Residency Prepared Nurse Practitioners:
The Solution to the Shortage of Cardiologists

 

KATHLEEN BALLMAN AND BARBARA BELL

 

Abstract

Cardiovascular disease (CVD) is the leading cause of death worldwide. The American College of Cardiology’s Workforce Workgroup projects a large deficit in the number of cardiologists needed to care for this growing population (Rodgers, 2009), and reports from the European Society of Cardiology (Escaned ,et al., 2007) predict a looming shortage of cardiologists as well.  A multidisciplinary approach to care and prevention of CVD is needed and nurse practitioners (NPs) can be one solution. While the NP is well-suited to help fill the gap, the education that is needed for specialized cardiovascular competencies is not included within the NP’s educational curriculum. The NP can become a more effective, efficient and legitimate member of the cardiology team after completion of a standardized cardiology residency program that has been endorsed by the leading professional organization as a model for education NPs in the field of CVD and its prevention.

 

 

ardiovascular disease (CVD) is the leading cause of death and loss of disability-adjusted life years worldwide (Yusuf, Reddy, Ounpuu & Anand, 2001). In the United States (US), the number one cause of death is CVD as well (Centers for Disease Control and Prevention, 2011). There are an estimated 82,600,000 American adults with CVD (American Heart Association, 2012). CVD claims more lives each year in the US than cancer, chronic lower respiratory diseases, and accidents combined (AHA, 2010). With the prevalence of CVD increasing by one to two percent annually, the American Heart Association (AHA) estimates there will be an additional 20 million people in the US with CVD by 2020 (35^th Bethesda Conference, 2003).

Cardiology Workforce Crisis

There is a growing concern that there will not be the needed number of expert cardiology healthcare providers in the workforce to treat and prevent the continued epidemic of CVD.  In 2001, the American College of Cardiology (ACC) identified several reasons for an anticipated shortage.  The incidence and prevalence of CVD is projected to increase due to demographic and lifestyle trends in the US including increasing numbers of the population with obesity, diabetes mellitus type 2, sedentary lifestyle, and metabolic syndrome (National Heart, Lung and Blood Institute, 2006).  The advancement in the treatment and the optimization of medical care in the US has resulted in a decrease in  mortality from CVD which has in turn increased the size of the population with chronic disease, especially those with heart failure.  Many of these patients need procedures that include internal cardiac defibrillators, pacemaker implantations and/or radio frequency ablations. Another growing population of patients who need extensive care and follow-up are cardiac transplantation recipients.  Also, the number of adults with congenital heart disease surviving to an older age substantially increases the need for specialized care (Rodgers et al., 2009).

Fewer cardiologists are choosing sub-specialization in interventional cardiology, electrophysiology, and heart failure over general cardiology.  This trend leaves a major deficit in the trained cardiologists skilled in the concepts of preventive CVD (Bonow & Smith, 2004). Reports from the European Society of Cardiology suggest a looming shortage of cardiologists as well (Escaned, et al., 2007). 

A focus on the cardiology workforce issue is not new. Foot, et al. (2000) conducted a study that analyzed demographic changes in the US population and the cardiology workforce over a 50 year period  (2000 -2050).  He predicted a shortage at that time.  In 2004,  the American Heart Association (AHA) using the expert opinion of Bonow and Smith (2004) declared that here was a foreseeable cardiovascular manpower crisis. With anticipation of the workforce shortage, the America College of Cardiologist (ACC) and the American College of Cardiology Foundation asked an independent research firm, The Lewin Group, and the Association of American Medical Colleges to conduct a workforce study of cardiologists.  The report results were published in the September 2009 issue of the Journal of the American College of Cardiology (Rodgers et al., 2009). After a detailed analysis of current and projected needs, as well as the current and anticipated number of practicing cardiologists, it was deemed that  cardiology has a “workforce crisis” ( p. 1195). Key findings included in the report emphasized a need for a substantial increase in the supply of general cardiologists over the next 20 years. As part of the study, there was an analysis of ACC practice survey which indicated that non-physician practitioners are an efficient and underutilized resource in cardiology practice. Recommendations included detailed research on effective and efficient use of non-physician practitioners, and to educate the cardiology community in team-based care. In addition, they supported expansion of general and cardiology-specific education programs for non-physician practitioners.

Nurse Practitioner’s Preparedness to Practice

Education, Certification, and Licensure for the Nurse Practitioner

The standards for NP educational programs in the US have been formulated through a collaborative effort between the American Association of Colleges of Nursing (AACN) and the National Organization of Nurse Practitioner Faculties (NONPF).  The standards are outlined by the AACN as the Essentials of Master’s Education for Advanced Practice Nursing Graduate Core Curriculum (American Association of College of Nursing, 2011) and by NONPF as the Domain and Core Competencies Nurse Practitioner Practice (National Organization of Nurse Practitioner Faculties, 2006). This document describes entry-level competencies for graduates of master’s and post-master’s programs preparing NPs.

