Why don't more NPs advocate for better training?

Spadeforce · Feb 21, 2019

Schools wouldn't listen and people have said things to the AANC and such, they dont care. They know the soccer moms out there love the easy couch curriculum and if they make it harder people will take the PA route instead and it will hit their pockets.

Oldmahubbard · Feb 21, 2019

I went to a respected B and M school and I have been an NP for 15 years. I would honestly be embarrassed for people to know the low quality of that program, and the fact that I am almost entirely self educated.

Some of it is built right into the stupid curricula. We desperately need to get rid of that nursing theory crap, it is such a waste of time. That fact has been widely known and agreed on for years, but no one does anything.

We are now headed in the direction of easier and easier, and low quality programs exploding everywhere. The department head of a new PMHNP program is not an experienced NP, he is a social worker. I find this disgusting, but you would have to pay an experienced psych NP very, very well. Not the case with social work.

It has gotten to the point now where I feel the tide is turned, and it is simply too late. The time to do something about this issue was 20 years ago.

It's all about the money for schools and all very short term thinking. I am just thankful I only have a few more years to work.

Trauma Columnist · Feb 21, 2019

I agree - we can advocate for better education by getting our legislatures involved. Belonging to your state's APRN organization, contributing to their PAC, talking with your legislators are all ways to impact our education

djmatte, ADN, MSN, RN, NP · Feb 21, 2019

1 hour ago, traumaRUs said:
I agree - we can advocate for better education by getting our legislatures involved. Belonging to your state's APRN organization, contributing to their PAC, talking with your legislators are all ways to impact our education

While I don't disagree that involvement in our local organization is important, I don't find they (mine specifically) are particularly interested in the quality of NP education programs. Certainly not enough to potentially hold back the profession on the stage of legislation and improving NP autonomy. If they ever suggested that NP education was lacking, the AMA would be all over that and two decades of progress would be a wash (appropriate or not).

IMO improving education starts at the either the school accreditation or the two organizations that certify NPs. The problem with both is there are too many organizations in the pot. There are multiple school accrediting agencies ranging from national to regional and all are generally accepted by certifying bodies. And as evidence by some of those schools with accreditation, many of the "low performing" schools still maintain high level accreditation. AANP and AACN specifically are in competition (especially since they don't allow cross certifications anymore) and their bread and butter is adding new members and ensuring those members continue to pay dues. They sure as F aren't going to risk a steady increase of members by adding additional restrictions.

A good area they could start is by certification bodies forcing new nurse practitioner graduates to complete residencies prior to certification. This could at least slow down the flood of new NPs and provide a more structured hands on education that those bodies control and have a vested interest in. But as previously mentioned, it slows down numbers (money) and increases their work (cost) by adding more programs to manage.

Advanced Practice Columnist / Guide · Feb 21, 2019

I felt like my ACNP program trained me enough for all the practical knowledge I would need to be in an entry level NP position in an acute care setting. But that was over 15 years ago and since then newer ACNP programs have popped up and what was once a small pool of programs has now gotten large.

There are some NP’s who have made initiatives to pressure schools to follow standards such as the one group led by a PMHNP in making CCNE adopt changes to its rules making sure programs offer preceptors to students instead of having students look for their own.

There are still good programs out there. We are part of a healthcare campus with a nursing school and I feel that our AGACNP program upholds higher standards than most programs.

allnurses Guide · Feb 21, 2019

On 2/20/2019 at 12:07 PM, Angeljho said:
I've seen a lot of complaints on this forum about the quality of NP education and training. However, while I mostly see complaints here, other forums and media defend NP education. If NPs feel that their training is inadequate, why not tackle this issue at a higher level to advocate for better training (or a better model of care)?

I do think we need to be careful here about grouping two different things together.

First and foremost, studies have time and time again demonstrated that nurse practitioners provide cost-effective quality care in addition to increasing access to care. Nurse practitioner training (on a macro level) has historically produced providers that provide (at least) equivalent care to physicians (on a number of different quality measures). When the media is talking about NP care, or NPs are talking locally/regionally/nationally, this is the most important point of discussion.

