Educating the nurse practitioner (NP) workforce has become challenging. Challenges include, but are not limited to, preparing sufficient numbers of NPs, an aging workforce, faculty shortages, faculty salaries that do not compete with clinical salaries, and an education model that mandates clinical hour numbers despite waning access to qualified preceptors in appropriate clinical sites and the current COVID pandemic (LeFlore & Thomas, 2016). A variety of models to offset the challenges to educating NP students have been proposed and partially adopted, such as simulation for clinical skill development, use of telehealth models, academic-practice partnership models, and competency-based skill development (Hodges et al., 2019; Jeffries et al., 2019; Kostas-Polston, Miedema, & Dickins, 2018; LeFlore & Thomas, 2016). Together, these models hold promise to assist educators in their goal of preparing adequate numbers of NP graduates who are practice ready at the basic level of clinical competency. But until these models are championed by professional organizations and adopted by NP education programs overall, educators must look to ways to bolster skill acquisition, clinical reasoning, and role competency. The purpose of this editorial is to describe a collection of papers we bundled with strategies to bolster NP knowledge and skill development.
Nurse practitioner knowledge and skill development
This themed issue includes a number of unrelated educational strategies and techniques to increase NP student knowledge. Whited et al. studied a multimodal educational intervention to determine clinically significant improvement in understanding anatomy in a NP health assessment course in the paper titled "An innovative technique to promote understanding of anatomy for nurse practitioner students." The educational intervention was an interactive laboratory activity with prosected human cadavers and a 55" multitouch, 4K resolution Sectra 3D anatomy table. Following didactic front loading, instructors led students through individual structures in five systems (Head, Eyes, Ears, Nose and Throat [HEENT], cardiovascular, respiratory, musculoskeletal, and neurological). Students discussed as a group how anatomical understanding for each of the five systems refined physical assessment and diagnostic reasoning processes. Following, the students were given case studies through the anatomy table to evaluate different pathologies such as fractures, traumas, and various disease processes. The pretest-posttest design allowed measurement of confidence in anatomy with improvement in self-reported confidence in all five systems. Statistical significance could not be evaluated due to the small sample size (14 completed pre- and posttests). Qualitatively, students reported that using the 3D Sectra table and prosected cadavers was beneficial. One limitation to using this intervention is that cost may be prohibitive for some NP programs. But the authors believe core elements of the intervention could be replicated using less costly, comparable, 3D electronic resources.
Integrating strategies for improving diagnostic reasoning and error reduction is the paper included by Nordick. The emphasis in this paper is implementation of the diagnostic and reasoning tool (DaRT) that includes evidence-based strategies of knowledge acquisition, metacognition, and logical reasoning skill throughout a patient encounter. Using a retrospective descriptive design, Nordick studied whether use of the DaRT led to improved Advanced Practice Registered Nurse (APRN) student understanding and application of diagnostic reasoning. A statistically significant increase in physical assessment scores and scores in the assessment of acute and chronic illnesses was noted in students who used DaRT compared with those who had not. The conclusion was that DaRT can be used as a teaching-learning strategy throughout clinicians' education, preceptorships, and immersion experiences. As a method of clinical instruction and diagnostic development, DaRT may increase diagnostic reasoning competence of students and clinicians alike.
Woroch and Bockwoldt focused on the growing need to prepare family NPs (FNPs) for a variety of practice settings, including those that require clinical procedures such as incision and drainage of abscesses and laceration repair. Their paper titled "The growing need to provide training in clinical procedures in family nurse practitioner educational programs" outlines the need for educators to ensure that their NP programs keep pace with rapid changes in health care. They cite the work of Scheibmeir et al. (2015) that compared NP education content to PA program content on procedures, such as x-ray interpretation, ECG interpretation, and suturing. In all three cases, NP programs had fewer hours devoted to these skills. The purpose of their paper was to report the results of a survey of FNPs at a national NP conference. One hundred ninety-eight FNPs participated, and more than half (61%) reported that they did not feel adequately prepared to perform procedures upon graduation from their programs. This alone calls for careful examination of NP program content that includes didactic content and supervised clinical practice components to match the needs these graduates have in their practice settings. It seems essential to survey graduates periodically to determine their perception of what NP programs need to be included to prepare graduates as practice ready. Additionally, it would also seem essential to ask employers what skills their new employees lack. Only this way can education keep pace with clinical practice needs.
