Writing the Prescription to Fix Broken Nurse Practitioner (NP) Education (Pt. I)

[cjcsoon2bnp]

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)?

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REFERENCES

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.

[shibaowner, MSN, RN, NP]

In the first place, it is entirely possible to go to NP school without a BSN -- witness the kazillion direct-entry programs that take people with no nursing experience or background whatsoever, ram them through a "quick 'n dirty" basic nursing education and put them directly into advanced practice programs. There are plenty of ADN-to-MSN programs out there, as well. And I don't have any idea what the proportions are these days of experienced-RN grad school applicants vs. direct-entry applicants, but I am certainly not willing to assume that it is true that "most" NPs have 1-5 years experience working as RNs. In the graduate program I attended, none of the direct entry students were working as RNs in school, and they all graduated and went into advanced practice without a single day of RN experience.

In the second place, am I the only person who's greatly amused that the same person who has been arguing that previous nursing experience is not necessary for advanced practice nursing, and that NPs without previous nursing experience are better clinicians that experienced-RN NPs is now pointing to NPs' previous nursing experience as making up for the fact that NPs have so many fewer hours of clinical education than PAs?

I don't know what school you went to. Perhaps one that wasn't very good, judging by your attitude and lack of ability to think logically. Or even to do any research to back up your claims and provide citations. You also seem to think it is ok to make sweeping generalizations based on anecdotal evidence (your school).

1. This is why I say most NPs (not NP students) have RN experience - because RN experience was a requirement in many programs until relatively recently. Therefore, we have a large population of NPs practicing now that completed their MSN when RN experience was a requirement. I did try to find the % of current NP students that have RN experience, but was unable to find this information. See, unlike you, I actually perform research.

2. I can see how you might find one of my arguments inconsistent. Let's look at this more closely. PA schools require 1,000 hours of clinical experience before starting PA school (CNA, tech, EMT, RN, volunteer, etc). However, PA students do not have to have a BSN or other clinical education equivalent. NP students must have a BSN or a direct entry MSN prior to applying to NP school.

3. Let's take case 1 = Jane. Jane completed a BSN program (1,000 clinical hours). She then worked as an RN for 1 year before starting NP school (2,000 paid clinical hours). Her Primary Care FNP program required 700 clinical hours. Therefore, upon completing her MSN, Jane has 1700 academic clinical hours and 2000 RN clinical hours = 3700 clinical hours, certainly comparable to a new grad PA.

4. Let's take case 2 = Amy. Amy completed a BSN program (1,000 clinical hours). She then went into an MSN NP program in Primary Care FNP (700 clinical hours). So, 1,700 clinical hours before starting NP practice. Yes, less hours than a new grad PA. So, see below for further analysis.

5. PA schools generally provide 1500 to 2000 clinical hours, but they also cover everything - acute care, primary care, women's health, peds, geriatrics, etc. NP schools require specialization. So, a primary care FNP is not going to do any acute care clinical hours, and so forth. So I fail to see how PA schools are superior for a given specialization.

6. I am not aware of any studies indicating PAs provide superior care to NPs. Over 100 studies demonstrate NPs provide care quality equivalent to, or better than, MDs. Do you think PAs provide care better than MDs? I ask this because that is the logical extension of your argument. If A = B, and B = C, then A = C.

7. At Johns Hopkins, in my class, about 1/2 the students in the NP programs had worked as RNs prior to starting the NP school. JHUSON does NOT recommend that NP students work. Med school and PA schools are also designed as full time programs and they are very clear about that. That said, at JHUSON, the first semester is purely didactic, so some students did work. However, once clinicals start, it is extremely difficult to work more than 10 - 15 hours per week, as the academics are so demanding, in addition to 16-20 hours clinical per week. So most of the NP students who were working as RNs at JHUSON, either quit working or dropped to part time work. Remember, if an NP student does not perform satisfactorily in school, no matter how wonderful an RN he/she is, then that student will not graduate to become an NP. No ticket, no wash.

[Corey Narry, MSN, RN, NP]

I don't know what school you went to. Perhaps one that wasn't very good, judging by your attitude and lack of ability to think logically. Or even to do any research to back up your claims and provide citations. You also seem to think it is ok to make sweeping generalizations based on anecdotal evidence (your school).

Let's keep our comments civil and professional. This is a free exchange of ideas and everyone is entitled to express their thoughts in a manner befitting the level of education we are representing.

