Preparing The Next Generation of Nurse Practitioners


 
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By Karen A. Van Leuven, PhD, FNP

Issues Affecting NP Preparation

To meet the health care needs of the nation, a growing, vibrant NP workforce is needed. The Affordable Care Act, although contested on numerous occasions, is expected to provide health care for an additional 34 million people who are currently lacking coverage. An influx of NPs is needed to meet this growing need. The Institute of Medicine Future of Nursing report has called for eliminating scope of practice restrictions on NPs in all states to increase access to care and provide needed primary care services. This will allow NPs to provide a broader range of services without restrictions on practice. However, the challenge of having an adequate supply of NPs remains.

Currently, all NP educational programs are delivered at the graduate level. Curricula focus on the management of health and illness, the NP-patient relationship, teaching and coaching of patients, managing and negotiating health care delivery systems, cultural sensitivity, and quality of care. To create a qualified practitioner able to meet the health needs of a diverse group of patients, all NP programs require a dynamic blend of classroom and clinical education.

NP educational programs require a sufficient network of NP faculty and clinical sites for students. Unfortunately, recruiting nurse faculty can be quite difficult. In 2011, US nursing schools turned away 75,587 qualified applicants from baccalaureate and graduate programs because of an inadequate supply of faculty, clinical or class sites, preceptors, or financial resources required to accommodate additional students. Two thirds of schools that turned away qualified applicants cited faculty shortage as rationale for not accepting students. Positions requiring doctoral preparation were the most difficult to fill (32.9%). Inability to compete with salaries offered in the practice arena (27.6%) was the second most likely rationale for faculty vacancy positions.

To prepare NPs to meet the primary care needs of the populace, NP faculty must be able to present evidence-based knowledge on health care conditions and simultaneously translate that knowledge into clinical practice. Algorithms for care are not sufficient. Care must be individualized into a format that is acceptable to each client in order for patients to succeed. This requires more than contemporary knowledge of a health condition; understanding patient and health system context is essential. As such, NP programs are best served by filling NP faculty positions with practicing NPs. However, the demands of both roles are frequently at odds.

NP Faculty Dilemmas

National certification requires a minimum of 1,000 hours of practice over a 5-year period, focused on the population for which the NP is certified to provide care. This requirement can be met by practicing 4 hours per week. However, limiting practice to this minimal requirement makes it difficult to follow patients or maintain a primary care practice.

Taking on a faculty role necessitates the analysis of personal goals. Limiting practice time facilitates transition into the faculty role. However, NPs who choose to embrace the clinical role and take on a faculty position often face a difficult balancing act. NPs who continue to work half-time or more in a clinical role are able to maintain a primary care practice and have much to offer academia. Real-world experience is a gift to students that cannot be underestimated. Clinical practice changes rapidly; therefore, continued immersion in the clinical world allows faculty to present up-to-the-minute practice guidelines and to realistically present the challenges and opportunities inherent in the NP role.

However, clinically practicing NP faculty must often juggle schedules and conflicting demands of each work setting. Clinical schedules require consistent patterns in order to meet ongoing patient needs and allow the NP to follow up on his or her patient roster. In the outpatient setting, the majority of patient appointments are prescheduled, with a portion of time allocated for more urgent visits. NPs who work in acute settings are usually scheduled in advance as well.

The demands of academia are quite different. Classroom teaching schedules typically alter every 10 to 16 weeks, depending on whether the program is on a quarter or semester system. An NP seeing a patient in a clinical setting may ask to see a patient back for follow-up in 3 months but have to change his or her schedule of available days in the interim. This generates work for office staff that must move patient appointments and jeopardizes follow-up. The faculty role also requires committee work. Committee schedules vary as membership is reconstituted each academic year and teaching schedules rotate each term. Therefore, the clinician-educator may struggle to participate.

