Quality of Online NP Programs and Providers

[ProgressiveThinking]

Hello,

I'm curious to see how practicing NPs feel about the proliferation of online NP programs, especially the diploma mill NP programs that accept applicants without prior NP experience. Do you feel like this is watering down your profession and/or possibly causing physicians and the public to have a negative view of your profession? OR, do you think that this is the future of education, and the current method of training NPs should stay the way it is?

I have no dog in this fight, but I constantly read physicians bashing the quality of online NP education, including the lack of clinical hours (<800). I'm curious to see how practicing NPs feel about this.

As an aside, I'm considering doing one of these online programs, so this post isn't meant to bash a specific field, but rather create a discussion on whether or not practicing NPs like the direction that their field is headed in.

Thanks!

[BostonFNP, APRN]

20 hours ago, ProgressiveThinking said:

I mostly agree with everything you've said, but I think that experience prior to matriculation should be an absolute minimum, unless NP program hourly clinical requirements are increased. Sure, you can have a stellar student who excels and matriculates in the right program be successful, but I think the average new grad RN completing 600 hours of clinical in an average program (with average being watered down by diploma mills) just doesn't seem like it's enough to make the push for independent practice (which seems to be what a lot of NPs are doing in their states).

Here are the problems I see with mandating any number of RN practice hours prior to NP graduation as many DE programs do (including the one I teach for).

1. It creates turnover in RN jobs. No employer wants to hire an RN for 600-1000 hours only to have them leave. It's not good for the units or the patients either.

2. It creates role confusion. A new grad RN socializing into the first year of practice is difficult enough. Combine that with going to grad school and doing student NP clinicals. I've seen new-grad RN student NPs be so turned upside down by this that they fail all three.

[ProgressiveThinking, MSN, CRNA]

18 hours ago, FullGlass said:

Please note that RN experience IS required for admission to an acute care NP program. RN experience is generally no longer required for admission to a primary care NP program, including the best schools like Hopkins, because the studies that have been done indicate RN experience does not benefit primary care NPs. Most RNs do NOT work in primary care, while 90% of NPs are educated in primary care and 75% of them work in primary care. This issue has already been debated ad nauseum.

I need to look these studies up. Curious to see the sample size and what outcomes were measured (academic or patient outcomes).

[ProgressiveThinking, MSN, CRNA]

13 hours ago, murseman24 said:

If your primary motivation is to "learn more" there is a new program in development at Wayne State University for a CRNA -> PhD in pharmacology degree. Either NP or something like this are better than a DNP to me.

I read that CRNAs will be able to get 32 credit hours towards the degree, and the didactic portion will be online. I'm definitely going to look into it. A PhD sounds nice, but I don't have much desire to do research. It would be nice to apply the knowledge clinically or even use the degree to teach later on. I'm currently looking into post master's FNP (1 year), MBA (1 year and cheap), DNAP/DNP (because everybody else will have one), and maybe even this PhD if the program (because it's viewed in a favorable light by those in academia). The FNP program seems to be getting the nod so far though.

[ProgressiveThinking, MSN, CRNA]

45 minutes ago, BostonFNP said:

Here are the problems I see with mandating any number of RN practice hours prior to NP graduation as many DE programs do (including the one I teach for).

1. It creates turnover in RN jobs. No employer wants to hire an RN for 600-1000 hours only to have them leave. It's not good for the units or the patients either.

2. It creates role confusion. A new grad RN socializing into the first year of practice is difficult enough. Combine that with going to grad school and doing student NP clinicals. I've seen new-grad RN student NPs be so turned upside down by this that they fail all three.

1. That's why you require 1800-2000+ hours since most new graduates (in the units I worked in at least) seem to leave after a year anyways.

2. I can understand this. I guess my narrow view can only compare my own experience where I see student registered nurse anesthetists who only have 1 year of ICU experience come into clinical fumbling and unable to manage their patients very well. These are different worlds though, so I have to keep that in mind.

As an aside, I'm not sure that I would want somebody who couldn't survive a year as a bedside nurse and the rigors of grad school making life or death situations for me or my family members anyways. Normally I disagree with schools that weed out certain individuals, but it sounds like this type of individual probably shouldn't be put in a position where they have the ability to affect so many lives with their decisions.

