Nurse Practitioner Residencies: The Ultimate Guide

While residencies have long been a staple of the medical training model for physicians, they are a much newer phenomenon for advanced practice providers. Completing a residency, APP fellowship, or transition to practice program is not a requirement for nurse practitioner practice, but can be a worthwhile supplement to the education NPs receive in school as well as provide a more supported transition from education into practice. In this post we’ll cover everything you need to know if you’re a NP considering a residency or fellowship from application timelines to the average salary for NP residents.

Why are Nurse Practitioner Residencies Valuable?

Nurse practitioners gain a foundation of knowledge in their NP schooling, however their education is much shorter than that of physicians and consists of significantly fewer clinical hours. In fact, in some cases, nurse practitioners may receive just 3% of the hands-on patient care hours that physicians do in medical school and residency. In the workplace, however, NPs and PAs are a heavily relied-upon resource and may be expected to care for complex patients. In some settings, nurse practitioners are expected to provide as much as 80% of the care that physicians provide – but with far less formal training.

This so-called “skills gap” presents a problem for new graduate NPs. Meeting the expectations of an employer who may not be set up to provide on-the-job learning is difficult, particularly when employers may not be set up to provide required support, mentorship and resources. Caring for complex patients is overwhelming as a less experienced nurse practitioner and results in uncertainty and dissatisfaction with the profession.

Recognizing these inconsistencies between nurse practitioner education and practice, healthcare facilities began to create residency programs for NPs. These programs set the employer and NP up for success by providing adjusted expectations for performance and productivity as new graduates continue learning in practice along with a formal curriculum to build on the education NPs receive in school.

Residency vs. Fellowship 

Although gaining popularity, residencies and fellowships for nurse practitioners are still relatively rare. This breeds some confusion over the terms associated with post-graduate advanced practice education. So, just what is the difference between a residency and fellowship for NPs?

Residency

A residency is a post-graduate program following NP school in your chosen specialty. So, for example, if you’re a family nurse practitioner, you might complete a residency in primary care.

Fellowship

A fellowship is a post-graduate program that helps the NP sub-specialize beyond the basics of the chosen specialty. For example, a family nurse practitioner might wish to work in gastroenterology or urology.

The residency/fellowship model in medicine was pioneered by physicians. For MDs, the typical path is to complete a residency followed by a fellowship. In the nurse practitioner profession, however, NPs don’t need to complete a residency prior to applying for a fellowship program. In fact, nurse practitioners looking for post-graduate education usually do one or the other.

Note: For the purposes of this article, we will primarily use the term residency.

Pros and Cons of NP Residencies

Since nurse practitioners are not required to complete a residency or fellowship, NPs must weigh the pros and cons of doing so. If you’re thinking of doing a residency or fellowship, consider these benefits and drawbacks.

Pros

• Clinical Knowledge – Residency-trained NPs can expect to emerge with a knowledge base significantly more robust than that with which they graduated. The additional year of patient care experience paired with a classroom-based curriculum (often delivered in weekly lecture sessions) takes NP’s skill sets to the next level.
• Supportive Practice Environment – Facilities offering nurse practitioner residencies understand the challenges that new graduates face in practice, particularly the “skills gap”. So, NP residents work alongside experienced providers who are willing to mentor and play a role in assisting with patient care throughout the year. This means that NPs get questions answered and procedures demonstrated in a supportive workplace setting.
• Peer Group – Most residencies and fellowships accept a small cohort of NPs each year. This means that participants are exposed to and practice with others who are in their same career-phase fostering professional relationships. In some cases, such as with ThriveAP’s ThriveAP programs, residents even participate in learning opportunities with other residents in different geographic locations providing access to an even larger professional support network. Life as a new graduate can feel lonely and a close cohort provides added support and encouragement.