In addition, faculty task forces meet on an ad hoc basis to address evolving concerns. This places the clinically practicing faculty member in a difficult spot in which he or she must decide whether to forego a faculty obligation or forego a clinical schedule. Regardless of the choice made, the clinician-educator is faced with making an unpleasant decision that may have negative ramifications on 1 side of the equation.

The academic role also involves scholarship and community service. Clinical practice as an NP requires engagement in the literature to determine best practices as well as community service. Recognizing these aspects of NP practice will help energize NPs to enter academia. However, adding additional demands to a stretched workforce will undoubtedly limit the number of NPs who are willing to enter academic ranks.

A part-time position as a faculty member is a potential solution to this dilemma; however, because of the faculty shortage, the NP may quickly be swept into ever-increasing requests for academic work. At the 2012 International Network for Nurse Practitioners Conference in London, American NPs spoke often of concerns around the clinician/faculty position. One American faculty member related a story about applying for a position as a site visitor for NP students. The NP chose this position because he felt it would be a way to explore academia while continuing to focus on clinical practice. However, the interview process quickly wooed the NP into a full-time role.

The administration offered assurances that the teaching schedule would be accommodating to the NP's clinical role. However, after accepting the position, the NP was asked to sign a form acknowledging that the teaching role was the primary job and that work outside the teaching role was subject to dean's approval. Conversations with the dean resulted in the NP being told that clinical work must be limited to no more than 8 hours per week outside the Monday through Friday daytime hours, yet the NP worked in an office practice that was open only during the prohibited times (anonymous, personal communication, August 21, 2012).

Other American NPs who have worked in a faculty role offered similar stories. Discussion largely focused on schools encouraging full-time faculty positions because of high demand for faculty, thereby placing the NP into a position in which he or she must choose between clinical work versus academia. International colleagues did not have similar experiences; the expectation of multiple roles was not an issue.

American NPs felt that a thriving faculty practice might alleviate concerns. Faculty practices at university medical centers offered the most promise. Working for 1 employer in 2 part-time jobs (clinician and educator) appeared to have the least discord, but the majority of NP faculty practices are often limited in scope based on regulatory mandates or part of a larger practice in which NP students may compete with medical students for rotations.

Push and Pull of Faculty Role

NP programs are typically situated within health professions schools that simultaneously offer an entry-level nursing program. These programs require a large number of faculty for classroom and clinical teaching. Students are placed in clinical sites working alongside registered nurses (RNs), but a faculty member is on-site supervising the clinical group. Faculty members working in staff nurse roles are able to stay clinically active by picking up shifts. However, the goal of primary care is to manage patients on an ongoing basis. As a result, NP faculty members face quite different concerns from RN faculty when attempting to work clinically. Entry-level programs tend to be large in order to run students through the mandated rotations. In contrast, NP programs are typically smaller in size. Students are placed in rotations with NPs or physicians serving as preceptors. A faculty member makes planned site visits to ensure the placement is appropriate and that the student is making adequate progress. An NP faculty member may follow a student throughout the entire program. Faculty policy is often dictated by consensus. Because RN level programs tend to be large, policy is often set around the needs of the RN faculty. This may be counter to what is needed by an NP and therefore may serve as a deterrent to NPs entering the faculty role.

Increasingly, NP education programs use a Web-based format. Content is delivered using technology in combination with on-campus visits to assess clinical competency and allow students to directly interact with faculty. Web-based learning eliminates time and distance barriers to higher education; students can learn on their own schedule and in their home environment. This is ideal for students living in remote areas as well as working adults.

However, Web-based learning may be very time-consuming for faculty. Cavanaugh found that teaching online required twice as much time as traditional education programs. Time is spent directly answering student questions, responding to discussion threads, and providing feedback on student performance. Online course work is typically partnered with campus visits that consist of intensive interaction between students and faculty. Interaction may take the form of case studies, observed clinical practice, case presentations, and dialogue about practice along with didactic presentations. The flexibility of this format may appeal to a practicing NP; however, the time required may be more than if he or she teaches in a traditional model.

