a clinical setting—the benefit to APRNs of completing a residency is likely to grow as well. The committee believes that regardless of where the residency takes place—whether in the acute care setting or the community—nurses should be paid a salary, although the committee does not take a position on whether this should be a full or reduced salary. Loan repayment and educational debt should be postponed during residency, especially if a reduced salary is offered.

At the committee’s December 2009 Forum on the Future of Nursing: Care in the Community, Margaret Flinter, vice president and clinical director, Community Health Center, Inc., spoke about her organization’s decision to develop nurse residency programs for APRNs. The intensity and demands of providing service in the complex setting of a federally qualified health center (FQHC), Flinter testified, often discourage newly graduated NPs from joining an FQHC and the clinics from hiring newly graduated NPs. In 2006, she continued, her organization started the country’s first formal NP residency training program. The goal was to ensure that new NPs would find the training and transition support they needed to be successful as PCPs. The program is a 12-month, full-time, intensive residency that provides extensive precepting, specialty rotations, and additional didactic education in the high-risk/high-burden problems commonly seen in FQHCs. The NP residents are trained in a chronic care/planned care approach that features both prevention and chronic disease management, advance access to eliminate waits and delays, integrated behavioral health and primary care, and expert use of the electronic health record. In Flinter’s view and that of her organization, the initial year of residency training is essential to transitioning a new NP into a fully accountable PCP (Flinter, 2009). And indeed, the ACA allocates $200 million from 2012 to 2015 as part of a demonstration project that will pay hospitals for the costs of clinical training to prepare APRNs with the skills necessary to provide primary and preventive care, transitional care, chronic care management, and other nursing services appropriate for the Medicare population.

Residency provides a continuing opportunity to apply important knowledge for the purpose of remaining a safe and competent provider in a continuous learning environment. Paying for residencies is a challenge, but the committee believes that funds received from Medicare can be used to help with these costs. In 2006, about half of all Medicare nursing funding went to five states that have the most hospital-based diploma nursing programs (Aiken et al., 2009). The diploma programs in these states directly benefit from receiving these funds. Most states, however, and most hospitals do not receive Medicare funding for nursing education. The committee believes it would be more equitable to spread these funds more widely and use it for residency programs that would be valuable for all nurses across the country.

Demographic Challenges

As discussed in Chapter 2, the population of the United States is growing older and is becoming increasingly diverse in terms of race, ethnicity, and



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