Again, this is from my narrow perspective coming from a different world where patients are actively trying to die on you, so I apologize if I come off as ignorant. Thank you very much for your contribution.

[ProgressiveThinking, MSN, CRNA]

57 minutes ago, BostonFNP said:

Poor vs quality is the main issue.

The real problem is the proliferation of poor quality NP programs and this is certainly not exclusive to online programs. There are some fantastic online and hybrid programs from quality universities. The problem that poor programs are further compromised by the online/hybrid model for two reasons: 1. they often have rolling admissions churning out poor graduates in greater frequency and, 2. they seem to cater to the students looking for the trifecta of cheap, easy, and fast.

Its the exact same with prior RN experience. There are longstanding programs with decades of history producing quality NPs with no prior RN experience, however, these program attract in the highest tier students. Now with poor quality programs attracting (often) poor quality students (again, cheap, fast, and easy) not having prior RN experience becomes magnified.

I don't have a particular problem with the number of clinical hours provided those hours are quality hours. Unlike the medical/PA model, NP hours are 1:1 direct supervision learning hours in a single clinical area. I would be happy if there were more hours required, and I am please that the accreditation boards are becoming more involved in clinical experiences of programs.

All said and done, if we eliminated poor quality programs and didn't address online vs hybrid vs brick and mortar or prior RN experience we'd be far better off than doing anything about the latter two.

My biggest gripe with online programs is that is does to nursing faculty.

Very nicely stated. Thank you!

[BostonFNP, APRN]

2 minutes ago, ProgressiveThinking said:

1. That's why you require 1800-2000+ hours since most new graduates (in the units I worked in at least) seem to leave after a year anyways.

2. I can understand this. I guess my narrow view can only compare my own experience where I see student registered nurse anesthetists who only have 1 year of ICU experience come into clinical fumbling and unable to manage their patients very well. These are different worlds though, so I have to keep that in mind.

As an aside, I'm not sure that I would want somebody who couldn't survive a year as a bedside nurse and the rigors of grad school making life or death situations for me or my family members anyways. Normally I disagree with schools that weed out certain individuals, but it sounds like this type of individual probably shouldn't be put in a position where they have the ability to affect so many lives with their decisions.

Again, this is from my narrow perspective coming from a different world where patients are actively trying to die on you, so I apologize if I come off as ignorant. Thank you very much for your contribution.

Requiring that many hours would, at very least, serve as a rate limiting step for NP programs, which isn't a bad thing. Having spend a lot of time in both didactic and clinical education of FNP students, my thoughts on this have evolved with time. I've seen students with decades of RN experience struggle and students with no experience thrive, and vise versa. My personal thoughts on the matter is that the variability between individuals is far greater than the variability with RN experience. I also am a believer that some students absolutely need it. At the end of the day I think nursing needs to move away from this notion that RN and APRN are linear: novice RN -> experienced RN -> expert RN -> novice NP -> experienced NP -> expert NP. Just because someone is an experienced or expert RN doesn't mean they will make a better NP nor does it mean they even should be an APN.

I have zero experience with the CRNA path but I would assume that ICU experience directly relates to the foundation that program require. RN experience and FNP education doesn't always directly apply.

Nursing needs to start weeding out the weak, IMHO, especially in the APN pathway: close the poor programs and put up some barriers to assure quality entry and exit.

[ProgressiveThinking, MSN, CRNA]

I agree with the putting up barriers statement and that experience as a rate limiting step might not be a bad thing. Just to let you know where my initial point of view came from: The knowledge that CRNAs gain in the ICU is invaluable. Admission committees view bigger ICUs with sicker patients in a more favorable light.

In the ICU we learn how to deal with critical situations, how to run codes, pathophysiology, how to titrate vasoactive gtts, how to manage sick patients, and keep patients that are intubated hemodynamically stable and most importantly, alive. The patho and skills that I learned in the ICU were absolutely crucial to my success in both the didactic and clinical portions of CRNA school. Our didactic curriculum basically assumes you know everything that the CCRN certification exam covers. Schools then take this information and go much deeper and relate it to the anesthetics we give. So, it's all relevant except now we're the ones intubating our patients and determining what drugs to give/not give based on comorbidities and fluid volume status. I can definitely see how this would be helpful with an acute care NP program, but maybe not somebody whose goal is to work in primary care.

