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)?

---

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.

[Cococure]

As usual a very good discussion goes sideways ...I too am enjoying a glass of wine. I have been on this board since I was a CNA and this always happens ...good points and then drama. Well I am glad this discussion is back on track. As a NP student I chose to go to hybrid program from a State university...cost was of concern to me. I was advised by fellow NP friends to not attend for profit programs, no need to name we all know the programs I am referring to. This advise was given because some practices and hiring bodies are growing concerned with the lack of performance by some of the graduates. Most primary care practices don't give extensive training and they expect the new NP to be able to manage the basics seen in that setting. But although I am in a somewhat traditional program I find it lacking. So I am doing what I need to do...cut back my working hours to focus on school, read additional texts and I found a great primary care doc to precept me. I know I have to bring my A game so I gotta study my butt off. Overall I do feel that NP education does need to be changed...it has positives and negatives but I do feel that adding more clinical hours and science classes would help. The PA's are more prepared to hit the ground running because of the way their program is designed. I am not getting into a PA vs NP discussion cause we essentially perform the same job t they have a better starting point in my opinion. I think we can all agree that changes need to be made but how do we go about it? I got eaten up and chewed out by professors for asking why are we doing theory and research again? Or why don't we have a skills class that teaches procedures we may do in primary or urgent care. So guess what I am going to do a skills class outside of my school. Should I have so do this? In my opinion no but it what it is until the education is improved you will continue to see a variety of new NP's.

FYI please excuse any typos ...having hand issues

[BostonFNP, APRN]

The PA's are more prepared to hit the ground running because of the way their program is designed. I am not getting into a PA vs NP discussion cause we essentially perform the same job t they have a better starting point in my opinion.

I am not sure I agree with this 100% but it is a different debate for sure.

Or why don't we have a skills class that teaches procedures we may do in primary or urgent care. So guess what I am going to do a skills class outside of my school. Should I have so do this? In my opinion no but it what it is until the education is improved you will continue to see a variety of new NP's.

My program did. Others don't. You answer your own question: some programs take the view that is is easier to attend workshops once you are practicing to hone the specific skills you will need for your practice. Technical procedures are easy, it's the understanding behind them that requires expertise.

Where are you in your program now? It would be interesting to see if your view changes as you enter the more clinical portion of your education and when you enter practice.

[BostonFNP, APRN]

However, my disappointment with nursing "academia" began in my BSN education -- and I do believe some of the downfalls of conventional undergraduate nursing inform these NP programs in a significant way.

This is an interesting point that I have discussed with program planning: if we are going to have DE program which are designed to take talented applicants and prepare them, in an accelerated way, for advanced practice without requiring RN experience, then why do they typically spend nearly 50% of the entire program teaching undergraduate nursing from undergraduate professors then try and make an abrupt turn to graduate level work often repeating the same material at two different levels. Wouldn't it better serve everyone to start teaching advanced practice from day 1?

[Cococure]

BostonFNP I am in my 4th semester of my part time program and I start clinicals in the spring and I hated the fact that I had to find my own sites ..that is a whole other debate unto it self. I am sure my view will evolve as it has over my nursing career. As a student I am aware that I am an adult learner and much of my education and experience will be up to me but I am paying for an education. No system is perfect and I am sure PA's education design has their flaw but the education for us needs to be more streamlined.

[BostonFNP, APRN]

BostonFNP I am in my 4th semester of my part time program and I start clinicals in the spring and I hated the fact that I had to find my own sites ..that is a whole other debate unto it self.

In my opinion is is a central part of the current debate: APN programs which have stopped securing clinical sites, in simple terms, are telling every student that they care more about money than they do about their education. The quality of the clinical portion of NP education is vital to the overall quality of the novice NP that is produced and the fact that many programs have given up control of this astounds me. We can follow the money on that one and it is fairly clear why programs are doing this in increasing numbers.

That being said, you also have quite a ways to go and haven't really gotten into the major part of your advanced practice education, which in my opinion, begins with the start of clinical rotations and the associated didactics. It might get better for you shortly.

