Advanced Education? TMA Pushes State for Standards in APRN Clinical Training
For about five years, Coppell pediatrician Anne Georgulas, MD, has served as a preceptor overseeing advanced practice registered nurse (APRN) candidates doing hands-on patient care training. Over the past year or so, she’s noticed a trend among the candidates who study with her: When it comes to finding a place to do those clinical rotations, they’re on their own.
The trend has at least one leading organization that oversees APRN education looking at its own standards.
Previously, prospective APRNs Dr. Georgulas mentored arranged about half of their clinical training hours. Programs typically help with the rest. But in the past 12 to 15 months, every APRN candidate she’s welcomed has said they must line up all of their rotations. Dr. Georgulas says those APRN students are of varying quality.
“Some of them are excellent,” she said, “and some of them are not very prepared for their rotations.”
She also has concerns about the quality of education APRN students get when left to search clinical preceptors on their own. For example, Dr. Georgulas says one of the APRN candidates who studied with her had done a previous rotation in a holistic medicine-focused practice. That candidate seemed accepting of some treatments that Dr. Georgulas says don’t have any scientific studies to back up their efficacy.
“I’d say, ‘I don’t have any proof that any of that stuff works.’ Now, I don’t mind people using [the treatment] as an adjunct if it’s not going to hurt them,” Dr. Georgulas said. “But she was getting fairly brainwashed to think that this was somehow well-studied medicine. That’s obviously not safe for the public at large.”
Dr. Georgulas says the students approach her from both online and brick-and-mortar APRN programs. Her experience reflects an issue that has been on the Texas Medical Association’s radar for some time, TMA lobbyist Dan Finch says: Many online-only APRN courses have candidates arrange their own clinical experiences.
TMA has encouraged the Texas Higher Education Coordinating Board to study advance practice education in online masters-level programs. With another state legislative session just a few months away, TMA remains vigilant of efforts by APRNs and other professions to expand their scope of practice beyond what their education, skills, and training safely permit. That’s something TMA has consistently opposed.
“The question is, if [APRN] candidates are arranging their own clinical experience with little guidance as to the type of experience that they should be receiving, the quality of that experience, and the evaluation of the learning involved in that experience, is this actually adding value to the educational program?” Mr. Finch said. “And do we need to look at ways of standardizing this so that we can ensure that folks who are in these programs are actually being trained to the degree that their certification says they are? These are important questions for patient care.”
Progress could be on the way with 2019 changes to the standards used by at least one of the APRN program accreditation bodies.
You don’t know what you’ll get
Two national organizations accredit nurse practitioner programs: The Commission on Collegiate Nursing Education (CCNE) and the Accreditation Commission for Education in Nursing (ACEN). Current standards for both organizations say preceptors must be “academically and experientially qualified” to assist students, and APRN programs must “clearly communicat[e]” and “clearly defin[e]” preceptors’ roles.
According to the 2016 Criteria for Evaluation of Nurse Practitioner Programs’ guidelines published by the National Task Force on Quality Nurse Practitioner Education (NTF), programs must ensure nurse practitioner (NP) candidates receive at least 500 “supervised direct patient care clinical hours” in their training.
NTF criteria also require enough faculty “to ensure quality clinical experiences” as well as “adequate supervision and evaluation.” Each program must show “evidence of contractual agreements with agencies or individuals used for students’ clinical experiences” and extensive details about those facilities and the clinical preceptors.
But there are questions as to how closely some APRN programs follow those criteria.
Dallas family physician Chrisette Dharma, MD, runs Clinical Training Network, which helps arrange clinical experiences for Dallas-area NP students. Dr. Dharma founded the organization specifically because of problems NP candidates have when they must cold-call physicians’ offices to arrange their clinical experiences.
“They send these letters and resumes just — I want to say it nicely — begging to get rotations. And [the letters] sit on desks of office managers, and when the physician might get a message or an email, it’s at the end of the day when you have 50 charts, another 40 messages. So typically, it’s very difficult” for students to secure clinical training unless they rotated or worked with a physician as a registered nurse, she said.
Because nurse practitioner programs have such a wide range of entry qualifications, physicians who agree to be preceptors don’t know what they’re getting in an NP student, Dr. Dharma says. Clinical Training Network helps match preceptor physicians to talented students by interviewing students ahead of time.
Typically, she says, preceptors are expected to approve a log of the clinical hours students work. Preceptors don’t grade students, Dr. Dharma says, but provide evaluative input that school faculty use as part of their grading.
School standards for APRN programs aren’t uniform, Dr. Dharma says.
“They’re real variable, honestly. There is no standardization across the board. Sometimes it’s three, 10-week rotations. Sometimes it’s four, six- to eight-week rotations. There’s no rhyme or logic behind it, and they don’t run on semesters. So one student can be starting at the end of July [for] one rotation; the next one can be starting the middle of July.”
When Dr. Georgulas hears APRN candidates’ accounts of clinical training at other rotation sites, it makes her question the quality of those experiences.
“I’ve heard from some of the [candidates] that at one clinic that they only got to see a certain-age patient or, ‘We only did well [checks] at this one clinic. We never did any sick visits.’ One person said, ‘We only did teenage wells at one of the clinics.’ Well, that’s not a very broad experience in pediatrics if they’re doing a family practice nurse practitioner [program] and their only experience with kids is teenagers for well exams. They have lost a lot of the actual experience of pediatrics,” she said.
Dr. Georgulas recently hosted APRN candidates from the University of Texas at Arlington who arranged their own preceptorships. She says she didn’t receive any guidelines on how to shape their clinical experience, such as what cases they should see, how many well-child appointments they should have, or any requirements related to correct diagnoses.