Cons

• Reduced Salary – Adjusted expectations such as lower patient volumes for NPs in residency translates to a lower salary. NP residencies and fellowships typically pay anywhere from $65,000 to $80,000 salary for the duration of the year-long program. This is compared with the average nurse practitioner salary of more than $90,000 for NPs in traditional employment arrangements.
• Limited Flexibility – There are few residency and fellowship options available to NPs compared with the number of students graduating each year. This means that you may need to relocate to participate in a program or work in a setting or with a patient population that doesn’t fit directly with your ultimate career goals. Participating in a program like ThriveAP or ThriveAP+ in which a residency-like curriculum with flexible implementation options can be a solution for NPs who want exposure to a larger number of opportunities or who want to work for a specific employer.

What and How Will You Learn in a Nurse Practitioner Residency?

Most residency and fellowship programs deliver education in two formats:

1. Formal Curriculum
2. Patient Care + Backup

NP Residency Curriculum

Residencies include a formal didactic curriculum usually including lecture content with a few hands-on skills sessions built in. Didactic content is typically delivered on a weekly basis. The formal curriculum expands on the basic knowledge obtained in a nurse practitioner program relating directly to the specialty and setting in which the residency takes place. The ThriveAP family practice/primary care residency curriculum, for example, covers topics from “Rheumatology Lab Interpretation” to “ECG Interpretation” and “Initiating Insulin Therapy in the Diabetic Patient”. Curriculum may be delivered in an in-person or online format but typically is integrated into the workday. Facilities may create their own didactic curriculum internally, or may partner with a nearby university or medical residency program to provide these learning opportunities.

Patient Care Support / Expectations

Hands-on patient care makes up the other half of residency education. There’s no substitute for applying clinical skills and knowledge in real-life scenarios. In some facilities, residents may start by treating lower acuity or lower complexity patients. In most facilities, patient volumes are significantly lower for residents to allow time to use resources or to seek assistance with providing care. Experienced providers offer support to residents when questions arise. This support comes in two forms – preceptorship and mentorship.

Preceptorship is along the lines of a modified job shadow experience with some independence, similar to what nurse practitioners complete in their NP programs. Mentorship falls more along the lines of an experienced provider being available to answer questions or offer support throughout the workday as needed, but not necessarily being involved or having oversight over every patient encounter. Most NP residencies include a blend of preceptorship and mentorship as part of the experience. An increasing level of autonomy will be expected throughout the program.

Specialty Rotations

Many programs also include focused training in specialty areas relevant to the practice area. For example, a primary care NP residency may offer rotations in women’s health, psychiatry and pediatrics. These may take place within the same facility or with an outside partnering organization. Offerings depend on the availability of these focused practice settings and vary significantly from program to program.

Nurse Practitioner Residency Locations

There are two main classifications for residency-like programs when it comes to location:

1. On-site programs – These are programs run and operated by the facility where the nurse practitioner will be working, so location is fixed.
2. Customizable or flexible programs – These programs are offered by an outside organization so nurse practitioners employed in any facility across the country can enroll and participate regardless of the location where they work. A primarily online delivery format means the NP can attend sessions from any location.

Both types of programs are available nationwide. Primary care nurse practitioner residencies tend to be primarily located on the coasts with a number in states like Rhode Island and Connecticut as well as California and Washington State. 

Nurse practitioners who cannot relocate or who are not interested in living in these locations may find their own employment and opt to enroll themselves or ask their employer to enroll them in a residency-like post-graduate learning opportunity. ThriveAP is an example of such a program that we refer to as a transition to practice curriculum or solution. This gives the NP flexibility with employment and living circumstances while also allowing for the option for a post-graduate enhanced educational experience.

Nurse Practitioner Residency Settings

The overwhelming majority of residencies and fellowships available to NPs are offered in primary care. So, they take place in outpatient clinics. Most are offered by Federally Qualified Health Centers (FQHCs) that care for underserved patient populations. These clinics may be located in rural areas that are geographically underserved. Or, they may be located in urban areas but work almost exclusively with patient populations that are underserved such as the homeless.