[Cococure]

In my opinion is is a central part of the current debate: APN programs which have stopped securing clinical sites, in simple terms, are telling every student that they care more about money than they do about their education. The quality of the clinical portion of NP education is vital to the overall quality of the novice NP that is produced and the fact that many programs have given up control of this astounds me. We can follow the money on that one and it is fairly clear why programs are doing this in increasing numbers.

Yes you are correct I have quite a ways to go and i hear many complaints from students that are much farther along and those that have recently graduated and most went to their local universities. I couldn't agree more it is very disheartening when a student has to find their own clinical sites. When I interviewed at this particular school that was one of my my questions and they stated that they assisted students in securing sites. Well, I now know that they meant I found the site and they do the contract. In my opinion all schools should have preceptors that meet the schools standards. One school in my area that had established clinicals is Emory and I could not afford the $80k for their NP program.

Thanks I do hope it get better and this is just another bump in the road. It is what it is I guess

[Corey Narry, MSN, RN, NP]

That being said, you also have quite a ways to go and haven't really gotten into the major part of your advanced practice education, which in my opinion, begins with the start of clinical rotations and the associated didactics. It might get better for you shortly.

I feel the same way in that clinical rotations is where the important learning happens.

Having said that, the way NP clinical rotations are structured needs a lot of rethinking. One, I think we need to move away from the current "apprenticeship" model in clinical rotations where NP's pretty much mirror the role of their clinical preceptor and merely watch and learn how "they do things" without necessarily ensuring that the way things are done conforms to standards of practice based on the strength of evidence in research.

Two, this model promotes the failed policy of finding your own preceptor some schools try to sell under the guise that graduate students should be mature learners who must already possess the skills to network, know their goals for NP education, and have a job lined up after they are done. This creates an unfair advantage to experienced nurses with pre-existing connections vs younger, fresh out of BSN students who could learn fast but are new to healthcare.

Three, we don't learn by picking up two days of clinical rotations a week eventually collecting enough hours to meet the program mandated semester hours for the rotation. Consistency is sometimes the key, and at least in the acute care setting, we get better by being in the clinical setting longer and in closer succession. This may mean NP programs can no longer be "nice" and allow students to work their RN jobs while in school.

The current approaches contribute to the inconsistencies in training and educational holes in the final product produced in the NP's who graduate in our programs. I propose standardizing clinical rotation only in settings that have had long tradition of teaching students and follow a structured exposure to clinical scenarios covering all the important points in the didactic curriculum with adherence to current standards of practice. Unfortunately, these types of practices are only likely to be found in settings that have affiliation with academic institutions.

[Jules A, MSN]

Two, this model promotes the failed policy of finding your own preceptor some schools try to sell under the guise that graduate students should be mature learners who must already possess the skills to network, know their goals for NP education, and have a job lined up after they are done. This creates an unfair advantage to experienced nurses with pre-existing connections vs younger, fresh out of BSN students who could learn fast but are new to healthcare.

.

As usual you make excellent points but I'm not sold that we should be concerned about any "unfair advantage". Don't these sound like traits that would be beneficial to a new grad NP especially in light of how brief and inconsistent the current state of NP education is at this time?

The young BSNs would likely be well served by taking a few years to get to the point where they also have this advantage. I know for the schools it is about admitting the most students to make the most money however as with the ability to work and go to school, although sounds delightfully inclusive and politically correct, I don't think an acceptable reason to lower the bar and that is exactly what this is in my opinion.

Working or not being able to work while in NP school might be an excellent topic for a new thread. 5 straight days of clinical would provide a more comprehensive education. As a business minded adult the thought of not being able to work would have forced me to think long and hard about starting NP school which might be a refreshing change as compared to today when anyone writing the check and filling out the application gets accepted. I continue to be alarmed by the number of people who are actually in a NP program and then post here indicating they are clueless as to what the program entails, don't know any NPs, aren't aware of the areas they will be certified to practice in and don't even know what salary they might be receiving. Ahhhh but make no mistake they are aware it is likely to be M-F, lol. Again raising the bar is not a bad thing in my opinion.

[JustKeepDriving]

I feel the same way in that clinical rotations is where the important learning happens.

Having said that, the way NP clinical rotations are structured needs a lot of rethinking. One, I think we need to move away from the current "apprenticeship" model in clinical rotations where NP's pretty much mirror the role of their clinical preceptor and merely watch and learn how "they do things" without necessarily ensuring that the way things are done conforms to standards of practice based on the strength of evidence in research.

