Standardization of NP Education

allnurses Guide · Jul 10, 2018

Of course, I wish we had more clinical hours, but I believe the best way to address that is through NP residencies.

How are residencies going to help? Honest question. What does a residency offer?

More collaboration?

More clinical hours of instruction or broader clinical experiences?

A holding pattern to decrease supply and increase demand?

What are the costs associated with them?

I am opposed to adding a bunch of classes and clinical hours to NP education because that is going to increase costs. NP residencies provide additional didactic instruction and clinical hours and also provide a stipend to the NP resident.

But you are for adding residency requirements which would significantly impact the cost effectiveness of NPs? Would you be willing to do the same job for a quarter pay for a few years?

I don't care about PA education and it is comparing apples to oranges.

Posters making the PA comparison really are just doing it out of ignorance of the process and model.

I agree admissions standards for NP school should be increased and am against the schools that admit anyone with a pulse. We need more high quality NP schools that can accomodate students that have to work their way through school.

How do you propose we "get" more high quality NP schools? Do you think that the more you increase accommodation the more you sacrifice quality?

Jules A, MSN · Jul 10, 2018

Lol nursing loves subjective data that's about it.

So in spite of your condescending jab about subjective data and my lack of a need for the actual temperature reading on the campfire to know not to stick my hand in as usual you have good questions so I'll engage.

How do you propose that "we" require schools to have stricter admission criteria?

Someone is approving these schools. The school admission process would fall back to the accrediting bodies and the boards of nursing. I remember when my state wouldn't accept one of the well known for profit schools. Unfortunately they now have approved every program under the sun. I have also gotten wind of some of the proposed updates to the most recent CCNE Standards for Accreditation and while there were one or two positive changes in my opinion much of it was just moving the text around to different locations and more vague guidelines.

What are the faculty and staff criterion for ACEN accreditation and how would you change them?

The lack of experience among instructors is what I found most disturbing in my programs. Many had minimal to no NP experience, they were the chronic students to professors. Perhaps that has changed now that there are more NPs? Would it be unreasonable to require a couple of years experience as a NP before teaching a diagnostics class? I could care less about the Populations and Public Health courses but for the meat and potatoes,of which there is so little, an experienced clinician is important, subjectively of course.

How do we change the current preceptor environment? Or should we? I've seen it argued here that "find your own preceptor" is a great thing.

I only have experience with schools who offered preceptors and fortunately I had my own physicians lined up as many of their NP preceptors had only graduated the year before. I think at least a couple of years experience in the field would be worthwhile and not so onerous as to shut things down completely.

djmatte, ADN, MSN, RN, NP · Jul 10, 2018

Posters making the PA comparison really are just doing it out of ignorance of the process and model.

Not necessarily. Some of us are envious of that model because of the flexibility of options and the broader education they receive. Beside independent practice (which is still not happening in most states), we are often in direct competition with pa graduates whom many mds are much more comfortable hiring. I'd argue the model of forcing NPs into inflexible roles is doing a broader disservice.

Jules A, MSN · Jul 11, 2018

Posters making the PA comparison really are just doing it out of ignorance of the process and model.

Or perhaps not ignorance but of disappointment of the nursing model as compared to the PA model? I am seriously jealous when I see PA curriculum as compared to what my programs offered. Hindsight is 20/20 and unfortunately I'm old and didn't make the smartest choices when I was younger but hopefully my experience can shed light for others to at least consider the options available.

allnurses Guide · Jul 11, 2018

So in spite of your condescending jab about subjective data and my lack of a need for the actual temperature reading on the campfire to know not to stick my hand in as usual you have good questions so I'll engage.
Someone is approving these schools. The school admission process would fall back to the accrediting bodies and the boards of nursing. I remember when my state wouldn't accept one of the well known for profit schools. Unfortunately they now have approved every program under the sun. I have also gotten wind of some of the proposed updates to the most recent CCNE Standards for Accreditation and while there were one or two positive changes in my opinion much of it was just moving the text around to different locations and more vague guidelines.
The lack of experience among instructors is what I found most disturbing in my programs. Many had minimal to no NP experience, they were the chronic students to professors. Perhaps that has changed now that there are more NPs? Would it be unreasonable to require a couple of years experience as a NP before teaching a diagnostics class? I could care less about the Populations and Public Health courses but for the meat and potatoes,of which there is so little, an experienced clinician is important, subjectively of course.
I only have experience with schools who offered preceptors and fortunately I had my own physicians lined up as many of their NP preceptors had only graduated the year before. I think at least a couple of years experience in the field would be worthwhile and not so onerous as to shut things down completely.

It wasn't a jab, or if it was it was directed at nursing in general. Nursing loves its small-scale qualitative research. Sure the campfire is hot, we don't need a temperature reading to answer the yes/no question of "is the fire hot". If we are now charged at keeping that campfire at an ideal temperature for the next 50 years, we need to know what temperature it is along with what factors are effecting it that we can control. The other option is we dump a bucket of water on it, rebuild it, cover it with lighter fluid, let it burn again, dump water on it, and repeat ad nauseam hoping for a better outcome.