For CRNAs, a lot of people think that 2-5 years of experience is the sweet spot. After that students are sometimes too far removed from school which makes didactic a little more difficult for them. Obviously this varies from individual to individual though.

I only say all this so that you can understand the viewpoint/belief system that is essentially grinded into CRNAs, and is the reasons why I initially assumed that all NPs should require clinical experience without knowing that studies show that NPs without experience have equal outcomes (albeit I'm unsure if this is academic success or clinical outcomes).

With that being said, do you think that NPs will ever band together to homogenize the accreditation process and perhaps shut down lower tiered schools that are not only saturating the market with lower quality providers, but giving physicians ammo to take shots at APRNs in an attempt to damage the public's perception of us?

[verene, MSN]

What you've highlighted are 3 separate issues:

1) poor quality programs vs high quality programs

2) online vs hybrid vs brick-and-mortor

3) experience necessary for role

Online vs in-person in many ways comes down to individual learning style and what checks and balances exist to determine student comprehension and still ensure high-quality clinicals. Online didactic content can be a highly efficient use of transmitting information - my brick-and-mortar program often made use of "flipped classroom" with our lectures online and in-person lab, exercises and in-person discussion of topics we were expected to have already reviewed via independent reading and online lecture -- it's the matter of making sure student understanding is intact which is important via in-person or online means.

Experience is another question to explore -- how much experience? Nursing experience in general vs nursing experience in related specialty? How does non-nursing experience which is directly relevant to NP specialty factor in?

I think the critical piece is the quality of NP programs - poor quality vs high quality that makes a large difference in student quality and student learning. Would you rather an mediocre RN with 15 years experience who works-full time and does a slap-dash diploma mill online program or a highly motivated direct-entry student who lives and breaths nursing/np education and role socialization for 3 years straight? The former has more experience but the latter may have more support and substantially more focused independent study skills. Is it better for students to have the experience and networking to find their own clinical placements or for school to place students in vetted clinical setting? What kinds of clinical exposure is most relevant in school -- is it better to have a wide range of clinical experiences which may be brief or a singular in depth experience? How much check-in exists between school faculty and the clinical site and preceptors? Does competitiveness of admission to program have an impact on graduate quality regardless of direct-entry vs experienced RN students?

I think the field as a whole needs to do a lot more research into the different pathways and the long-term outcomes for providers going through different training methods. So much in this field is really anecdotal and not based on strong evidence one way or another - and that is a huge weakness to evaluating the strengths and weaknesses of different educational and professional pathways.

[FullGlass, BSN, MSN, NP]

7 hours ago, ProgressiveThinking said:

I agree with the putting up barriers statement and that experience as a rate limiting step might not be a bad thing. Just to let you know where my initial point of view came from: The knowledge that CRNAs gain in the ICU is invaluable. Admission committees view bigger ICUs with sicker patients in a more favorable light.

We need better schools and education, not barriers. I am a primary care NP and went straight from ABSN to MSN NP. In many parts of the US, there is an acute shortage of primary care providers of ALL types. There are parts of the US where people have to drive HOURS to go to an FQHC. Some must rely on mobile clinics that are only on-site once a month.

I don't know why it is so hard for people to understand this: To be an acute care NP that works in a hospital, one must work as an RN!!! This makes sense, because RNs would gain valuable experience working in the hospital setting directly relevant to being an acute care NP. Some specialties, such as oncology, generally only hire NPs with prior RN experience. So why is there is so much complaining about NPs not have RN experience? They do have RN experience if they are working in the hospital!

MOST RNs DO NOT WORK IN PRIMARY CARE. That is why the studies that have been done have found that prior RN experience does not benefit primary care NP students. This topic has been beaten to death. Anyone who is interested can find those previous threads with links to the studies. And that is why most NP programs no long require RN experience for primary care MSN NP programs, and that includes all the best schools!