On the flip side:

1. Just because NP training has historically produced providers capable of providing quality care doesn't mean that it always will. I think many practicing NPs have concerns about the drastic increase of NP programs/graduates in the past 10-15 years and the subsequent increase in the number of sub-optimal quality programs and graduates as well. Additionally I think many of us are concerned in some of the trends we are seeing in NP education: shifts to online and for-profit programs with rolling admissions, programs disinvesting from students, lack of preceptor oversight, decreasing clinical hours, less experienced novice NPs, etc. We are concerned because it jeopardizes our future; by the time data shows worsening outcomes it will be too late for NPs, we will lose any ground we've made in independent practice, our relative value and salary will plateau and start to decrease. We need to have ongoing vigilance and apply ongoing pressure for the certifying bodies and the programs themselves to invest more in the quality preparation of novice NPs.

2. Some of the negativity on the internet about NP education/preparation stems from the ignorance of the poster: those that have never been through NP education or practice, those with financial interests, etc.

FullGlass, BSN, MSN, NP · Feb 22, 2019

Philosophically, I believe it is up to the individual to get a good education - plenty of good schools are out there. It is then up to the free market to decide who gets hired. Personally, I felt my school did a good job (Johns Hopkins). Schools vary in quality and it is up to prospective students to research schools. Employers do have some idea of which schools are good and which are not. A new grad NP who went to a reputable school is going to find it easier to get a good job than a new grad NP who went to a crappy school.

Honestly, do the many complainers on this forum think that hiring managers of NPs, who are likely to be MDs or NPs, are completely clueless as to which schools are decent? I currently work in a Northern California rural FQHC and we precept NP and PA students from UC Davis and actively try to recruit from there because we know that is a good school.

My mentor is a brilliant MD (Georgetown Med, Mayo Clinic residency) and he told me he didn't expect me to know anything as a new grad NP and he wanted me to ask a lot of questions. He is happy with my progress as a first year direct-entry NP (with no RN experience) and so is our Medical Director.

Are we supposed to believe that employers are unable to read a resume, assess experience, and unable to conduct an interview and monitor shadowing time adequately? If employers are unable to do these things, then the fault is with their hiring process.

Actually, I do think hiring is not done very well in healthcare in general. Since my previous career was in business, I can say with certainty that the hiring process is much more rigorous in the best corporations than I have seen in healthcare. Here are some of the things that would be standard in corporate America:

- extensive interviews with both management and one's prospective peers

- one-on-one and panel interviews

- often, some sort of written exam to test basic knowledge, writing, and analytical skills

- some sort of evaluation of one's ability to do the job in the form of a case study or simulation. I was surprised that not one of my shadowing days included evaluation of my ability to take a basic H&P and do a basic PE.

Employers could easily increase the rigor of their hiring process to weed out the chaff.

Finally, I think there are some unrealistic expectations out there of a new grad NP. It is expected the first year will be a steep ramp up period. That is because NP residencies are few and far between. Smart employers know that and plan accordingly.

Here's what I would expect of a new grad NP:

- how to do a basic H&P and document appropriately on an EHR; ability to learn EHR in a reasonable period of time

- basics of a PE and what type of focused PE to do for common issues like URIs, UTIs, etc.

- fundamentals of pharmacology; most common meds for common diseases, when to give antibiotics or not

- how to research and find information when one does not know something, like using Uptodate and Epocrates, etc.

- basic labs/tests to order for common conditions

- ability to demonstrate critical thinking and reasonable knowledge to develop differential diagnoses

- ability to give a good report when asking questions or requesting consultation by a more experienced provider

All of the above could be reasonably assessed with a rigorous hiring process.

We have a serious shortage of primary care providers in many areas of the USA. This is both a supply and distribution problem. The last thing we need is to reduce the supply of PCPs.

As for increasing the length of school and mandating NP residencies, that has to be balanced against cost issues. Yes, MDs have 4 years of school and then internship and residency, but the average MD emerges with 200K to 300K of debt! Do any new or prospective NPs out there think it would be ok to increase the student debt of NPs?

Those who think PA education is superior are free to go to PA school. Those who want to be MDs can do the work and go to med school. Personally, I am satisfied with my NP education. Are there some things I wish had been covered in more detail? Absolutely. That doesn't mean the whole system sucks.