P.S. I think the poster you're addressing graduated from an Ivy League institution that rhymes with "Kale".

[shibaowner, MSN, RN, NP]

If they went to Yale, it's even more disappointing. I also went to Yale as an undergrad. On the other hand, I'm thinking the contents of the "rhymes with kale poster" posting demonstrates that this individual is indeed correct and that NP schools are not selective and rigorous enough. Oh, and my comments were civil and professional. Someone commented I had a chip on my shoulder and no one came to my defense. I also did not complain.

[shibaowner, MSN, RN, NP]

I see the point you're trying to make but you have a majority of students pursuing the FNP degree and then not practicing in primary care, rather, treating it like a PA degree, thinking they can practice in any area they so desire upon graduation. So you have an FNP program providing 700 clinical hours and students thinking they are ready to practice wherever they want. Hours spent in a BSN program do not count, nor do hours working as a RN. You are not evaluating as a provider, diagnosing or prescribing, etc.

I'd also be concerned if this is the case. NPs are not supposed to do this, but employers and state BONs are also at fault if this is happening. At my school, we had acute care and primary care tracks and then further specialization within acute care and primary care. Our faculty warned us repeatedly to only practice within the scope of our training unless the employer provides extensive training.

It is true RNs are not in the diagnostic role. However, all the existing evidence indicates NP care is as good as PA and MD care.

What I strongly support are nurse practitioner residency programs. More of these programs are becoming available, but the problem is funding. This would be a great area for NP political involvement.

[shibaowner, MSN, RN, NP]

There are direct entry programs that do not award a BSN. Students graduate with an MS and that's it. Off hand both UCSF and Columbia's programs are set-up like that and I had to check their websites to confirm. FWIW, both are USNWR top-rated institutions.

Academic Programs - MEPN | UCSF School of Nursing

MDE FAQs | School of Nursing

Correct, these are direct entry or master's entry programs. Of course they do not award a BSN! An MSN is awarded, but the students are NOT allowed to apply for an NP license. They are only qualified to apply for the RN license. If they want to become an NP, then they must attend a post master's certificate program, usually 2 years of FT study, to become an NP. I don't see why that is a problem.

[BostonFNP, APRN]

Please keep the discussion about the topic and leave the personal stuff out of this, it serves to do nothing but move us away from a topic that warrants continued debate. There are different opinions and that's a good thing. I have had many debates with elk and jules but I absolutely respect them and their positions. We are all on the same team and (I think) we all have the same goal: lets continue to work towards that.

[BostonFNP, APRN]

Correct, these are direct entry or master's entry programs. Of course they do not award a BSN! An MSN is awarded, but the students are NOT allowed to apply for an NP license. They are only qualified to apply for the RN license. If they want to become an NP, then they must attend a post master's certificate program, usually 2 years of FT study, to become an NP. I don't see why that is a problem.

That isn't true.

There are a number of programs locally here that are DE programs and do not award a BSN. They don't award a BSN so those with prior BA degrees can use federal graduate loans to pay for the entire program. These students sit for the NCLEX and work as RNs even though they do not have a BSN or an ADN or an MSN. At the end of the MSN program they are eligible to sit for APN boards in their specialty.

[shibaowner, MSN, RN, NP]

Anecdotal or otherwise experience with practitioners is more relevant to me than a study of 10 years ago that does not address performance in practice. There are exception to all rules and some neophyte NP may perform brilliantly and I applaud that, but I do work in a specialty where the acute care background does influence my decisions on who we hire. I have never worked day one in family practice and would probably flounder horribly.

You seem to have a wee bit of a chip on your shoulder. I hope you can work through it, because 10 years post graduate none of where you were trained or what your background was will matter. If you have not developed skills by then everyone around you will notice.

Chip on my shoulder? No. I am quite happy and secure. I do get frustrated with NPs who do not let the evidence get in the way of their biases. My fear is that such NPs will discourage talented individuals.

I do agree that RN experience is an advantage to acute care NPs. I have stated that repeatedly. However, the vast majority of NPs are in primary care. No one has yet explained to me why RN experience is such an advantage in this environment. Most RNs do not have primary care experience.

The studies I cited were within the past 5 years. There are additional studies that support my position dating back to the 1990s. I am not aware of any studies that refute my position. If you have such evidence, I would be delighted to see it.