The Advanced Practice Registered Nurse (APRN) Consensus Work Group, made up of representatives from numerous leading professional organizations and the National Council of State Boards of Nursing, developed a framework  of requirements for licensure, graduate program accreditation, professional certification, and education for all APRNs. This collaboration was to ensure standardization, which has been lacking in the US (American Association of College of Nurses, 2008). The APRN Consensus Model provides a framework for standardizing NP education in a broad generalist manner as seen in the diagram (Figure 1).  Specialization in a particular area is seen as outside of the scope of the NP educational framework, which means that specialty certifications must be provided by the specialty’s professional organization (Stanley, 2009).

 

Figure 1. American Association of College of Nurses. (2008).  APRN Consensus Work Group and National Council of State Boards of Nursing APRN Advisory committee. Consensus Model of APRN Regulation: licensure, accreditation, certification and education. Retrieved from: http://www.aacn.nche.edu/education/pdf/APRNReport.pdf

 

 

Specialized Nurse Practitioner Education

Traditionally, NPs have become specialists in CV care through informal orientation programs, individual mentoring and self-teaching. As a result, the scope of knowledge, performance and practice greatly varies by individual and practice site.

The professional development and mentorship needs of the NP while moving from novice to expert nursing practitioners have not been fully explored. Doerksen (2010) conducted a study in which a survey was taken followed by focused discussion groups to investigating the professional development needs of advanced practice nurses. The participants in the study provided several suggestions and identified the need for more formal developmental programs (Doerksen, 2010).

Adequacy of NP preparation for practice was examined by Hart and Macnee (2007) with a cross-sectional descriptive study using a written questionnaire. A total of 562 questionnaires were completed after they were administered to attendees at two large national NP conferences in 2004. They found that 10% of the sample perceived that they were very well prepared for practice as an NP after completing their basic NP education, and over 51% perceived that they were only somewhat or minimally prepared. Current age, years since graduation from an NP program, and age when attending the NP program did not differ significantly for those who felt prepared versus those who did not. Of the respondents, 87 % indicated that they would have been interested in a clinical residency program had it been available (Hart & Macnee, 2007).

Kleinpell (2005) conducted a five year longitudinal study of acute care nurse practitioner (ACNP) practice. After the first year following certification, a 44-item questionnaire was utilized to assess role aspects and role changes.  Respondents were asked to rate the degree to which they felt prepared for their position as an ACNP.  Of the 445 respondents only 32% reported that they were prepared fairly well to go into practice and 14% reported that they were not very well prepared. These respondents listed recommendations for the ACNP educators.  The number one recommendation, from 66% of the respondents, was for more clinical or residency hours.  56% of the respondents requested increased time with other ACNPs.

Formalized practice residencies in the US have been developed for the nurse in the acute and critical care practice areas as a post-baccalaureate graduate. Many hospitals sponsor such programs for the entry level nurse.   A descriptive, comparative study after the implementation of a one year residency program was conducted by Krugman, et al (2006).  They found that after a formalized residency there was a higher rate of retention, decreased stress by the nurse over time, improved organization and prioritization of care and increased satisfaction, when compared to nurses that did not have a formalized residency. No research studies were found for NP residencies.

The Novice Nurse Practitioner

Yeager (2010) affirms that the first year as an NP is a year of transition and maximum potential is generally not reached until after five years or more of practice. Hamric and Taylor (1989) disagree however, and suggest that while returning as a novice in the advanced role, the practitioner generally transitions through the role development phases to an expert in a shorter period of time. 

It is likely that the new NP will experience scrutiny (both external and internal), feelings of inadequacy, and self-doubt during the uncomfortable novice phase.  These feelings can result in a phenomenon described as the “imposter syndrome” by Clancy and Imes (1978).  The imposter syndrome is used to describe the internal feelings of lack of self-confidence and intellectual fraudulence.  Symptoms of this phenomenon include generalized anxiety, frustration, and depression.  To overcome the imposter syndrome, the novice NP must first identify their feelings and recognize that the feelings of anxiety are normal.  Obtaining foundational clinical experiences to develop specialized clinical competences along with proper mentorship allows for a successful development of the NP’s confidence (CalTech Counseling, 2010).

