Year after year, states consider legislation that expands what nurse practitioners (NPs) are allowed to do in the nation’s exam rooms, clinics, emergency departments, and other settings without any physician involvement.
In a family medicine setting—which encompasses caring for pediatric, adult and geriatric patients—some states go as far as allowing nurse practitioners to diagnose, prescribe and manage treatment plans for patients without any physician involvement.
The AMA says that inappropriate scope of practice expansions are concerning because nurse practitioners, while they are valuable members of the physician-led patient care team, do not have the same skill set as physicians. This is primarily due to the differences in education and training of nurse practitioners compared to physicians, including the lack the rigor and standardization of nurse practitioner programs. Studies show that a number of family nurse practitioners get little direct patient care training before they are allowed to practice.
According to a study published in the Journal of Nursing Regulation, “many” family nurse-practitioner students did not have clinical experiences that reflected tasks deemed essential by nurse-practitioner educators. For the study, researchers examined the types, frequency and depth of direct patient care experiences that nearly 4,000 American family nurse-practitioner students experienced during their training.
“These gaps and inconsistencies in requisite learning experiences require a critical conversation among leaders in academia, regulation and certification to examine competency expectations, clinical learning environment availability, and preparation for advanced practice, as well as to ensure the development of qualified FNPs [family nurse practitioners] who will provide safe, high-quality care across patients’ lifespans,” says the study.
The AMA is fighting scope creep, defending the practice of medicine against scope of practice expansions that undermine physician-led, team-based care.
Hands-on experience lacking
For the Journal of Nursing Regulation study, researchers looked at 84 clinical tasks across four areas that family nurse practitioners were likely to participate in during their education: assessment, diagnosis, treatment and evaluation.
According to the study, these were areas that aligned with the 2016 National Task Force on Quality Nurse Practitioner Education, which stated that the operational definition of direct patient care is “care that involves assessment, diagnosis, treatment and evaluation of real clients or patients—not simulation or lab exercises with trained client/patient actors.”
While some students reported doing some clinical tasks in each domain or with each population more than 10 times (the maximum offered for selection), “there were large number of students who reported never experiencing” those same tasks, the study says.
Among the highlights of the study’s findings:
- When it came to pediatric experience, more than 10% of respondents reported never evaluating “treatment and educational outcomes related to chronic pain,” never “performing primary care procedures (e.g., wart removal, suturing, cerumen removal)” in pediatrics and never “performing a mental health assessment.”
- Across all patient populations, students most frequently reported that they had never completed a mental health assessment during their training. Among the students, 2.9% said that was true when it came to the adult population, 3.6% when it involved the geriatric population and 11.2% for the pediatric population.
- Ordering diagnostic tests—essential for accurate diagnosis and treatment—was the diagnostic clinical task students reported most often never having completed, with 1.9% of students saying they hadn’t completed that task in the adult population, 2.1% hadn’t ordered a diagnostic test in the geriatric population and 3.9% reported not ordering a test in the pediatric population.
- In the treatment task area, students across all populations indicated that the primary care procedures task was the one they most often never performed. This was true for 6.0% of students when it came to adults, 9.6% for geriatric patients and 13.6% for pediatric patients.
- The large number of students who reported “never” on all eight clinical tasks in the evaluation task area for pediatric patients is “noteworthy.” Among those tasks, 15.1% of students said they never evaluated treatment and educational outcomes related to chronic pain, while 5.9% said they never evaluated treatment outcomes related to acute pain.
Stay up to date on fight against scope creep
See how the AMA defends against scope of practice expansions that threaten patient safety.
In addition, researchers found that:
- 39% of those surveyed said they prescribed medications to adults 10 times or fewer.
- 35% ordered diagnostic tests for adult patients 10 times or fewer.
- 46% performed a mental health assessment on adult patients 10 times or fewer.
Nurse practitioners receive far less training than physicians. For example, they have no residency training requirement and generally complete just 500 to 750 patient-care hours in training. Meanwhile, physicians through their medical school clinical rotations and residency accumulate between 12,000 and 16,000 hours of patient-care experience. All that comes after physicians complete four years of medical school and earning a bachelor’s degree.
Building on previous research
Other studies have found a similar lack of experiences among family nurse practitioner students and recent graduates. For the Journal of Nursing Regulation study—published in 2021 but still relevant in light of a recent Bloomberg news article series (read parts one and two) that has detailed problems with lax nurse-practitioner training standards—researchers surveyed the medical literature and found a wide variety of clinical experiences, with varying levels of confidence in their preparation and ability to practice independently after graduation. For example, several studies conducted between 2018 and 2020 found that educators have concerns with student learning outcomes in the traditional clinical education model, especially when it comes to diagnostic and clinical reasoning. And studies from 2016 to 2019 found that new nurse practitioners reported uncertainty in their role, including self-doubt. They also reported feeling minimally prepared in caring for patients with complex problems, including mental health issues and geriatric health and in providing certain procedures.
In 2023, a three-year study of emergency departments in the Veterans Health Administration found nurse practitioners delivering care without physician supervision or collaboration resulted in higher costs and worse outcomes. The study found nurse practitioners increased patient lengths of stay by 11% and raised 30-day preventable hospitalizations by 20% compared with emergency physicians.