It sounds like we agree that the changes need to come from the regulatory bodies which takes more people with passionate thoughts about this issue getting involved with the process.

Nursing is having a tremendous problem with faculty. Clinical practice pays more than teaching and teaching is a (for the most part) full-time job. Not many people want to work two full-time jobs, work a job that pays less money than their full-time job, or work in clinical practice part-time. So how do we address that? I think most quality programs do this by 1. finding the rare individuals that both practice and teach, and 2. have clinical decision making groups that are led by practicing providers and help bridge the clinical and didactic experiences. Both of these things are expensive to do so these programs cost more money while the cheapo programs just ignore it. Other solutions?

The preceptor issue is rapidly becoming the bottleneck and above all else is my personal favorite for mvp in ruining the APN reputation. As students and programs become more desperate, especially with newer programs, they will rely more and more on recent alums doing precepting. Now we have generations of poorly trained NPs teaching each other.

allnurses Guide · Jul 11, 2018

Not necessarily. Some of us are envious of that model because of the flexibility of options and the broader education they receive. Beside independent practice (which is still not happening in most states), we are often in direct competition with pa graduates whom many mds are much more comfortable hiring. I'd argue the model of forcing NPs into inflexible roles is doing a broader disservice.

Honestly, I think there is a bit of the grass-is-greener going on with NPs and PAs. I speak with PAs fairly often at conferences and have a few personal friends that are PAs, and the majority seem to either wish they went the NP route or would go the NP route if they had it to do over.

Clinicals: I do think that PA students are stronger than NP students at the start of their clinical rotations, but this is secondary to the front-loaded didactics. NP students entering clinical rotations often haven't had much if any graduate classes, but they learn as they see. PAs have structured clinical rotations which means broader exposure but less depth, and often there are multiple students with a single preceptor. PA preceptors are also paid. NPs clinicals lack structure and perhaps breadth and the depth may be entirely focused on a different area then they ultimately practice in and/or with a poor preceptor. I had an FNP student years back that was one semester from graduating without ever having a true adult primary care rotation, that's an issue.

Education: PAs follow block schedules with a disease-centered focus, like the medical model. NPs follow semester schedules with an integrated patient-centered focus. It could be argued here that NPs actually have a much broader preparation, especially when the breadth of pre-lisc nursing school is considered. If the graduate portion of NP education is to move away from what we call "fluff", will it impact the patient-centered focus of NPs?

Independence: Purely from a legislative standpoint, NPs have a huge advantage here with now nearly half the states with full independent practice (and 4-5 more coming in 2018 from the looks of it). NPs are prepared to be independent providers, something I think the vast majority of us take for granted in our day-to-day practice, in regards to our clinical decision making. PAs can and do function this way, but that is learned with on-the-job experience not from the foundation (at least from working with PA on comittees and summarizing what I've heard).

Job Prospects: NP salary has been steadily increasing and PA salary has somewhat stagnated though this may represent a correction for underpaid NPs. Job outlook for both is still relatively strong. I haven't really seen a strong preference by physicians/practices for PAs over NPs (or vice versa) here locally, though there are some specialties where there is probably a large gap between the two.

myelin · Jul 11, 2018

It also bugs me that so many people complain that their program wasn't any good, and then it turns out that they did less research to choose a graduate program than they would to buy a new refrigerator, and just went to the closest or most convenient or cheapest school without asking any questions or considering any other options. How many of the people who post here about how bad their program is are the same people who post here asking about which programs are the quickest and easiest (as people often come here to ask)?

oh my god PREACH!

myelin · Jul 11, 2018

I wrote a large reply but honestly I think it boils down to this: nurses want crappy/easy schools. We do. We want convenience, cheap, online, etc. We as a field have a huge problem and until this mentality changes NP schools have 0 incentive to make this change. How many times do we see people seeking out programs with low barriers to entry because they're "too scared" to take the GRE or they "couldn't possibly go part-time" during NP training. I mean, I don't think anything will change unless we change the mentality that studying medicine (and lets be real, NP school is basically another approach for practicing medicine) is something that someone shoehorns in during their spare time while they work their "day job." Learning to be a provider should be your day job!!

Also, I agree that comparing PAs to NPs is apples and oranges. Entirely different. PAs are meant to be able to jump into any area of medicine and be a provider. NPs are meant to be trained for a specific scope (I agree with limiting FNPs to only primary care BTW). And to be honest, I've had a few new hire PAs shadow me for a psychiatry job (psych NP here) and I was appalled by how terribly prepared they were. One asked me what schizoaffective was! Then I found out his "psych rotation" in PA school was not done with a psychiatrist, but rather that he was allowed to count any anxiety/depression visit during his family medicine rotation as "psychiatry hours." He had never even rotated in a psychiatric unit/clinic before. And don't get me started about his lack of didactic knowledge. I mean, my experience is that PAs are not uniformly better trained than NPs. It really depends on the clinician.