Problem Identified

Due to the increasing number of Americans with CVD, goals for caring for patients with CVD are outlined by Healthy People 2020. These four goals are as follows: 1. Prevention of risk factors; 2. Detection and treatment of risk factors; 3. Early identification and treatment of cardiovascular events; and 4. Prevention of recurrent cardiovascular events (U.S. Department of Health and Human Services, 2010).  Emphasis must be placed on filling the cardiology workforce gap. Those filling the gap and providing specialized care must be experts in the prevention, detection and treatment of CVD.

The ACC declared a cardiology workforce crisis in 2009. They (Rodgers et al., 2009) suggested that this is an opportunity for sharing best practices by building partnerships between cardiologists and NPs. Education for the NPs is considered to be the corner stone of the development of effective models for team- based care (Walsh, 2009).

There are very few NP residency programs in the U.S., and only one with a general cardiology focus (Mayo Clinic, 2011). The development of a standardized CV NP residency program would promote a more thorough and consistent approach to the education of NPs. The NP will become a more effective, efficient, and legitimate member of the cardiology team after completion of a CV residency program that is developed with a multidisciplinary approach in an academic setting. Developing a model for a CV NP residency program that is endorsed by the ACC, the leader in formulating national guidelines and standards in professional education will serve as a benchmark for CV NP residency programs across the US.

A Standardized NP Cardiovascular Residency Program

Theoretical Framework

A CV NP residency program strongly founded in educational theory and science will give it credibility, and allow it to be reproduced in universities nationally and internationally.  The implementation of a standardized model of education for the CV NP will provide the medical community and the public with a standard by which they can gauge the NP’s  performance.

Newly graduated NPs and NPs without prior CV experience who want to practice as a CV specialist lack the practical skill set that are inherent to the specialty.  Once licensed, the NP will begin to transition from the role of a registered nurse (RN) into the role of the NP.  During this adjustment into a new practice role, the novice NP goes through several stages before being able to perform at an expert level. The study of Benner’s Novice to Expert theory (Benner, 1984) yields practical insight to the development of an APRN residency program.   Patricia Benner published her research focusing on the learning characteristics of critical care nurses, in which the novice nurse progresses to an expert level (Benner, 1984).  Benner’s theory was based on Dreyfus’ model of skill acquisition, in which increments of change (based on training and experience) occur with increases in skilled performance (Dreyfus & Dreyfus, 1980).  This model describes the nurse passing through five levels of development before reaching an expert level.  Benner’s premise is that the development of knowledge in applied disciplines (such as medicine and nursing) is composed of the extension of practical knowledge through research and the understanding of know-how through clinical experience.  In short, knowledge acquisition and experience is a prerequisite for becoming an expert.  This theory can be applied to all new NPs, even those that enter an advanced education program as a RN who is a clinical expert. A CV NP residency will provide the novice NP the opportunity to gain knowledge and clinical experiences on the road to reaching CV competencies through expert mentorship.   

Kolb’s Experiential Learning Model (1984) has long been used as a framework for medical education (Curry, 1999) as well as nursing education (Laschinger, 1990) and has practical application to the development of a NP CV residency program.  This model focuses on concrete experience and abstract conceptualization as a means to acquire experience, and relative observation and active experimentation as a means of transforming experiences.  The residency program should be developed with this theory in mind.  

There is a lot of interest of recent in theories related to interprofessional education (Interprofessional Education Collaborative, 2011). A residency that capitalizes on the strengths of the medical and nursing profession by educating medical doctors and nurse practitioners together will enrich the educational experience for both disciplines.

Program Development

When developing any new program, there must be an evaluation of the needed resources. This evaluation is best achieved by setting up a planning group. Each member of the group must be committed and have an identified role with a clear-cut understanding of individual responsibilities (Witkin & Altschuld, 1995).  The planning group for the development of standardized NP CV residency is made up of individuals with varying backgrounds and expertise which allows for a multidisciplinary approach. 

The needs assessment committee (NAC) for the residency program is headed by two principal investigators (PIs). These two leaders are experienced NPs with backgrounds in caring for patients with CVD. One of the leaders is also an educator in a university academic setting and the other is a clinical educator in a university based cardiology practice.  The leaders are supported by members that represent stakeholders in providing healthcare to patients with CVD and the education of NPs. These NAC members are from a college of nursing (CON); college of medicine (COM), Division of Cardiology with an accredited cardiology fellowship program; and the American College of Cardiologists (ACC).