UT Arlington’s College of Nursing confirmed in an interview with Texas Medicine that some of its nurse practitioner candidates find their own preceptors.
Judy Leflore, PhD, associate dean for simulation and technology, says UT Arlington follows NTF standards.
“In the past, our school has tried to provide preceptors for all of our students, but that is just not a possibility,” Dr. Leflore said. “We have a database with [preceptors], and we make those preceptors that have agreed to take students, have been vetted, we provide that opportunity for our students to go with those preceptors. However, if they have someone they want to go with, or the preceptor we provide is out of their local area and they’re going to have to drive too far … then they can find their own preceptors. And most of the time, they do find their own preceptors.”
After that, Dr. Leflore says students give preceptors a packet that includes an agreement to accept the student and provide the school with information about the physician’s licensure. A team of clinical coordinators at the school then validates the information.
The packet provides an overview of the school’s expectations for the student. Specific guidelines or objectives are in the student’s syllabus, which he or she is supposed to provide to the preceptor, Dr. Leflore says.
UT Arlington asks preceptors to evaluate students “within the last week or shortly after the clinical experience is over with,” she said, but sometimes the program requests an evaluation in the middle of the rotation as well. APRN students evaluate their preceptors at the end of the clinical experience. But beyond checking the physician’s licensure and board certification, the school doesn’t evaluate preceptors for skill.
“Their ability to practice with an unencumbered license should speak to their ability to perform whatever area of medicine that they are working in,” Dr. LeFlore said.
She says it would be ideal to have a larger database of preceptors so students wouldn’t have to find their own, for example if nursing schools were associated with a hospital the way medical schools are. “But nursing schools are not typically associated with a hospital system like that. So I’m sure there are things that could be done that would be better. But again at this particular point, the way we do things seems to be producing quality nurse practitioners,” she said.
The University of Texas at Austin School of Nursing assigns preceptors to its students, says Gayle Timmerman, PhD, the school’s associate dean for academic affairs. Sometimes students request a mentor with whom they’ve had a preexisting relationship, for instance, and the school evaluates the request.
“If it is a good match and if the preceptor’s qualified and all of that looks good and lines up, then the student can be placed there,” Dr. Timmerman said. “But sometimes students don’t always know what they need at what time, and so sometimes we’ll have them placed elsewhere. It kind of depends on the course [and] the course objectives. But our program does not have students go out and find preceptors.”
The school’s preceptor pool comes together through networking and relationship-building, she says, and finding them is “a pretty time-intensive process.” UT faculty visit both preceptors and students in person, sometimes giving new preceptors feedback and mentoring.
State regulating boards don’t have control over the variance in APRN program operations and requirements.
Jolene Zych, APRN consultant at the Texas Board of Nursing, says the board doesn’t have statutory authority to review and approve APRN education programs in the state the way it has authority over registered nurse and licensed vocational nurse programs. “The Higher Education Coordinating Board, they have authority to approve the program to operate in Texas. But in terms of setting specific education standards, they don’t have that authority, either,” she said. “It is all through the national accreditation organizations.”
The potential for clearer NP program standards came in August, when CCNE updated its accreditation requirements for 2019. The new standards say schools will be “responsible for ensuring adequate physical resources and clinical sites.” Those sites must be “sufficient, appropriate, and available to achieve the program’s missions, goals, and expected outcomes.” The current standards, set in 2013, didn’t have that language.
Jennifer Butlin, executive director of CCNE, says it already held programs responsible for ensuring that students get the clinical practice experience they need, and that qualified individuals serve as preceptors. Although the new standards still don’t address “whether the students are allowed or are encouraged or told to find them, at the end of the day, the program has to provide assistance and support to students,” she said, noting that students who can’t participate in clinicals can’t complete the program.
“I do believe that we have better clarity in the revised standards,” she said. “But it was never acceptable to CCNE, even under the 2013 standards, if a program were to say, ‘Well, that’s your problem. You didn’t find the site, that’s your problem, and we don’t have to do anything to support you.’”
Also starting in 2019, CCNE standards say programs must use a “defined process” to determine availability, accessibility, and adequacy of its resources, which includes clinical sites. To view the new standards, visit tma.tips/ccne2019.
TMA is monitoring the lack of regulation over APRN education. Mr. Finch, the TMA lobbyist, says APRN candidates should be held to the same educational standards as physicians in training.
“Medical school clinical rotations and residency training are intensely organized to provide a clear, definable, and objective set of experiences that educate the medical student or the resident physician,” he said. “There are clear goals, there are clear experiences that they have to have, and there is a profound series of evaluations that are performed on both the candidate and the clinical instructor. And that should be present in advanced practice nurse training.”
In Dr. Dharma’s experience, some nurse practitioner programs “are really on top of it and really watch out for their students,” such as those who send their clinical coordinators to her office to discuss student experiences. She says the lack of standardization, not the quality of the programs, is the problem.
“It’s really unfair [students are] expected to go and get rotations when they’re paying money to have the education. And for them to do cold calls, I think that’s ridiculous. It’s unheard of, and we just sit and watch it. I think someone has to do something.”
Delegating duties to nonphysician practitioners, such as an advanced practice registered nurse (APRN), can be a great enhancement for your practice. But make sure you know the law — and the ethical and other considerations for doing so. TMA’s whitepaper, “Delegation of Duties by a Physician to a Nonphysician,” is free for TMA members. It covers the law, ethics, standing orders, prescriptive authority, and other factors when delegating to APRNs, medical assistants, physical therapists, pharmacists, and midwives.
Download the whitepaper at www.texmed.org/Delegation.