Dodongo, APRN, NP · Jul 11, 2018

Nope, sorry. I rotated alongside PAs in general surgery and precept them now, and they are almost unanimously better prepared than the NP students. NP education relies on the preceptors, for the most part, to do the actual clinically oriented education on how to be a medical provider. PA didactics are intensive.

And your comments about Caribbean based medical school is a false equivalence argument. All foreign/offshore/international medical schools are still required to take the USMLE step exams and find a residency - all of which is a huge limiting factor - you admitted this yourself. Poorly trained grads will find it incredibly difficult to pass the step exams and find a residency spot. No residency spot = not able to practice. Those that do find themselves lucky enough to score well enough on the step exams and land a residency will receive training to bring them up to speed. All foreign trained grads - even those from respectable foreign schools in Western Europe - have to complete an American residency and pass the USMLE steps. It is not comparable to the NP situation in which AMERICAN NP schools are churning out wave after wave of poorly trained providers with no similar limiting factor.

And you constantly post about requiring data. Again, nurses love throwing around buzzwords like data, and EBP. But they don't really understand what they are saying, and will often cite poor quality "research" to support their bias. Please, how would you design a study to evaluate this problem? Nursing loves relying on "studies" that are all poorly designed, observational, cross sectional, and rely on questionnaires to gather "data". They are heavily biased. They are low evidence. They are unnecessary in many instances. The Flexner Report, in conjunction with the CME, was essentially an "expert council" that sought to homogenize and strengthen medical education by setting forth recommendations. They didn't do it by conducting research. They used their heads - common sense. What a thought.

myelin · Jul 11, 2018

I'm not sure if the above person is replying to me (it seems unclear but I'm guessing no), but I have to say - PAs really vary IMO. NPs do too. But I have met enough scary PAs to think that maybe everyone should do a residency. Hah.

allnurses Guide · Jul 11, 2018

Nope, sorry. I rotated alongside PAs in general surgery and precept them now, and they are almost unanimously better prepared than the NP students. NP education relies on the preceptors, for the most part, to do the actual clinically oriented education on how to be a medical provider. PA didactics are intensive.

I have very little surgical experience and surgery certainly is a PA-dominated specialty. I do find it strange that any amount of didactic intensity would better prepare a student for specialties that are primary dependent on technical skills. Here I would think that those NP students with RNFA experience would be leaps ahead of any other students, save for surgical techs perhaps. Again I know very little about major surgery. You would say that PAs of the same experience level are more competent than you at this point?

And your comments about Caribbean based medical school is a false equivalence argument. All foreign/offshore/international medical schools are still required to take the USMLE step exams and find a residency - all of which is a huge limiting factor - you admitted this yourself. Poorly trained grads will find it incredibly difficult to pass the step exams and find a residency spot. No residency spot = not able to practice. Those that do find themselves lucky enough to score well enough on the step exams and land a residency will receive training to bring them up to speed. All foreign trained grads - even those from respectable foreign schools in Western Europe - have to complete an American residency and pass the USMLE steps. It is not comparable to the NP situation in which AMERICAN NP schools are churning out wave after wave of poorly trained providers with no similar limiting factor.

I think you missed the point of my post which was that medicine is able to control entry to practice in this fashion and perhaps that is something that could be used for NP practice as well. All graduates regardless of quality of program do have to take the same board exam ultimately, however, if they also had to compete for regulated preceptorships similar to residency match it would be an interesting solution to several problems.

And you constantly post about requiring data. Again, nurses love throwing around buzzwords like data, and EBP. But they don't really understand what they are saying, and will often cite poor quality "research" to support their bias. Please, how would you design a study to evaluate this problem? Nursing loves relying on "studies" that are all poorly designed, observational, cross sectional, and rely on questionnaires to gather "data". They are heavily biased. They are low evidence. They are unnecessary in many instances. The Flexner Report, in conjunction with the CME, was essentially an "expert council" that sought to homogenize and strengthen medical education by setting forth recommendations. They didn't do it by conducting research. They used their heads - common sense. What a thought.

You can't cite Flexner in the same sentence that you disregard data and research, he'd roll over in his grave! In all seriousness, it would be incredibly easy to design a study to evaluate NP preparedness in novice practice. The largest hang-up would be in incident-to billing which makes it difficult to study outcomes. That and nursing academia has zero desire to fund it.

Oldmahubbard · Jul 11, 2018

No doubt PA students are better prepared for their clinicals. Mainly because the first few classes in the NP curriculum are sheer nonsense courses, Nursing theory and Issues in Health Care, or whatever that nonsense was called. None of which teaches you a thing about being an NP.

Then, all of a sudden, you are expected to arrange your own clinical. Clinical? you say. What is that? I have been studying energy fields and health care controversies.

The coursework for the most part seems disconnected and random. This is not your imagination.

Major changes are needed, but the people who are currently teaching "energy fields" are not qualified to teach the appropriate content.

And qualified people would have to be paid double what the current "professors" are paid.

Standardization of NP Education

What immediate requirement will improve NP education