The NAC is subdivided into planning groups with each group charged with distinct responsibilities. The members from the CON along with the PIs are instrumental in investigating financial resources through grant funding and planning future research. Members from the COM are work with the PIs to make a draft of an APRN CV resident curriculum. They are adapting the ACC training guidelines for fellowship programs (COCAT3) curriculum, and the American College of Cardiology Foundation’s Cardiology Competencies as a template for an NP CV residency while planning methods for didactic and clinical support for the resident. The ACC member is an expert resource and liaison who was instrumental in gaining endorsement from the Executive Committee of the ACC supporting the proposed development of the APRN CV residency program.  The Executive Board of the ACC agreed to work collaboratively with the two PIs, the CON and COM, to develop a model for the education and training of NPs in the field of CVD and its prevention. The ACC will work with the PIs and a selected panel of experts to provide access to CV medicine educational experts and work with the team to utilize existing peer-reviewed CV medicine content where appropriate, and participate in the development of NP specific curriculum content. The ACC member is also facilitating the support for the generation a nationally recognized board certification through portfolio with the American Nurses Credentialing Center.

The major work of the NAC is assessing the level of cardiovascular skill that would be needed by NPs practicing in academic, urban, rural, and underserved areas as well as the development of the residency model, curriculum and proposed credentialing guidelines. An expert panel, with representatives from leading medical and nursing organizations, will be assembled to develop a consensus model for the NP CV residency program. During the implementation of the consensus model, a NP CV specialist certification portfolio will be developed in conjunction with the American Nurses Credentialing Center. The NP CV residency program will be first piloted as a post-master’s certificate program.  Ultimately, a curriculum will be developed for a CV Doctorate of Nursing Practice Degree program.  Doctoral prepared CV specialists will have the education and clinical expertise to be leaders in translating research and implementing change in CV care and health care delivery systems.

After the implementation of the program, consideration will be given to identifying areas of sub-specialization, in high need areas of CV practice, including heart failure, cardiovascular disease prevention, electrophysiology and cardiac critical care. After implementation, there will be an emphasis on model evaluation, dissemination and replication. By standardizing a model for a NP CV residency, there is a potential to transform nursing practice and nursing training through interprofessional education.  Description of the NP CV Residency Program

This project has four broad-ranging aims to answer the question: What are the components of an effective nurse practitioner cardiovascular residency program? 

Aim 1: Develop an NP CV residency program model and credentialing guidelines by consensus of an expert multidisciplinary panel.

Aim 2: Assess the perceived competence and confidence of NP CV residents longitudinally throughout the residency in comparison to NPs who have not participated in a specialized residency program.

Aim 3: Measure the impact of the NP CV residency on public perception of NP’s competency.

Aim 4: Analyze the impact the residency has on the cost of providing CV care and improving access to care with a team-based model.

By identifying a model for an NP CV residency with an aim to improve NP confidence and competency, this project addresses a research priority established by the Institute of Medicine that will transform nursing practice (Institute of Medicine of the National Academies, 2010). 

The components of the consensus model will be described through case study. Residents will be assessed for competence and confidence via quantitative testing at the beginning of the residency program, at specific intervals during the program and at the conclusion of the program. A comparison group of non-resident NPs who work in cardiology will be similarly assessed. The residency program will be evaluated by patient and provider satisfaction, access to care, and cost of care.  Surveys will be utilized to measure the general public, patients, practitioners and administrator’s perceptions of the NPs capabilities, looking for statistically relevant changes due to the residency program. A cost benefit analysis will be performed to evaluate the economic impact of the program.

Determining Impact

     The possible short-range impacts will begin with developing a model for a standardized NP CV residency that has been endorsed by the ACC, the national leader in cardiology.  Participating in a residency will increase the NP’s confidence and competence.  After the completion of the residency, the NP will be eligible for specialty certification. The American Board of Nursing Specialties (2010) suggests that nursing certification can create and promote optimal patient care. This certification is attained when practice guidelines derived from  a standardized curriculum are utilized for the examination.  Certifications validate skills, knowledge, and abilities, and in turn contribute to better patient outcomes.

An increased implementation of an evidence based NP CV residency program will have a long range impact on quality of care. With an increasing presence of NP CV specialists, access to care will increase.  Residency prepared NP CV specialist working with cardiologists using a team-based approach is a remedy for the cardiology workforce crisis nationally and internationally.

 

About the Authors  Kathleen Ballman, RN, MSN, ACNP-BC is an Assistant Professor of Clinical Nursing at the University of Cincinnati, College of Nursing. Contact Kathleen Ballman at Kathleen.Ballman@uc.edu; Barbara Bell, RN, MSN, ACNP-BC is a Cardiology NP with the Division of Cardiology, University of Cincinnati, University Hospital. Contact Barbara Bell at Barbara.Bell@uc.edu.

 

Keywords: Cardiology workforce, nurse practitioner residency/fellowship

 

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