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?
I’m an FNP student. I am not pleased with my hybrid education (part online and part in person) and yet am grateful that my program has provided some clinical didactics that fully online programs likely do not. I have not found any students who are happy with programs in my region. I would love your organization to advocate for higher quality clinical education for NPs. NPs programs are not going away. We want to join physicians in providing excellent care for patients and the need for NPs is evident. Your support is crucial for the healthcare of rural and underserved populations where PCPs are needed. Please become supportive of our quest to become high quality providers.
Yes. I agree wholeheartedly. I have a decade of ER nursing experience and multiple degrees. I am a seasoned student and avid learner and have been fully disappointed in my DNP program. I am grossly underprepared, will graduate in May, and have no plans to practice as an NP currently. I may consider multiple additional certificates and additional residency training before I approach this question again, but as of now, I would never position myself in the role.
I left NP school because I began to see that the education level was inadequate for what I would be later required to do. I also looked around and saw my cohorts who were NP graduates grossly unprepared for their jobs. There’s no way you can teach someone to do a similar job in 2ish years when it takes a physician many more. I transferred to continue my graduate education as an executive leader.
I’m a PMHNP student and am set to graduate this November. I do not believe the education that I have received has come anywhere near the level I need to provide competent and safe patient care on an independent level. I have been a nurse for 10 years across many areas and have learned from some talented physicians who have been willing to teach me. Yet still, I should not, and will not, set out to practice individually at this point. I ask that physicians remember that not all NP’s are looking to usurp a physician’s place of honor. Some of us just simply want to continue our education and help where needed. Practicing independently at this point seems a bit like a physician skipping the entire residency program. If I had not already been 40 I would have attempted med school, but, alas, I’m a bit old and since I still want to learn and grow and care for people, NP school is my path. Is the program lacking? YES! Are there students who are passing that I might not let treat my pet? YES, but not all.
I am glad to raise my hand to help stop the extremely poor education that is being offered at many of the online and hybrid programs. Feel free to provide ways to help that you may have heard that I, and other NP’s, can help make change and I will gladly follow through.
I ask that you please refrain from responding with more negative and caustic words, as then you become more of the problem, and an ignorant and lazy approach says much more about the speaker than one likely intends. I’m on my own hunt for other like-minded and action-focused individuals looking to make changes from this side, but I am happy to hear any other intelligent ideas out there as well.
I agree, not all NPs want to practice independently. A lot of students would just like to further the education from BSN to MSN and also help others. But I do agree NP school curriculum should be remodeled. Enough of writing papers and more on clinical hours.
I am an Acute NP and fully agree with you! I want to bring my experience to the table and sit with my physician peers not replace them. Their education and experience is not replaceable but we can supplement the care the team delivers to patients. I will be with you raising my hand. Until the quality of education and training improves, we have no business asking for full practice authority.
I totally agree with this. FPA is irresponsible and unnecessary. I also want heavy clinical training and less garbage coursework. The original intent of the DNP was added clinical training; what the hell happened to this?
I am a critical care nurse and looking at the possibility of NP in a few years, once I hit the ten year mark. Looking over countless schools there is a sad lack of quality. It feel like anyone can pick up an NP degree which scares me. Where is the prestige if a minimally experienced nurse can jump into an NP role with minimal education and clinical? Requirements for entrance should be a minimum of 5 – 10 years of bedside experience in the field of desired NP practice. Schools should be more stringent on with more hands on mock clinical as well as more patient clinical. Patient’s should have confidence in their provider. Since all my research on NP schools and requirements, I now question each NP on ability and experience. I find myself asking, “Do I want to be an NP? Will I have enough experience to be a reliable and competent provider?”
I am a recent graduate of the Acute program at Duke and fully agree with you. I had been a nurse for 20 plus years before I felt ready to enter NP school. I was sadly disappointed at the lack of quality I was seeing as I researched schools before making my decision to attend Duke. Yes, it was an investment but I felt like I was worth the investment, and I owed it to my patients. But, also needed higher quality training in order to earn the trust of my peers. I encourage you to continue to look at NP programs but look at the higher-quality programs. We need nurses like yourself on our team. Earning the respect and trust of our physician colleagues is important but must be earned.
