The National Task Force (NTF) on Quality Nurse Practitioner Education released the draft version of the Criteria for Evaluation of Nurse Practitioner Programs 6th edition with a goal of final release in December 2021.
The National League for Nursing (NLN) stands with our colleagues in the National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA) in opposition to the proposed clinical hours requirements outlined in the 6th edition. While the NLN CNEA is appropriately listed as a National Task Force Organizational Member, it did not vote in favor of the proposed increase in clinical hours. Although the NTF has indicated it will not accept written commentary, the NLN is documenting its concerns to support its organizational beliefs and those of schools that have expressed concerns to the League.
The revisions proposed by the NTF place several graduate nursing programs at risk of closing; move the goal of graduate nursing education out of the reach of many promising nurse practitioners; and limit the potential access of the public to health care services these nurse practitioners might provide. These revisions occur during a global pandemic when health care systems are in crisis, nurses are in great demand, and inequitable access to health care has never been more visible.
The NLN supports innovation in nursing education at all levels that lead to better prepared graduates for an ever-changing world. Innovation can occur in small tests of change, much like what the Institute for Healthcare Improvement has undertaken for decades. Those innovations that are proven to be effective are adopted into practice based on sufficient evidence to support a national or global practice. The proposed changes lack cited, documented evidence.
Most specifically, no evidence is cited to support the change from 500 to 1,000 direct care clinical hours. Nurse practitioner outcomes have been documented to equal or excel those of physician peers under the current educational structure, which relies on 500 direct care clinical hours.
Even though no statement was made in the prior standards about simulation, the proposed document identifies that a maximum of 250 hours may be completed using high fidelity scenarios depicting direct care clinical experiential practice, although time developing skills is not to be included. Once again, no data/cited evidence is included to support these recommendations.
The NTF also calls for a faculty ratio of one full time equivalent to 12 – 24 nurse practitioner students (didactic and clinical courses) and a faculty to student ratio not to exceed 1:6 to 1:8 for oversight of clinical learning. The additional requirements for faculty student ratios and direct care practice hours have a direct and immediate effect on the cost to deliver programs, while lacking the support of compelling evidence.
As noted in the NTF report, currently the lack of evidence prevents measuring role competency, which is also a significant concern regarding the American Association of Colleges of Nursing’s The Essentials: Core Competencies for Professional Nursing Education (2021). Imposing costly requirements of additional time, faculty, and resources in response to an inability to evaluate competency is incompatible with the core values of professional nursing practice. The NTF document states, “the consensus was that NP education has not developed CBE and assessment processes sufficiently to support the elimination of a minimum number of direct care clinical hours for quality education” (pg. 4). In addition to adding the increased burden of cost for academic organizations and students, doubling the required minimal direct clinical care hours and imposing ratios will delay entry into this advanced practice role and increase the need for additional faculty, clinical sites, and preceptors at a time of significant shortages of all of those elements.
These unintended consequences undermine the goal of increasing access to a diverse population in advanced practice nursing. The latest data (US Census, 2016), which reference nurse practitioners and nurse midwives as one category, indicate that 3.4% were Latino/a, 6.6% were Black, 5.8% were Asian, 0.2% were Native American, and 1.2% were Multi-ethnic. Only 5.7% were male. The diversity within faculty (full-time) was equally underrepresented: 3.7% were Latino/a, 9.4% were Black, 2.7% were Asian, 0.4% were Native American, and 0.6% identified as two or more. Male full-time nurse educators totaled 6%. The well-documented barriers to increasing advanced practice nurse diversity are a lack of diverse faculty, cost, and access to programs. Once again, the NTF document calls for programs to view activities through the lens of diversity, equity, inclusion, and social determinants of education, yet the proposed NTF document stifles the ability to achieve these goals.
The NLN commends the NTF task force for their ongoing efforts and support of competency-based education. In order to establish the evidence for these proposed changes, the NLN proposes the development of rigorous research to support evaluation of competency instead of adding an unwarranted burden on our current health care system and adverse impact on an already overwhelmed workforce. This research must include, at a minimum, the following factors:
• The relationship of a minimum number of clinical hours to expected role competencies as identified in the Essentials (Advanced Level)
• The workforce projections of demands for nurse practitioners by clinical and role specialties
• The economic impact on prospective students and families, especially those of diverse backgrounds who would reflect the populations they would serve
• The faculty population available to accommodate changes
• The validity of limiting simulated experiences, including artificial intelligence, to a specified number of hours
• The impact on rural, master’s level, and liberal arts-based colleges in serving their communities
• The projected impact on care in communities where nurse practitioner graduate programs serve as the primary source of health care providers
• Proposed changes must be made in context of supporting diversity, inclusion, equity, and social determinants of education.
Competency must be measured by valid, reliable, and nationally standardized instruments. Without this clarification, the possibility for inequities exists at a time when concerted efforts are being made to reduce such inequities.
Before the NTF votes, currently scheduled for this fall, nursing still has the opportunity to address the criteria for Nurse Practitioner Programs. These criteria to assess quality must address the needs of our diverse population and be based on the outcomes of educational research and patient care. Both voice and action are required to move toward a data driven approach to competency-based criteria.
The NLN invites our colleagues to join us in a call for action to support an evidence-based approach for the criteria for evaluation of nurse practitioner programs.
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