Two, this model promotes the failed policy of finding your own preceptor some schools try to sell under the guise that graduate students should be mature learners who must already possess the skills to network, know their goals for NP education, and have a job lined up after they are done. This creates an unfair advantage to experienced nurses with pre-existing connections vs younger, fresh out of BSN students who could learn fast but are new to healthcare.

Clinical rotations can vary so, so much and I agree that the apprenticeship model needs changed. My program placed students and even there - it was a lot of variation (and we still had to interview at our placement sites which created differences in student outcomes based on how much experience the student had in the specialty). So the students that entered without psychiatric experience or those who just had limited working nursing experience in general had less diverse placements - they ended up doing only outpatient, only community heath, only crisis houses etc - working one - on- one with the same preceptor for the entire two years while those who had a lot of in-specialty experience were picked up by the teaching hospitals for clinical rotations.

I understand to that a lot of it is safety on the side of the site - like in my last semester my site tried to expand to include students with more diversity after the school pushed the teaching hospital site to take on students with the DNP focus over the ones with a MSN focus, stating it would allow people with less nursing experience to have more competence - but man the lack of basic psych nursing experience created some hazards (like students trying to transport patients expressing SI/GD/DTO from the non-LPS facility to the ED down the street alone with the patient absconding), students getting their personal belongings stolen and then trying to offer the patient money to get those belongings back instead of reporting the theft (and then meeting patients alone without telling preceptor staff), playing around on their cell phones (not looking up drugs, not reading articles related to the cases being assessed - but straight up playing on facebook) during intake assessments and students being unable to handle pimping questions/criticisms during case presentations and arguing with the MD attendings.

Which is just frustrating as the school totally misrepresented the DNP students to the clinical site. So I can completely understand why some preceptors/sites really just don't want to take on NP students/have that school-site relationship (they have no say in admissions and even with requiring interviews/references for clinical site applicants, the schools will sometimes vouch for the merits of the individual based on the school's agenda - like pushing for DNPs to get the better placements to promote that program - and not the individual's competence).

[Jules A, MSN]

I understand to that a lot of it is safety on the side of the site - like in my last semester my site tried to expand to include students with more diversity after the school pushed the teaching hospital site to take on students with the DNP focus over the ones with a MSN focus, stating it would allow people with less nursing experience to have more competence - but man the lack of basic psych nursing experience created some hazards (like students trying to transport patients expressing SI/GD/DTO from the non-LPS facility to the ED down the street alone with the patient absconding), students getting their personal belongings stolen and then trying to offer the patient money to get those belongings back instead of reporting the theft (and then meeting patients alone without telling preceptor staff), playing around on their cell phones (not looking up drugs, not reading articles related to the cases being assessed - but straight up playing on facebook) during intake assessments and students being unable to handle pimping questions/criticisms during case presentations and arguing with the MD attendings.

The nuances can be the kiss of death and without that experience no idea what they don't know and yet often rather smug about their innate abilities.

Inappropriate self disclosure is probably my biggest complaint but one of the cherries on top was a colleague's student who didn't have the insight to know a knee length flowy dress sans nylons (or heck even with nylons) and strappy flats are totally inappropriate on a locked unit with known sex offenders who also happen to be psychotic. That was the first and last student my friend precepted from that school.

[shibaowner, MSN, RN, NP]

Clinical rotations can vary so, so much and I agree that the apprenticeship model needs changed. My program placed students and even there - it was a lot of variation (and we still had to interview at our placement sites which created differences in student outcomes based on how much experience the student had in the specialty). So the students that entered without psychiatric experience or those who just had limited working nursing experience in general had less diverse placements - they ended up doing only outpatient, only community heath, only crisis houses etc - working one - on- one with the same preceptor for the entire two years while those who had a lot of in-specialty experience were picked up by the teaching hospitals for clinical rotations.