PA clinical hours cover everything, while NPs must specialize on entry into the program. That is the main reason PAs have more clinical hours. If NP schools also covered everything from the ER to ICU to primary care, then we'd have about the same number of clinical hours. People who want that can go to PA school.

With an acute shortage of primary care providers, the last thing we need now is to throw up more barriers to producing primary care providers. 90% of NPs are educated in primary care, and 75% of them work in primary care.

This thread is in the NP specialty area. There is a separate area for CRNAs.

For goodness' sake, let's get real. The top schools have been turning out direct-entry primary care NPs for awhile. They are not going to change their policies at this point. Requiring RN hours for primary care NPs is not going to do anything to address: 1) quality and 2) access.

Most of us would like to see better oversight of NP schools and would also like to see more NP residencies. That would solve the quality issue.

Honestly, I am so sick of the "PA school is so much better" If you want that experience, there is nothing stopping a person from going to PA school! I prefer to have choices, I prefer the nursing model of care, and I like that NP school is more flexible for students that have to work while going to school.

[murseman24, MSN, CRNA]

Can we all agree to get rid of all the nursing theory fluff? Switch it with clinical sciences to increase the quality and rigor of the program and the comparisons between PA and NP won't be as valid.

[BostonFNP, APRN]

6 minutes ago, murseman24 said:

Can we all agree to get rid of all the nursing theory fluff? Switch it with clinical sciences to increase the quality and rigor of the program and the comparisons between PA and NP won't be as valid.

I’ve made the argument at conferences to try and move away from spending “equal time” in DE programs on RN and NP education and rotations. If we are going to have DE programs then make them extra heavy on the APN material and drop the fluff of pre-licensure and post grad.

[ProgressiveThinking, MSN, CRNA]

4 hours ago, FullGlass said:

1) We need better schools and education, not barriers. I am a primary care NP and went straight from ABSN to MSN NP. In many parts of the US, there is an acute shortage of primary care providers of ALL types. There are parts of the US where people have to drive HOURS to go to an FQHC. Some must rely on mobile clinics that are only on-site once a month.

2) I don't know why it is so hard for people to understand this: To be an acute care NP that works in a hospital, one must work as an RN!!!

3)This thread is in the NP specialty area. There is a separate area for CRNAs.

4) Honestly, I am so sick of the "PA school is so much better" If you want that experience, there is nothing stopping a person from going to PA school! I prefer to have choices, I prefer the nursing model of care, and I like that NP school is more flexible for students that have to work while going to school.

1) Yes and no. We do need better education, but not having any barriers will just saturate the market and result in lower salaries. In my area there are a ton of FNP new grads who work at the bedside for one reason or another (area saturation, lower salary, etc). None of them are flocking to these shortage areas. I don't think that having less barriers would suddenly make graduates want to relocate to these areas. Incentives have to be provided to recruit people into these areas. Increasing access to programs for people who are from these areas who wish to stay in the area and practice might be a good idea as long as standards and quality are maintained.

2) I think that this was already established earlier on in the thread.

3) I'm not sure what your point is. I was providing my frame of reference in order to convey my thought process as to why I thought the way I initially did. This thread was specifically posted in this section because I'm considering pursuing a post master's FNP, but I'm somewhat on the fence and was looking for insight from practicing NPs on issues that may affect me in the future if I do choose pursue the field.

4) I can see how this frustrates you. In those people's defense, I can see how one could jump to this conclusion. In my ICU, the NP students worked full-time, had families, and still managed to go out on the weekend. To me, this was just a reflection of the schools they attended. A buddy of mine went to a different program and received phenomenal training, and was stuck studying most of the time. The program piggybacked off his RN experience and he graduated feeling prepared to be a solid provider. He actually had to cut hours at work. If I didn't know that the more rigorous program existed, I probably would have jumped to the conclusion that NP training is < as well. Again, this is just a reflection of the NP schools in my area. One of them actually recruited a friend of mine who had a 2.5 GPA and said his experience would make up for his lack of GPA since the school didn't really have enough applicants. They basically rolled out the red carpet for him. Couldn't even make this up.