Time for the 4th P in APRN Education: Physical Assessment, Pathophysiology, Pharmacology, and Procedures

Purpose: Primary care nurse practitioners perform advanced diagnostic and procedures skills (ADPS) in various settings, including acute care, primary care, specialties, and urgent care. It is unclear how they are being educated and trained to perform such procedures during their educational preparation relative to the scope and depth of the skills and procedures expected of them upon entry into practice. A systematic review of the literature was conducted to answer the following question: Among primary care nurse practitioners, does current educational program curriculum align with the performance of advanced procedures and skills in the clinical setting with competent, independent skill level?

Methods: The databases PubMed, Cochrane, Scopus, CINAHL, and Embase were searched between inception and 2018 using the search terms “advanced practice nursing, clinical competence, diagnostic techniques or procedures, and primary health care”. Following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines, nine articles were included in the synthesis. The use of a web-based software program, Covidence, assisted in maintaining academic rigor and adherence to PRISMA guidelines.

Results: Nine articles were selected for inclusion in the systematic review using the Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Guide. All studies were nonexperimental with reasonably consistent results and recommendations. Due to the abundance of descriptive data and limited availability of statistical analysis, a meta-analysis could not be performed with the nine chosen articles. Throughout the literature, two common themes and corresponding characteristics were identified. The first theme involved employment of the primary care nurse practitioner and the self-reported frequency of ADPS in practice, actual frequency of ADPS according to billing claims, perception of the importance of ADPS in practice, and perception of the need for additional ADPS training after graduation. The second identified theme refers to education of the primary care nurse practitioner and the perception of nursing faculty and a professional state level organization regarding the importance to teach ADPS during initial education, as well as reports of ADPS taught in primary care nurse practitioner education programs.

Conclusion: There is scant research regarding nurse practitioner educational preparation of skills and procedures. Study findings indicate that advanced practice nursing programs are not teaching all the procedures deemed important for entry into nurse practitioner practice. Educational programs should promote improved congruence between the skills and procedures taught in program curricula and those used in clinical practice. Nursing leaders in academic settings have opportunity to influence this change across both academic and practice settings.