I understand to that a lot of it is safety on the side of the site - like in my last semester my site tried to expand to include students with more diversity after the school pushed the teaching hospital site to take on students with the DNP focus over the ones with a MSN focus, stating it would allow people with less nursing experience to have more competence - but man the lack of basic psych nursing experience created some hazards (like students trying to transport patients expressing SI/GD/DTO from the non-LPS facility to the ED down the street alone with the patient absconding), students getting their personal belongings stolen and then trying to offer the patient money to get those belongings back instead of reporting the theft (and then meeting patients alone without telling preceptor staff), playing around on their cell phones (not looking up drugs, not reading articles related to the cases being assessed - but straight up playing on facebook) during intake assessments and students being unable to handle pimping questions/criticisms during case presentations and arguing with the MD attendings.

Which is just frustrating as the school totally misrepresented the DNP students to the clinical site. So I can completely understand why some preceptors/sites really just don't want to take on NP students/have that school-site relationship (they have no say in admissions and even with requiring interviews/references for clinical site applicants, the schools will sometimes vouch for the merits of the individual based on the school's agenda - like pushing for DNPs to get the better placements to promote that program - and not the individual's competence).

It seems to me that the problems you are describing could be rectified by 1) the precepting organization having clear rules and regulations in place for transporting patients, storing personal effects, etc., and 2) the school being very clear on proper behavior and dress by students.

In addition, the precepting organization should document these bad behaviors and have a no-nonsense meeting with the nursing school to state these are unacceptable behaviors and students that engage in them will be kicked out of the clinical for good. If the behaviors continue, tell the school that preceptorships for that school have been discontinued. Problem solved.

I don't see how this has anything to do with MSN vs DNP students. During the course of my ABSN and MSN studies, I had 3 psych rotations and 3 additional clinical rotations that had a lot of psych issues in the patient population. The students from my school never engaged in this type of behavior in the BSN or MSN programs because our school gave us very stern warning about this and indicated this was grounds for failing clinical, and possibly, expulsion. This was Hopkins, so they are also highly selective of which students they let in.

[Corey Narry, MSN, RN, NP]

As usual you make excellent points but I'm not sold that we should be concerned about any "unfair advantage". Don't these sound like traits that would be beneficial to a new grad NP especially in light of how brief and inconsistent the current state of NP education is at this time?

The young BSNs would likely be well served by taking a few years to get to the point where they also have this advantage. I know for the schools it is about admitting the most students to make the most money however as with the ability to work and go to school, although sounds delightfully inclusive and politically correct, I don't think an acceptable reason to lower the bar and that is exactly what this is in my opinion.

Working or not being able to work while in NP school might be an excellent topic for a new thread. 5 straight days of clinical would provide a more comprehensive education. As a business minded adult the thought of not being able to work would have forced me to think long and hard about starting NP school which might be a refreshing change as compared to today when anyone writing the check and filling out the application gets accepted. I continue to be alarmed by the number of people who are actually in a NP program and then post here indicating they are clueless as to what the program entails, don't know any NPs, aren't aware of the areas they will be certified to practice in and don't even know what salary they might be receiving. Ahhhh but make no mistake they are aware it is likely to be M-F, lol. Again raising the bar is not a bad thing in my opinion.

We have to circle back to the question of what advanced practice nursing education really is. You an I came from the traditional model of experienced nurses in our respective fields of specialization who went on to pursue graduate education in the same specialty to become NP's. That seemed ideal and for some years was the defense NP's use to justify the inconsistencies in education and limited clinical hours. It made sense for us, we were just filling in holes in our knowledge in terms of how we would transition as providers in a milieu we were already familiar with.

That's not the case with advanced practice education now. We have various routes and a diverse student body representing a spectrum of new inexperienced nurses and those who have been in practice so long that it's hard to undo what they already know (good or bad). However, the educational approaches has not kept up with this reality...didactics and clinical rotations are still being offered in a manner that seems to assume a pre-existing level of expertise that new nurses would never have. That's our problem with DE programs - we can't wrap our minds around being able to produce competent NP's without the pre-existing knowledge we brought to the program.

That's why I'm proposing uniformity and no assumption whatsoever of any pre-existing knowledge prior to entering the NP program. And, yes, I was one of those students who took the NP route because of the ability to work at the same time while attending the program. Again, it was along the lines of me being experienced, knowing my way around Critical Care as a nurse, and being able to figure out what is useful in my education and what is pure fluff that I can easily ignore.