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I agree with you there anonymous. The comments here seem a little fishy.
I am very concerned. I have been a nurse for 17 years working in different clinical areas. I’m seeing nurses with as little as 2-3 years of bedside nursing experience becoming FNP’s. This is scary for me. Doctors spend so many years in med school and then in training in the clinical setting before becoming certified. Why isn’t there a higher recommendation for FNP’s whom carry similar abilities. This is putting people’s lives in danger.
I graduated from DNP school in 2018, one that required clinical hours. I also had 5 years of bedside nursing experience in acute care that contributed to my experience in healthcare, and 4 years of nursing school and 7 years as a nurse aid if you want to go further back. But I know that pales in comparison to the level of training and experience of MDs. Overall I feel my preparation was sufficient for safely entering my practice as an NP by working with physician colleagues to continue to learn and hone my skills. But I am frustrated that DNP school wasn’t everything I had dreamed of. The amount of effort a student puts in is how much they get out. So for many, in-depth learning could be lacking. I echo what others say. If you want equal care for patients, be the change you want to see. Advocate for greater knowledge sharing and bridge programs between medical and nursing schools, consult on courses, advocate for NPs to be able to have access to more clinical hours in teaching hospitals, access to exam prep courses and be able to test in the same exams offered to physicians. It’s one thing to advocate for better patient care, and another to just put down an entire profession and act like they’re not good enough but keeping them down at the same time.
Is there a reference page or citations for the statistics in this article/commentary? For example, “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.”
“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).”
Just wanting to look more at the stats/numbers . . . look at the sources directly.
If you click on links within the blog post, you’ll find the sources of the data cited.
I think that this is a concern for most NP students, at least in the Northeast. I am an RN and a student as well, and will be looking into doing a qualitative research study on this, eventually leading to a petition. If anyone would like to advise / contribute / discuss I welcome this, email me at email@example.com
I agree with the author. I have been a nurse for 36 years and I am in an NP program wherein some of my classmates have no, ZERO, clinical experience except that which they received while earning their BSN – It’s frightening to me. I work as an RN along side of MDs, PAs and NPs. In nearly all cases, the MDs have an incredibly deeper understanding of nearly every disorder and all associated statistical data.
correction: BSN – it’s frightening to me.
Also, I have 21 years of critical care experience. I think every NP student should have a minimum of ten years experience working as an RN in critical care. Early on, I felt ICU was the best pathophysiology lab anyone could experience. You could observe patients improving, holding-steady or declining on a 24-hour basis, often due to the physicians’ interventions and nursing care.
There is just as much research showing the benefit of having nurse practitioners on board with patient care. Patient satisfaction, outcomes, and overall care increases. If these unprepared NPs are passing board certification exams, and go on to then be supervised by MDs, which most are required by law to do so, then whats the issue?
“Nurse practitioners are contributing to nursing shortage” not our problem.
“Not all physicians believe team based care works” Thats nice, data says otherwise and physicians who dont want input from other physicians shouldn’t work in a team based field like healthcare.
” These types of educational experiences cannot possibly prepare an NP for the breadth of care from infant to elderly patients.” That is probably why NPs are not GPs then, eh? There are specialties for a reason. NPs are not meant to provide care cradle to grave for anything and everything.
“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.” lol what. People have bills to pay, and is just thinly veiled classism which explains a lot about the physicians I’ve seen in their treatment of poor folk. Programs like mine are extended and lighter credit per semester loads to accommodate working nurses.
While it is important that NP programs have more oversight for things like quality and emphasis on proper expertise, it seems like this site is just a group of folks who don’t know what NPs do, what their training is like, legality per state, onus of training of patients vs MDs, and trying to just focus on negatives for a topic they don’t understand.
I’m sure this will get deleted or whatever by the admins, but thats okay, I wouldnt expect anything less. NPs arent going anywhere anytime soon, and again we have a long way to go to standardize education and it’s standards, this group does nothing to assist with that, just docs trying to raise themselves up on a pedestal again while nurses still catch countless MD errors on the floors.