Triple Status

A unique twist to the NP clinician-educator role occurs when NP faculty members are asked to precept their own students. This may occur as a convenient way to gain access to clinical sites but may be demanded by school programs if a paucity of clinical sites is available. In essence, this puts the NP in 3 roles: clinician, educator, and preceptor. It is unclear whether this triple status is beneficial or merely creates yet another tightrope to navigate.

In the faculty role, the NP must assess students' performance as they advance through the curriculum. Working as a faculty member charged with supervising NP practica involves interaction with preceptors, interaction with the student, and site visits during which the faculty assesses the suitability of the clinical site and the preceptor as well as the student's performance in the role. This assessment is facilitated by the objective position of the faculty member, who is able to observe all aspects of the interactions that occur during the site visit.

In contrast, an NP preceptor continues to see his or her own patients and maintains responsibility for the overall care management of the patients. An NP preceptor permits student accompaniment that can take the form of observation alone, participation in care management, or oversight of care delivered by the student. In the course of this accompaniment, dialogue is exchanged that helps the student understand how best to conduct practice as an NP. Ideally, this interaction involves learning and mentorship. Mentorship involves knowledge transmission but is also relationship based, involving psychosocial support and extended face time. Mentoring also imparts social capital (ie, a student who is mentored acquires some prestige from the relationship with the mentor). If the mentor is widely respected, this association has clout. If the preceptor is not considered an expert or has limited clinical skills, this association can have a negative effect on the students' progression in the role.

Assigning a faculty member to simultaneously teach, evaluate, and mentor while also providing patient care creates unique problems in a curriculum. Students who are placed with faculty preceptors have greater face time and bonding than their fellow students who have other placements. This may be perceived as an unfair advantage for some. In addition, because practicing NP faculty members wear many hats, they may not be lead clinicians in their sites because of the need to divide time between roles. Therefore, the NP faculty member may not have as much social capital as a full-time practicing clinician. This may negatively impact the opportunities the faculty member can offer a student and negatively affect the opinions students form about their own faculty.

NP faculty may easily be caught between roles. When acting as a preceptor for students from other programs, patient flow and schedule can be maintained by placing the student in a more observational role. However, when wearing the clinician, educator, and preceptor hats (all at one time), it can be very difficult to stay on schedule. Students have expectations that their faculty member will answer their questions, fill in information gaps, and teach techniques. Taking over and placing the student in a more observational role may result in voiced negative feedback from students; their expectations are higher because they deem the relationship to be different. As a result, clinician productivity drops. This can have a negative effect on NP and/or clinic earnings, which may result in limiting student placements.

Theoretically, this triple status is a total immersion into the NP role. NP faculty members are immersed in the literature and can translate that knowledge back to the clinical setting. Working with students who require explanation for care management strategies requires constant rethinking of how best to explain care—a skill that is useful with patient management. Being a preceptor for students eliminates the need for site visits because the faculty member can assess progress as he or she works with the student.

However, this theoretical position is difficult to realize. Practicing as an NP and teaching in an NP program already require delicate balancing. The additional role of preceptor places significant burden on the NP. In addition, it blurs the line between roles. University programs reap the benefit of the NP's experience and clinical role, yet clinical sites may not gain. If NP productivity drops because of students expecting more from faculty preceptors, the clinical sites are in essence subsidizing the university. Furthermore, in the event that a student is struggling, the faculty member has no objective third party for student evaluation. Student placements become tied to faculty worksites, which may not be ideal. For example, in order to navigate the complex scheduling of academia and clinical practice, the NP may change his or her clinical position to a site that allows sporadic work. This does not allow the student to follow up on patients and may limit the level of complexity to which the student is exposed. On the other hand, if the NP works with a complex high-acuity population, the site may be overly demanding for students and, therefore, not an ideal learning site.

