There has been a dramatic proliferation of nurse practitioner training programs in the past 15 years. The total number of programs has increased from 382 in 2005 to 978 in 2018. Further, the number of Doctor of Nursing Practice programs has increased from 0 to 553 in that time.
Many of these Nurse Practitioner programs are recognized as “diploma mills.”
These NP training programs promise quick certification, do not rigorously screen applicants (59 programs have 100% acceptance rates), and do not organize or structure the 500 hours (minimum) of clinical experience required. In many programs, students have to arrange for their own clinical experience. Many programs have no institutional input, or control, regarding the quality of these clinical experiences, and some are of scandalously poor quality. Examples exist of students who were not allowed to look at any medical record during training, students who were being supposedly trained for family nurse practitioner (FNP) positions, and yet had done never a single PAP smear, and other students being prepared for FNP positions who spent their entire clinical experience in a peripheral vascular disease clinic. These types of educational experiences cannot possibly prepare an NP for the breadth of care from infant to elderly patients.
It is critical to understand something about DNP programs. The programs themselves are sharply divided between those that teach administrative skills, preparing students to become administrators (85% of the programs) and those that would prepare students for clinical responsibilities (15% of all DNP programs). The DNP programs self-identify as being clinical or administrative. Those going through an “administrative” program are, nevertheless, allowed to take qualifying exams which would allow them to work in a clinical setting. But it gets worse – 82 of these programs do not require what they call “masters’ level clinical skills”. Translated, this means that the student may never have worked with patients before this degree and their entire patient experience may be the 50o hours of clinical experience (of questionable quality) that they must find themselves. There are a number of programs that have designed “direct-entry” NP programs for those who want to become an NP after, for example, obtaining a Bachelor of Fine Arts degree, without any time spent working in a clinical setting.
A recent poll of NPs revealed that, incredibly, 92% maintained a full-time job while obtaining their NP degree. This is strong evidence that these programs are designed, not to teach excellent care of patients, but for the convenience of their customer-students. No medical student can possibly maintain a full-time job while going through medical school. Medical school is properly an immersive experience, requiring everything the student has to give – 80+ hours per week. The responsibility for patient lives requires no less.
There should be no place in medicine for those who want an easy degree.
Mary Mundinger, perhaps the one person most instrumental in developing the Doctor of Nursing Practice (DNP) degree programs, has recently acknowledged that the driving force behind these DNP programs is NOT clinical excellence, but institutional financial considerations:
Schools are making rational decisions about their internal resources when they choose to formulate a nonclinical DNP as opposed to a clinical DNP. Great rigor and expense are entailed in developing a clinical degree program. A limited number of faculty are prepared for teaching DNP clinical practice, and state and national advancements in authority and reimbursement have not yet been forthcoming for the clinical DNP. These issues make it less likely for schools to invest in training advanced clinical NPs. However, our analysis documents that the short-term advantages of developing nonclinical programs is leading to a distortion in numbers between clinical and nonclinical DNP programs, which may lead to serious shortages of NPs in the future. Leaders of nursing education programs, and more broadly, of our profession, have a responsibility to improve the health of the public by making choices that serve the public’s interest, not the short-term finances of the school. (Mundinger)
How well do even the “clinical” programs prepare the students for actual clinical work? As it turns out, that experiment has already been done. In an effort to validate their graduates, it was arranged with the National Board of Medical Examiners to provide an exam based on the Step 3 exam, the exam given to all prospective physicians. This exam, while quite difficult, is passed by > 97% of all physician candidates. It is a requirement in order to be licensed to practice medicine as a physician in the US. This exam was modified (made easier) for the DNP candidates. Despite this, the pass rates between 2008 and 2012 were, sequentially 49%, 57%,45%, 70%, and 33%. Keep in mind, these were candidates from programs with a strong emphasis on clinical education, not the programs that concentrate on administrative topics. Presumably those “administrative” candidates would do even worse. Additionally, this occurred in a time when there was less proliferation of online diploma mills.
The exam was discontinued for DNP candidates after 2012. No official reason was given. However, since their goal was to prove their candidates equal to physicians, and since that was clearly disproven, and did not improve with time, it seems likely that they realized it was a failure, and discontinued it to avoid further embarrassment.
What happened to the large proportion of DNP candidates who failed? There has been no official accounting of these people, but they were still qualified to take their NP “Board exams” (AANP or CCNE) until they passed, and presumably they did so and are now practicing, possibly with no supervision in one of 23 states.
The Flexner report, written at the turn of the 20th century, was a comprehensive overview of medical education done in response to the understanding that there were a large number of players developing seat-of-the pants medical schools essentially to profit from the students. There were no controls on curriculum, the clinical experiences given were largely non-existent. In response, the medical community rose up to put the mills out of business and, for the benefit and protection of the public, to establish stringent requirements on the remaining medical schools to ensure proper training of those who would impact the lives of their patients.
Astonishingly, this situation has arisen again, now playing out on a nursing platform. The public needs to be protected in the same way it was 100 years ago. These mills need to be put out of business in the name of public safety.
If the remaining schools wish to have their graduates performing the same duties as physicians, at the same level as physicians, there must be a dramatic change in the way they are trained and in the way they are tested and certified. Anything less is a tacit admission that our society is fine with allowing some patients to receive second tier care. The question is – will our society continue to allow this?