'It's on us': How health systems navigate NP education gaps

Mariah Taylor (Email) - ?Becker’s Health

In 2024, nurse practitioner education programs made national news over their education practices. Specifically, critics were concerned that NPs were not receiving the necessary education to maintain patient safety — but healthcare leaders tell a different story.

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"NP education doesn't end at graduation. It starts there," Todd Roark, MBA, RN, ACNP-BC, vice president of APPs at Norfolk, Va.-based Sentara Health, told Becker's. "Instead of focusing on differences in education models, we need to ask: How do we create equal opportunities for all clinicians to gain experience and grow? It's on us as a healthcare industry to provide [structured pathways to build experience]."

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Are there knowledge gaps for new grads?

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Nurse practitioners enter the field from three avenues: working as a bedside nurse for years before pursuing an advanced degree, going straight through school and entering the workforce without prior bedside experience, or earning a doctorate in nursing practice and focusing on clinical leadership, education and executive roles.

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"These paths result in different levels of experience when entering the workforce," Mr. Roark said. "Someone with years of bedside experience ramps up faster, while someone new to practice may need more time to develop clinical confidence. It's not a deficiency, it's just a difference in how they get there."

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Leaders said they have seen more students enter NP programs without prior bedside experience.

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"When students don't have that foundational nursing experience, it puts more pressure on employers to ensure they are competent and safe providers when they enter practice," Kristin Ramsey, MSN, RN, chief nursing officer and senior vice president of quality at Chicago-based Northwestern Memorial HealthCare, told Becker's.

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There can also be issues with the curriculum some nurse practitioners receive. The existing criticism includes variability in clinical hours during training, online and accelerated programs with inconsistent quality, deficiencies in specialty training and limited exposure to complex cases, Brooke Schweitzer, DMSc, executive director of advanced practice providers at UChicago Medicine, told Becker's.

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While critics look at nurse practitioner knowledge gaps in school, hospital leaders told Becker's the true gaps stem from poor understanding of the NP education program and difficulty finding clinical rotations.

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Among systems, there is still confusion about nurse practitioner training and their job responsibilities.

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"I think there's a lot of misunderstanding — especially from hiring entities like private practices and hospital systems — about how advanced practice registered nurses are trained," Brian Graves, PhD, vice president of advanced practice at Tampa (Fla.) General Hospital, told Becker's. "One common misconception is that all APRNs are trained like physician assistants — with generalist training and specialty rotations. But that's not the case. APRNs follow a population- and role-based training model, which is very different from the generalist and specialty rotation training used in medical schools and PA programs."

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Although many organizations recognize this difference, some still believe a family nurse practitioner can do everything, and "that's simply not true," Dr. Graves said.

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A similar misunderstanding is also common among NP students. Nurse practitioner training is specific to a population, so if they want to work in acute care, for example, they need an acute care NP education program.

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"These experiences aren't interchangeable," Ms. Ramsey said. "Unfortunately, some students assume that an NP degree is an NP degree, but that's not the case. We sometimes see graduates who think they can work in any setting, but their training hasn't prepared them for that."

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This can lead to a disconnect between students' career goals and the training they receive.

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But for many students, finding clinical placements can be the greatest challenge. Many programs leave the responsibility for securing clinical rotations to students and the organizations that accept them for training.

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"Students shouldn't have to fight to find quality placements, and the organizations hosting them shouldn't bear the entire responsibility for filling those educational gaps," Ms. Ramsey said.

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From which programs do systems recruit?

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More than 600 nurse practitioner programs have popped up across the country in recent years — three times the number of medical schools. In 2022, 39,000 NPs graduated. However, programs do not have standardized training and many students complete coursework entirely online.

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With so many avenues for NP graduates to take, systems must strategize regarding which students to accept. In the end, most systems fall somewhere on the spectrum between hiring only from specific programs and hiring based on an individual's experience.

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UChicago Medicine accents NPs students only from the universities with which it has an existing partnership. However, Dr. Schweitzer said the health system receives emails almost every week from new programs wanting to partner.

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"Unfortunately, we can't accept students from every program, especially those from schools without a strong reputation," she said.

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Meanwhile, Sentara Health prioritizes hiring based on their staff needs, the applicant's clinical background and whether the health system has the ability to train them.

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"Where they attended school is less important than what they bring to the table," Mr. Roark said.

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Both Sentara and UChicago have hundreds of NPs, so picking which strategy comes down to organizational goals and partnerships.

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Many systems are also investing in larger APP leadership structures to improve the transition-to-practice and manage the growing workforce. Dr. Schweitzer was the first APP executive leader to join the system, and UChicago also recently hired its first medical director for advanced practice provider education.

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How do systems train NPs?

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Once an NP joins the system, hospitals begin providing more specialized training.

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Nurse practitioner fellowship programs are the most common form of education for new hires. These programs primarily consist of hands-on clinical training, didactic learning and professional development. For NPs going into specialty services, some systems, including Sentara, also provide a three- to 12-month training program tailored to that area.

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At UChicago, NPs also participate in APP procedure days in which they learn new procedures, refresh existing skills and ensure the staff is using standardized best practices.?

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Some systems also help to train students before they enter the field by offering clinical rotations as part of their arrangement with local programs.

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Northwestern Memorial Healthcare hosts about 1,800 clinical rotations annually, Ms. Ramsey said. Many of those students train at the system for two and a half years before graduating.

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At Tampa General, Tiffaney Randolph, DNP, program director for APP fellowships and manager of APP professional development, oversees the NP education programs. These include a fellowship program, competency based orientation programs and mandatory training classes for APPs including social determinants of health simulation, point-of-care ultrasound training, EKG boot camp and transplant 101. They also support 150+ advanced practice students each semester through clinical placements and shadowing opportunities.

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What systems want more from NP education programs

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Leaders have a few items on their wish list for NP education programs.

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"There is an opportunity for schools to do a better job advising students during the application process," Dr. Graves said. "Many experienced critical care nurses are misled into choosing FNP programs because they're told it's 'more marketable,' only to realize later that it doesn't prepare them for the ICU and more acute specialty roles they want. Schools need to guide students toward the right population track based on their career goals."

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Dr. Schweitzer said adding more procedural and simulation training would help make the transition from student to practicing professional easier.

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Most importantly, leaders told Becker's they want to see more collaboration between programs and systems.

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"To me, the sweet spot is collaboration: having industry leaders and education leaders at the same table to align training with real-world practice needs," Mr. Roark said. "This is how we drive policy change and improve funding for clinician education."

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