I do thank you for your concern about my career. Since I had a previous career that was actually more demanding in many ways than being an RN or an NP, and that required excellent people skills in order to succeed, I am quite confident in my "skills" and ability to develop NP skills In fact, the 2 MDs precepting me on my last clinical rotation wanted to hire me, but I could not stay in Baltimore. Also, I had multiple job offers shortly after graduation, and headhunters contact me frequently. Oh, and I am doing very well on my new job. The clinic I work for hires new grad NPs and PAs, provides extensive training, and also believes in precepting NP and PA students. We're going to hire at least 10 NPs and PAs in the next year. This group has a long history of hiring new grad NPs and PAs, and because of the excellent training, has never had a problem.

[shibaowner, MSN, RN, NP]

That isn't true.

There are a number of programs locally here that are DE programs and do not award a BSN. They don't award a BSN so those with prior BA degrees can use federal graduate loans to pay for the entire program. These students sit for the NCLEX and work as RNs even though they do not have a BSN or an ADN or an MSN. At the end of the MSN program they are eligible to sit for APN boards in their specialty.

I am not familiar with the local schools in your area. UCLA and Johns Hopkins both have direct entry MSN programs for individuals with a BA or BS in a non nursing field. You are correct, graduates of these programs can indeed sit for the NCLEX. They cannot sit for an NP license exam without additional schooling.

I do not understand why this is an issue. I will provide my understanding of this situation and look forward to your comments:

1) Jane goes to a BSN program. She graduates with about 1,000 clinical hours. She sits for the NCLEX.

2) Amy goes to a direct entry MSN program. She graduates with about 1,000 clinical hours. She sits for the NCLEX.

I don't see why this is a problem. Both have covered the same academic nursing curriculum and have the same # of clinical hours in order to become an RN.

If either Jane or Amy want to become an APRN, then they must complete additional schooling and clinical hours.

I am looking forward to your response.

[Corey Narry, MSN, RN, NP]

Correct, these are direct entry or master's entry programs. Of course they do not award a BSN! An MSN is awarded, but the students are NOT allowed to apply for an NP license. They are only qualified to apply for the RN license. If they want to become an NP, then they must attend a post master's certificate program, usually 2 years of FT study, to become an NP. I don't see why that is a problem.

Actually that's not true. I work in the academic medical center of one of those 2 institutions I cited (won't say which one as it's easy to figure out). The direct-entry program students who graduate with an MS and no BSN at all are eligible to sit for NP certification.

[JustKeepDriving]

Correct, these are direct entry or master's entry programs. Of course they do not award a BSN! An MSN is awarded, but the students are NOT allowed to apply for an NP license. They are only qualified to apply for the RN license. If they want to become an NP, then they must attend a post master's certificate program, usually 2 years of FT study, to become an NP. I don't see why that is a problem.

So, a good look at the link shows MEPN admission with a list of MS specialty area's on the right hand side that admit master's entry students and include AGPCNP, FNP, PMHNP, WHNP ect.

I've worked with graduates of such programs before my attending barred anyone without at least 2 years of RN experience in specialty prior NP licensing from working at my facility.

There are some MEPN programs (UC Irvine for example) that will grant a generalist master's degree to individuals without a BSN and they would have to obtain a post-masters certification as a NP in order to get credentialed and licensed as an NP. There are also MEPN programs that take individuals with an unrelated bachelor's degree straight to NP without a BSN - UCSF (linked) is one of those programs. No post masters necessary and they are eligible for credentialing and licensing post-graduation.

[Corey Narry, MSN, RN, NP]

If they went to Yale, it's even more disappointing. I also went to Yale as an undergrad. On the other hand, I'm thinking the contents of the "rhymes with kale poster" posting demonstrates that this individual is indeed correct and that NP schools are not selective and rigorous enough. Oh, and my comments were civil and professional. Someone commented I had a chip on my shoulder and no one came to my defense. I also did not complain.

I think you need to cool off and step away from the discussion for a while. Many of us have been members of this forum for a long time and through the years have seen discussions get heated and the issues are no longer being addressed because comments become personal. The statement "perhaps one that wasn't very good, judging by your attitude and lack of ability to think logically" does not convey a thought process that defends a strong case for an argument.

It comes off snarky and can be interpreted as immature, hence, not along the lines of being civil and professional. Adding the statement "someone commented I had a chip on my shoulder and no one came to my defense" makes it even sound more adolescent in my opinion. Let's just stick to supporting our arguments without writing personal snarks before this particular thread gets reviewed and closed.