Hot Topics in Nurse Practitioner Clinical Education: An Evidenced-Based Review

Sunday, 27 July 2014

Julie A. Stanik-Hutt, PhD, CRNP, CNS, FAAN
Department of Acute and Chronic Care, Johns Hopkins University, School of Nursing, Baltimore, MD
Benita Walton-Moss, PhD, FNP-BC
Department of Community and Public Health, Johns Hopkins University, School of Nursing, Baltimore, MD

Clinical competence is the core of NP practice. High quality clinical education is crucial to the development of NP competence. The purpose of this presentation is to discuss controversial issues related to clinical preparation of NPs. Evidence on the four issues will be presented and discussed, including: registered nurse (RN) experience prior to NP preparation, requirements for a minimum number of hours of student clinical practicum, use of simulation to supplement or replace clinical practica, and incorporation of interprofessional education (IPE) in order to produce graduates who are ready to create interprofessional practice.  It is time for NP educators to consider and apply available evidence to improve student outcomes and change outdated requirements.

RN experience. The first NPs were experienced nurses who completed additional formal post graduate education and supervised clinical practice before embarking on their advanced practice role. Initially, admission to NP programs required at least 2 years of professional nursing experience. However several years ago, NP programs began offering admission to highly qualified students immediately after graduating from their initial nursing education or offered them admission to both the baccalaureate (BSN) and the master’s (MSN) program simultaneously so that students could matriculate directly from the BSN into the MSN.  In some schools however, it has become the norm with up to ½ of NP students entering the program directly from their BSN program without practicing a day as a RN. Acute care NP programs are the notable exception to this trend. Advocates for so called ‘direct entry’ from the BSN to the MSN argue that the requirement for RN experience is an outdated notion and that we need to encourage students to enter graduate school early or they will never pursue same. They also assert that those without RN experience are just as successful in graduate school and on certification examinations after graduating, that they haven’t picked up bad habits from practice, and that their previous life experiences also support their preparation for practice as an NP. Opponents argue that those without RN experience are weak clinically, have difficulty internalizing advanced skills, and do not identify themselves as a nurse. They also cite lack the clinical judgment and confidence that is forged in practice. What is the evidence for or against requiring professional nursing experience before matriculation in an NP program?

Clinical hours. Accreditors require NP programs in the US to provide students with a specific minimum number of hours of supervised direct patient care during which they can practice clinical skills.  Students preparing for practice with a single age group population (e.g. pediatric NPs who care only for children) must complete at least 500 hours of supervised clinical practicum.  The 500 hour ‘rule’ applies to neonatal, pediatric primary care, adult primary care, adult acute care, and women’s health NP students. Students preparing to provide care across age groups (e.g. Family NPs who care for adults, pregnant women, and children) are expected to complete more than 500 hours of supervised clinical practicum. The rational for requiring 500 hours, rather than some other number has been the focus of much discussion at recent meetings of NP faculty. The number of clinical practice hours vary among schools, and can range from 500 to close to 1000 for a single age group population. Some students meet performance expectations at less than 500 hours and others are not able to perform as expected after many more hours. What is the source of the 500 hour ‘rule’ and should mastery of clinical competencies rather than completion of clock hours measure student readiness for practice.

Clinical simulation. Simulation is a commonly used educational strategy in nursing education and practice. It provides learners an opportunity to apply critical thinking and clinical skills to complex situations without exposing real patients to the risk associated with an inexperienced provider.  In BSN education, simulation is replacing as well as supplementing student clinical experiences. Medical students spend many hours developing skills by working with highly trained standardized patients and using high fidelity patient simulators in multimillion dollar simulation centers. Acute Care NP students often complete skill and decision making in simulation labs. NP accreditation criteria do not allow simulation to replace required practice time. However, there is growing interest in greater use of simulation to supplement NP preparation.  This strategy has been suggested during a time when it is increasingly difficult to secure high quality precepted clinical placements for NP students. Some programs are considering the use of objective structured clinical examinations (OSCE) to assess student competency. What is the evidence regarding the use of educational as well as evaluative simulation in preparation of NPs? What can it offer? And how should it be used and evaluated?

Interprofessional education. Interprofessional practice (IPP), characterized by mutual respect, teamwork, communication and collaboration, is widely acknowledged as a key approach to produce patient centered care, reduce medical errors and improve healthcare outcomes. But how can we create IPP when students continue to study and learn in educational silos? Schools that prepare health care professionals are being pushed to develop and increase the use of IPE. IPE requires that students from at least two different health professions learn together during their pre-licensure professional education. NP faculty struggle to form alliances with faculty from other health care professions and to create meaningful opportunities to integrate IPE into sometimes rigid curricula. What can we learn from research on IPE? What are the best practices and strategies for implementing IPE that can help NP faculty successfully prepared graduates for IPP?