NURSE PRACTITIONER HISTORY
When Drs. Loretta Ford, RN and Henry Silver, MD developed the first NP certificate program in 1965 it provided experienced registered nurses (RN) with the additional training to work in pediatric primary care settings collaboratively with physicians to manage acute and chronic illness (American Academy of Nurse Practitioners, n.d.). Drs. Ford and Silver believed that majority of the healthcare needs presenting in pediatric primary care settings could safety be overseen by nurses with advanced training in physical assessment, pathophysiology, pharmacology, and disease management. After creating the program at UC, Dr. Ford continued to work to develop the NP role and advocate for its implementation throughout the country. Since the NP role began, education has evolved from certificate to graduate degree programs and now includes acute and primary care specialties serving patients across the lifespan. NPs work in clinics, community settings, hospitals and private offices; some work completely independently while others work collaboratively in multidisciplinary treatment teams.
Even with all of the progress achieved in advancing the NP role, debate continues regarding the necessary education and training required for NPs. Some of the biggest points of dispute include minimum number of clinical practice hours, degree for entry to practice, prerequisite RN experience, and necessity of post-graduate residency/fellowship training. In this two-part series I will discuss each of these topics and offer my take on what is broken within the current system and then suggestions on how we can improve it for future practitioners. Please keep in mind that these are my opinions and do not reflect the views of any college/university or professional organization. This is not a critique of any specific education program but rather a general commentary about NP education in the United States with the hope of starting an open and productive dialog between members of this forum.
EDUCATION SYSTEM PROBLEMS
The first NP programs were designed to build upon the practice of experienced nurses but as time has marched on we have seen the emergence of new educational formats including online and accelerated programs. Students can now complete NP programs in online classrooms from anywhere in the world and non-nursing professionals from a variety of backgrounds can join our field through accelerated degree programs. Utilizing new educational tools and alternative paths to entry are important to remaining current but these methods present challenges for maintaining quality standards and the "nurse" identity of nurse practitioner. Studies have found that having previous clinical experience as an RN was not associated with improved academic success or stronger clinical skills as a new NP (El-Banna et al., 2015; Rich, 2005, Rich & Rodriguez, 2002). While I won't debate that non-nursing professionals can effectively complete accelerated programs and become successful NPs, I believe that these NPs miss out on critical socialization aspects of being an RN and are less likely to identify with the "nurse" aspect of being a nurse practitioner.
Another issue that comes under frequent discussion is the variation of clinical practicum hours that NP students have to complete depending on their program. The Commission on Collegiate Nursing Education (CCNE) mandates that programs have a minimum of 500 direct patient care hours but offer few other specific guidelines (2016). A review of programs from around the country, the average number of clinical practicum hours range from 500 - 1000 hours when a masters degree or post-graduate certificate is conferred and 750 - 1250 when a doctoral degree is awarded. At first glance, one might assume that the higher clinical hours associated with completing a doctoral program would mean more direct patient care hours but in most circumstances the additional hours are for the completion of a capstone quality improvement or research project. This has come under serious discussion as it has been suggested that the entry degree to practice be changed from the Master of Science in Nursing (MSN) to the Doctor of Nursing Practice (DNP). The idea of raising education requirements and improving scholarship is good in theory but many question the "value add" of the DNP degree for NP when the additional clinical hours required for the degree are not typically related to direct patient care but are instead focused on a quality improvement or research project. The purpose of this article is not to debate the merits of a particular degree but to consider its value specifically as it relates to improving the ability of a NP to provide direct patient care as a clinician.
Another major hurdle for many programs is securing appropriate clinical sites and preceptors. Many prospective NP students and healthcare professionals outside of nursing are unaware that in a number of programs it is the responsibility for students to find their own preceptors and clinical sites, which is challenging and results in unnecessary delays for program completion. For the more programs that take the responsibility of matching students with preceptors it can still be difficulty because most nursing programs do not pay experienced practitioners a stipend for having a student work with them and instead rely on volunteering and offers of continuing education credits or course credit at the affiliated college/university. In this writer's opinion, forcing students to find their own preceptors is inappropriate and contributes to a lack of standardization in quality education. Also, by not offering some form of financial compensation or stipend to preceptors it sends the message that the preceptor's time is not valuable and the education of NPs is less valuable than physicians or physician assistants (many PA and medical school programs provide financial compensation to preceptors for their time working with students).
In the next segment I will discuss some problems seen with the modern graduate student and then provide a "prescription" for how fix a broken system. My question for the readers is, do you think that any major change is needed to this system at all? Do you feel that most NP programs are successfully producing graduates who are fully ready to assume the NP role in our current healthcare landscape? Or do you think that a majority of the issues are due to problems in education programs, healthcare institutions, and to a degree, the students themselves (e.g. professionalism, behavior, experience, expectations)?
American Academy of Nurse Practitioners. (n.d.). Historical timeline. Retrieved from AANP - Historical Timeline
Commission on Collegiate Nursing Education. (2016). Frequently asked questions: Clinical practice experiences. Retrieved from American Association of Colleges of Nursing (AACN) > Home
El-Banna, M., Briggs, L. A., Leslie, M. S., Athey, E. K., Pericak, A., Falk, N. L., & Greene, J. (2015). Does prior RN clinical experience predict academic success in graduate nurse practitioner programs? Journal of Nursing Education, 54(5), 276-280. doi: 10.3928/01484834-20150417-05
Rich, E. (2005). Does RN experience relate to NP clinical skills?. Nurse Practitioner, 30(12), 53-56.
Rich, E., & Rodriguez, L. (2002). A qualitative study of perceptions regarding the non-nurse college graduate nurse practitioner. Journal of the New York State Nurses Association, 33(2), 31-35.