Salary Concerns

Clinician educators must also analyze the financial ramifications of the dual role. The average salary for a full-time practicing NP in the United States is $95,000. Estimates from salary.com indicate that the average benefit package associated with an NP job is worth an additional $35,698. Benefits include disability, health care, retirement, paid time off, and social security. In contrast, nurse faculty salaries average $64,000 per year, with $69,647 as the average national salary for someone ranked as an associate professor. A comparable benefit package for a faculty member functioning in the associate professor role was valued at $27,999 annually. These data strengthen the assertion that faculty roles may often be overlooked because of higher financial rewards available in the clinical sector. However, with creative scheduling, an NP can simultaneously work in both worlds, often drawing a lesser clinical salary because of a cut in hours but combining the benefits of both worlds. In order to meet the growing demand for NPs in the clinical sector, experienced NPs must be incentivized to take on a faculty role and share their knowledge and expertise. Schools of nursing must also work with faculty to cultivate schedules that allow for dual roles. Failure to consider the importance of this accommodation will leave programs wanting for faculty with real-world experience. Clinician-educators can provide a wealth of knowledge to students and schools and reassure potential preceptors about the caliber of the NP program. In addition, schools must interface with clinical sites in order to place students for their clinical rotations. Current faculty practice facilitates student role development and ensures that faculty members have understanding of the ever-changing foibles of the health care system, including expectations of NPs in the clinical world. University support for dual roles is important. Support may take many forms, including spreading the required teaching load over a 12-month calendar rather than a traditional 9-month academic calendar. This allows the faculty member to lessen her weekly teaching load, thereby freeing up some time for practice. Support may also take the form of funding for clinical practice sites in which the NP can simultaneously teach and maintain a clinical practice.

Solutions

Creative solutions are required to grow the NP workforce needed to meet the health needs of the nation. Partnerships between clinical sites and academia will be necessary. Schools situated in university medical centers already have this marriage created; however, the remainder must scour their areas for appropriate sites. The need for NPs and primary care services is clearly growing. If clinical sites can be incentivized to affiliate with academic programs, sites will be able to grow their own providers because they can select from the pool of students that rotate through.

Funding for NP programs must also increase. NPs are needed to deliver primary care in the United States. Specialty physicians outweigh primary care providers by at least 2:1 in the US. In countries with better health outcomes, the specialty to primary care ratio is 1:1 and trending to a higher ratio of primary care providers. A multitude of reasons exist for this disparity, including the high cost of medical education that encourages physicians to enter higher-paying specialty roles and the perception that specialty care is more challenging and intellectually rewarding than primary care. To meet this gap, and ultimately improve the health of the nation, more NPs are needed. Furthermore, NP education, as well as job opportunities, needs to focus on primary care. NPs have the possibility of replicating the direction of physicians (ie, focusing on specialties). However, this will only perpetuate current problems in health care and force the system to look for the next group that might be able to fill the gap.

At the school level, NP programs may need to devise their own schedules and adjunct responsibilities rather than following the mold of traditional nursing programs. The schedule demands of primary care practice require greater flexibility than needed for traditional nursing roles. The NP role requires ongoing engagement in clinical practice in order to remain current. Creative solutions are needed to encourage NPs to function as both provider and educator. With additional NPs engaged in academia, NPs may be able to avoid the potentially vulnerable position as simultaneous provider, educator, and preceptor. Solving the discord between practice and academia has the potential to enrich both worlds and create a vibrant next generation of NPs. Failure to solve this discord may lead to the replacement of NPs by other providers.


 
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Articles in this issue:

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    Editor-in Chief:
    Kirsten Nicole

    Editorial Staff:
    Kirsten Nicole
    Stan Kenyon
    Robyn Bowman
    Kimberly McNabb
    Lisa Gordon
    Stephanie Robinson

    Contributors:
    Kirsten Nicole
    Stan Kenyon
    Liz Di Bernardo
    Cris Lobato
    Elisa Howard
    Susan Cramer

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