Dodongo, APRN, NP · Feb 22, 2019

My state has a bill in the house for independent NP practice. I have written to my representatives explaining NP education and recommending against FPA until NP education is standardized. I also refuse to precept NP students from for-profit, 100% online schools that don't require anything in the way of matriculation or graduation requirements

Spadeforce · Feb 22, 2019

It’s all cool and stuff if one person goes to a good school but we are judged by our worst as a whole so if even somebody went to a great place if bob swole goes to Walden or some other roflchopper for profit it drags us all down

Oldmahubbard · Feb 22, 2019

11 hours ago, FullGlass said:
Philosophically, I believe it is up to the individual to get a good education - plenty of good schools are out there. It is then up to the free market to decide who gets hired. Personally, I felt my school did a good job (Johns Hopkins). Schools vary in quality and it is up to prospective students to research schools. Employers do have some idea of which schools are good and which are not. A new grad NP who went to a reputable school is going to find it easier to get a good job than a new grad NP who went to a crappy school.
Honestly, do the many complainers on this forum think that hiring managers of NPs, who are likely to be MDs or NPs, are completely clueless as to which schools are decent? I currently work in a Northern California rural FQHC and we precept NP and PA students from UC Davis and actively try to recruit from there because we know that is a good school.
My mentor is a brilliant MD (Georgetown Med, Mayo Clinic residency) and he told me he didn't expect me to know anything as a new grad NP and he wanted me to ask a lot of questions. He is happy with my progress as a first year direct-entry NP (with no RN experience) and so is our Medical Director.
Are we supposed to believe that employers are unable to read a resume, assess experience, and unable to conduct an interview and monitor shadowing time adequately? If employers are unable to do these things, then the fault is with their hiring process.
Actually, I do think hiring is not done very well in healthcare in general. Since my previous career was in business, I can say with certainty that the hiring process is much more rigorous in the best corporations than I have seen in healthcare. Here are some of the things that would be standard in corporate America:
- extensive interviews with both management and one's prospective peers
- one-on-one and panel interviews
- often, some sort of written exam to test basic knowledge, writing, and analytical skills
- some sort of evaluation of one's ability to do the job in the form of a case study or simulation. I was surprised that not one of my shadowing days included evaluation of my ability to take a basic H&P and do a basic PE.
Employers could easily increase the rigor of their hiring process to weed out the chaff.
Finally, I think there are some unrealistic expectations out there of a new grad NP. It is expected the first year will be a steep ramp up period. That is because NP residencies are few and far between. Smart employers know that and plan accordingly.
Here's what I would expect of a new grad NP:
- how to do a basic H&P and document appropriately on an EHR; ability to learn EHR in a reasonable period of time
- basics of a PE and what type of focused PE to do for common issues like URIs, UTIs, etc.
- fundamentals of pharmacology; most common meds for common diseases, when to give antibiotics or not
- how to research and find information when one does not know something, like using Uptodate and Epocrates, etc.
- basic labs/tests to order for common conditions
- ability to demonstrate critical thinking and reasonable knowledge to develop differential diagnoses
- ability to give a good report when asking questions or requesting consultation by a more experienced provider
All of the above could be reasonably assessed with a rigorous hiring process.
We have a serious shortage of primary care providers in many areas of the USA. This is both a supply and distribution problem. The last thing we need is to reduce the supply of PCPs.
As for increasing the length of school and mandating NP residencies, that has to be balanced against cost issues. Yes, MDs have 4 years of school and then internship and residency, but the average MD emerges with 200K to 300K of debt! Do any new or prospective NPs out there think it would be ok to increase the student debt of NPs?
Those who think PA education is superior are free to go to PA school. Those who want to be MDs can do the work and go to med school. Personally, I am satisfied with my NP education. Are there some things I wish had been covered in more detail? Absolutely. That doesn't mean the whole system sucks.

A lot of great thoughts here. I know you went to an above average program and I am glad it has worked out well for you. I wouldn't say the whole system sucks, but the explosion of for profit schools with virtually no barrier to entry is frightening to me.

FullGlass, BSN, MSN, NP · Feb 23, 2019

11 hours ago, Oldmahubbard said:
A lot of great thoughts here. I know you went to an above average program and I am glad it has worked out well for you. I wouldn't say the whole system sucks, but the explosion of for profit schools with virtually no barrier to entry is frightening to me.

Thank you. I am curious as to how many subpar for-profit schools are out there. When I reviewed the list of accredited NP programs in California, there were only a few for-profit schools listed.

I think there is a place for for-profit schools, but am in favor of reasonable accreditation requirements. Some of these schools are decent, such as National University in California. They do help students who have to work full-time and need more flexible schedules. A student who goes to a crappy school, but puts in the work, can still get a decent education.