There are a few non-FQHC residency options available. These programs may be offered by hospital systems in outlying clinics or within hospitals themselves. Hospital systems are more likely to offer specialty-focused tracks such as Mayo Clinic’s cardiology nurse practitioner fellowship, to name one program.

NP Residency Specialty Options

Primary care takes the cake when it comes to NP residencies and fellowships. With more than 20 program options, FNPs are best situated to be competitive for one of these programs. Nurse practitioner graduates with specialty interests do have a few focused options scattered across the country. Hospital systems may offer inpatient residencies or fellowships for acute care nurse practitioners. There are also a handful of specialty options that may combine inpatient and outpatient medicine. Swedish Hospital and John’s Hopkins, for example, offer fellowships for APRNs interested in gastroenterology.

The bottomline? If primary care is your niche, you’re in good shape – there are plenty of places for you to apply for post-grad programs. If you’re interested in pursuing specialty post-graduate education, your options are limited but there are a handful of programs out there. Your next best bet is to land a specialty position with a supportive employer committed to teaching and mentoring.

(ThriveAP offers curriculums in both primary care and acute care)

What’s the Average NP Residency Salary?

Overall, nurse practitioner residents and fellows can expect to earn about a $65,000 – $85,000 salary for a one-year residency program. You can check out several specific compensation examples from NP residencies across the country in this post. This level of pay is excellent considering that it isn’t too far off from what the average new grad nurse practitioner can expect to earn. Not to mention, this is a higher salary than is offered to most physician residents. Compensation structure may be hourly or salaried depending on the employer. In addition, residents and fellows should expect to receive benefits and paid time off similar to other advanced practice providers employed in the practice. Residents are typically not compensated based on productivity as are NPs in a number of other employment settings.

One thing for applicants to note is that many facilities do require residents or fellows to commit to another one to two years of post-residency employment with the practice after completion of the residency program. Nurse practitioners applying to programs with such commitments should ask about compensation and benefits during the year(s) following the program to make sure compensation is adjusted based on level of experience.

Nurse Practitioner Residency/Fellowship Application Requirements

Most nurse practitioner residencies and fellowships, particularly those in primary care, have very similar application requirements. In general, they include these six items:

1. Resume or CV – It’s time to brush up your resume. Facilities look at resumes/CVs as a critical piece of the residency/fellowship application. Not only does this document outline your accomplishments and experience, it also serves as an indicator of professionalism. So, make sure to avoid errors in formatting and grammar to put your best foot forward.
2. Application form – Facilities ask for basic information about you as part of the application process. This is the simplest application component to check off your list. While the information may seem simple, it’s still imperative that applicants complete this step thoroughly and professionally.
3. Letters of recommendation – Residencies and fellowships typically ask for 2-3 letters of recommendation. These typically must come from a former employer, academic institution or other authority figure such as a preceptor.
4. Personal statement and/or essay responses – This is where applicants can expect to spend the most time on their application. Residencies ask applicants to reflect on anywhere from 2-4 essay prompts as part of the application process. These should be answered thoroughly and professionally with proper grammar and formatting. In general, prompts fall along the lines of:
   a. What experiences/influences led you to choose a career as a nurse practitioner?
   b. What is your motivation for applying to a residency? How will this experience help you reach your short-term and long-term career goals?
   c. Why do you want to work in a community health center (or setting/specialty of the residency)? d. Discuss your commitment to your specialty of choice.
   e. In what areas do you want to increase mastery/competence over the course of the program?
5. Transcripts – Not all, but many NP residency/fellowship programs will want to check out your transcripts. While they may want to review your marks, programs typically do not have a strict GPA cutoff for program eligibility.
6. Certification/Licensure Eligibility – If you’re a new grad or still wrapping up your nurse practitioner program, you may not yet be certified or licensed. Not to worry – programs simply ask that you be eligible to apply for these items by a certain date before the residency program begins. This is more something to be aware of than an actual application requirement. 

