emphasis on EKG and Imaging interpretation Increased procedural opportunities Cadaver labs Increased education on diagnostic testing More clinical case based assignments Better development of differential diagnoses (Hart, 2007) 9 3
4 Are they beneficial? In a study of PA s after completion of a post-graduate program, respondents noted improved knowledge in the following topics: 98%--establishing a diagnosis 96%--ability to recognize disease and pathology 96%--critical thinking skills 96%--ability to develop a differential diagnosis (Hussaini et al., 2016) (Asprey, 2000) 10 Are they beneficial? In a study of PA Post-Graduate Fellowship Program Directors, Directors offered the following motivations for developing their programs: 50%--Need for additional training in specialty area 25%--Need to expand coverage for Medical residents and House Officers 19%--Provider recruitment Employers and hiring managers reported greater confidence in the skillset of the PA which were key benefits from the programs (Hussaini et al., 2016) (Asprey, 1999) 11 Challenges for New Graduate NPs Study performed by Brown and Olshansky (1997) Before starting position: Recuperating after school Negotiating bureaucracy Looking for a position General worrying After starting position: Feeling real Getting through the day Time management Confronting daily anxiety (Brown, 1997) (Twine, 2018) Meeting the challenge of the position: Increasing competence Gaining confidence Learning the system Broadening their perspective : Developing comfort with the system Affirming self as an NP Transitioning from novice to competent 12 4
5 Challenges for New Graduate NPs Transition from RN to NP Transition from experienced RN novice NP is challenging Change in role identity Lack of clarity on how to develop in the role as an NP Worry about effective mentorship Perception of Preparedness Not feeling prepared Wanting more training Using past experience to fill knowledge gaps Perceived Challenges Developing new relationships with colleagues Developing trusting relationships with patients (Twine, 2018) (Brown, 1997) 13 Challenges for New Graduate NPs Transition from RN to NP New graduate NPs face many challenges during the first two years of practice 50% of newly licensed NPs feel that they practiced outside their competency level during their 1 st year in practice Ineffective transition can lead to ineffective delivery of patient care Fellowship programs are an avenue to ease the transition from RN to NP Offer combination of didactic and hands-on learning to improve competence and confidence Offer mentorship and supportive professional relationships which are KEY to successful transition Offer support while learning a new role, new skillset and new identity 14 (Brown, 1997) (Twine, 2018) (Wiltse, 2015) UR Medicine Emergency Medicine APP Orientation History Scope of the problem: STATS 15 5
6 Why were APPs unsuccessful on orientation? What and where were our deficiencies? Support from leadership team Mentorship and teambuilding Routine educational opportunities Current orientees without a forum to share experiences with like colleagues Comfort level with patient presentations & consultation calls Charting Comfort with procedures Ability to debrief challenging patient situations Understand the different disciplines of our key colleagues at UR Medicine and pre-hospital medicine Interdisciplinary professional relationships with colleagues Teaching new staff members to enjoy Emergency and Urgent Care Medicine 16 What was our wish list for a APP Fellowship program? Emphasis on teaching Procedural Skills: Cadaver Lab and Procedure Lab Interdisciplinary collaboration EM Physician Residency Program educational opportunities Simulation Experiences Evidence based and ethical presentations National conference attendance Expansive CME and educational class opportunities Mentorship with former APP Fellows Real time feedback tools 17 What were our clinical wish lists for the APP Fellowship program? Adult & Pediatric Emergency Medicine Psychiatric Emergency Program ED Observation Unit Urgent Cares ED Pharmacists EMS & Mercy Flight Radiology Orthopedics Urology Endocrine & Diabetic Educator Oncology Palliative Care OB/GYN Heart Failure & VAD Clinics Cardiology Neurology General & Stroke teams Toxicology ICU s 18 6
7 Emergency Medicine APP Fellowship Program What came next? Develop a budget Department and Hospital Leadership approval and support Develop syllabus Develop application process Recruitment strategies Interview process Start annually in August Emergency Medicine = 1 year in duration Urgent Care = 6 months in duration 19 How does the APP Fellowship program differ from previous orientation programs? Orientation Fellowship 6 month to 1 year program Set length of orientation Required initial didactic CME programs List of recommended resources Procedure Days & Cadaver Lab Orient with variety of preceptors Syllabus with expectations and recommended Feedback from preceptors in real time readings for all rotations Orientation coordinator provides feedback Written evaluation forms for all locations mid and end of orientation Weekly chart reviews Routine chart reviews Weekly Fellowship conferences with required Support from orientation coordinator and presentations supervisor Weekly ECG and Imaging review with Co- Directors 20 Emergency Medicine APP Fellowship Programs Current Focus Developing APP Fellows with flexibility and adaptability Bringing the APP Fellows to the best learning opportunities Emphasizing areas with greatest deficiencies Developing Fellowship conferences to address these areas Improve APP Fellows procedural competencies Improve APP Fellows competence and comfort with higher level acuity patients Provide every learning opportunity available during program KEY responsibility of the Co-Directors RETENTION---this is PRICELESS for the Emergency Medicine department21 7
8 What are the differences that these programs have made for the Emergency Medicine department? Potential APP Fellows are better informed about the role before starting Robust interview process and application APP Fellows have increased comfort with the EM team, consultants and EM policy and procedure upon completion of the program APP Fellows feel respected and understand that they are active learners during the program APP Fellows do not experience the sink or swim orientation process APP Fellows productivity and knowledge base are evaluated throughout the program and feedback is provided frequently during the program APP Fellows feel supported and know that the team wants them to be successful APP Fellows have a better understanding of their resources 22 References AANP Nurse Practitioner perspective on education and post-graduate training. The NP Roundtable's discussion paper, May 6, Retrieved from legislation-regulation/policy-toolbox/np-policy-essentials/445-aanp-and-the-np-roundtable-joint-statements Accessed April 20 th, Asprey DP, Helms L. A description of physician assistant post-graduate resident training: the resident s perspective. Perspectives in Physician Assistant Education. 2000:11(2): Asprey DP, Helms L. A description of physician assistant post-graduate resident training: the director s perspective. Perspectives in Physician Assistant Education. 1999:10(3): Brown M., Olshansky E. From limbo to legitimacy: a theoretical model of the transition to the primary care nurse practitioner role. Nurse Res. 1997: 46(1): Hart AM, Macnee CL. How well are nurse practitioners prepared for practice: results of a 2004 questionnaire study. Journal of American Academy of Nurse Practitioners 2007; 19: Hussaini SS, Bushardt RL, Gonsalves WC, et al. Accreditation and implications of clinical postgraduate PA training programs. JAAPA 2016; 29: References Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from Accessed April 20 th, 2018 Morgan H, Edmonds M. An academic based nurse practitioner transition to practice program. Journal of Medical Education and Training 2017; 1: Pasquini S. Postgraduate PA school residency and fellowship programs Available at: Accessed April 20 th, Twine N. The first year as a nurse practitioner: an integrative literature review of the transition experience. Journal of Nursing Education and Practice 2018; 8 (5). Wiltse Nicely KL, Fairman J. Postgraduate Nurse Practitioner residency programs: supporting transition to practice. Academic Medicine 2015; 90:
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