Apply for ThriveAP's transition to practice curriculum

Application Timeline

Though each program is unique, there are several themes as to application timelines for NP residencies and fellowships. These timelines vary depending on the type of program to which you are applying. Here’s an application timeline overview based on the main types of post-graduate education options available to nurse practitioners.

Primary Care NP Residencies and Fellowships

Most primary care NP residency application timelines follow a typical college/university application timeframe (or somewhat similar). Applications open in January for entry to a program beginning in September of that same year. Applications remain open for only a few months so it is important to be prompt and research these opportunities in advance. NPs should apply to these residencies about 6-8 months before they plan to start the residency.

Flexible Entry Primary Care NP Residencies

There are a few post-graduate nurse practitioner options, like our ThriveAP and ThriveAP+ programs, that operate on a more flexible timeline. Applications for these programs are rolling and applicants are accepted year-round with multiple entry points to the program. These programs work well for NPs who may not have planned ahead to apply for residencies or who realize months or even a year or two into their careers that a post-graduate learning opportunity would enhance their career skill set.

Specialty NP Residencies and Fellowships

Specialty residencies and fellowships for nurse practitioners vary more significantly from one another so outlining a trend among programs is difficult. If this is the path you plan to take, you’ll need to look at each program individually to make sure you’re on track with a timely application. Many programs have tight application windows with application periods starting earlier than those for primary care (ex. November of the year before you plan to participate), so advanced planning and research into your options is critical.

Can You Apply for a Residency if You Aren’t a New Graduate?

It’s common for nurse practitioners to enter practice only to realize they aren’t quite as prepared as they thought. Patients are complex. Demands from employers are high. Support for less experienced NPs in many hospitals and clinics is lacking or even nonexistent. So, if you  find yourself overwhelmed in your nurse practitioner job, why not enroll in a NP residency, even if you aren’t a new grad but simply aren’t thriving in your NP job?

Most nurse practitioner residencies and fellowships, especially those in primary care, accept applications from NPs who have graduated less than 12-18 months prior to application or enrollment, depending on the program. This means that you’ll need to put some thought into your post-graduate plan. The most competitive applicants for NP residencies will not have long gaps between graduation and application. Rather, they are those who proactively apply before graduation.

Another scenario nurse practitioners might find themselves in is one where they struggle to find post-graduation employment. A job search turns cold as clinics and hospitals give preference to experienced providers. Or, perhaps personal life circumstances lead to taking a break between graduation day and employment. In most cases, a residency won’t be a viable option for these NPs. Given this 12-18 month timeline, a significant gap between graduation and applying for a residency doesn’t make you a strong applicant, particularly as most programs offer only a few residency slots each year. You can always ask for consideration under your personal circumstances but it’s typically best to apply for a residency even before you graduate.

List of Primary Care NP Residencies / Fellowships

If you think a residency or fellowship could be the right option for you as a less experienced nurse practitioner, here is a list of primary care NP residencies available throughout the country. You may also wish to request information about ThriveAP, ThriveAP’s post-graduate transition to practice program. This program mirrors the didactic component of other residency programs, while allowing the NP to work for any employer. The program works well for nurse practitioners who are currently employed but find they lack the knowledge application or confidence to be successful in the workplace. Or, it can be a great option for NPs who are already achieving at a high level but want to augment their knowledge and skill set.

Takeaways

Applying for nurse practitioner residencies or fellowships requires some research and planning, but overall offers a supported way for NPs to transition from education to practice, building knowledge and confidence in the first year(s) of practice. The benefits of these kinds of programs are significant, with very little downside.

Flexible post-graduate education options, like ThriveAP, can take some of the legwork out of the application process and serve as an option for NPs who may already be employed or lack the flexibility to relocate for fixed residency opportunities.

The bottomline? If you’re a less experienced nurse practitioner and could use a boost to your clinical skill set, learn more about how a residency, fellowship, or similar post-graduate learning opportunity can help.

ThriveAP's Transition to Practice Curriculum