"Empowering the novice family nurse practitioner: Promoting readiness to practice through immersion in an innovative educational strategy" by Finneran and Kreye note that NPs are key to addressing the current and future shortage of health care providers in primary care. They purport that the demand for primary care providers in the United States is increasing but has projected shortages by the year 2025. The purpose of their paper was to assess the implementation of a structured Clinical Transition Program (CTP) embedded within an FNP education program to strengthen readiness to practice and promote successful role transition in new FNP graduates. Finneran and Kreye define the CTP as a learning strategy that supports readiness to practice upon graduation for FNP students by providing varied clinical experiences and opportunities to build strong clinical backgrounds addressing the complex needs of patients. Embedded into the final two clinical courses in an FNP program, the CTP emphasized cardiology, pulmonology, and endocrinology to match chronic disease prevalence in Ohio compared with chronic disease in adults nationally. Using a descriptive design, master's-level students in the last two semesters of their FNP program were surveyed to determine the overall effectiveness of the CTP for practice readiness, quality of clinical education, and specialty site placements. Two student cohorts participated and reported significantly higher perceived readiness to practice 9 months after graduation compared with the cohort that did not participate in the CTP. Of importance, students in the CTP had required clinical experiences in rural and underserved areas, providing students opportunity to learn the complex and unique health care needs in such settings. It seems important to note that a program like the CTP requires additional clinical placement, support staff, and clinical preceptors in rural and underserved areas; however, such programs hold promise to positively impact student perceived readiness to practice before graduation and continued postgraduation.
Recognizing the need for NP students to have better education and training in screening, brief interventions, and referral for treatment for patients who overuse alcohol or substances, Arends and colleagues contributed a paper titled "Screening, brief intervention, and referral to treatment training for family nurse practitioner students." They developed a curriculum for screening, brief intervention, and referral to treatment (SBIRT) to identify and intervene before development of chronic disease conditions. The curriculum included the all important "how to start the conversation," which has traditionally been difficult for some students. The purpose of their paper was to discuss the evidence-based intervention and to identify changes in the perception of importance and acceptance of SBIRT and clinical implementation among FNP students who were trained in the method. The project included a sample of 95 students trained in using SBIRT who provided data on satisfaction and use, open-ended comments from reflection papers at final practicum end, knowledge of SBIRT, and attitudes toward working with patients who use drugs. Quantitative findings included statistically significant improvement in attitudes toward patients who use alcohol and drugs. More than 80% of students had applied SBIRT training to clinical practice 30 days after training, whereas 80% said that they used SBIRT in NP practice one year after graduation. Of interest, work satisfaction for the APRN students increased with patients who use alcohol but did not increase significantly for patients who use drugs. The authors postulate that this may be due to the students having more opportunity to work with patients who use alcohol than those who use drugs. They conclude that implementing SBIRT into NP curriculum allowed students to gain the knowledge and skills needed to care for these patients in the practice setting. This curriculum could be a positive addition to NP programs especially as the health care community anticipates an increase in alcohol overuse and drug use since the COVID-19 pandemic.
Enhancing curriculum related to telehealth
Since the COVID-19 pandemic began, health care organizations and providers have increased the use of telehealth and e-visits to reduce viral transmission. Many patients have been asked to accept a phone visit or telehealth visit with their provider rather that the traditional face-to-face format. This increase in usage of telehealth modalities drives a need to bolster telehealth competence among NP students and is a fine example of practice need influencing NP educational program content. Two papers are included in this themed issue that aim to improve telehealth competence to prepare students for the challenges of a changing health care system.
"Development and implementation of an e-visit objective structured clinical examination to evaluate student ability to provide care by telehealth" by Quinlin and colleagues responded to the NONPF recommendation to incorporate telehealth into the NP curriculum by developing and implementing objective structured clinical examinations (OSCEs) delivered via an online format. Students received a 15-minute e-visit assessing and managing the care of a standardized patient with recent symptoms of dysuria. The video conference included the FNP student, standardized patient, and faculty evaluating via a specially designed rubric. Structured group debriefing followed the e-visit via conference call. Postexercise student and faculty feedback and evaluations positively reflected the importance of preparing students for practice via telehealth. The authors recommend that this OSCE exercise be included for more advanced graduate nursing students who have some knowledge of innovative use of technology and sufficient primary care practice knowledge to examine a patient via telehealth. The authors discuss cost of the curricular addition related to time, energy, and effort of faculty but advise that the educational value and benefits for the students' readiness to practice in a transformed health care system are essential.
Arends et al. contributed a paper titled "Enhancing the nurse practitioner curriculum to improve telehealth competency" to address the rapid expansion of telehealth in recent years. Nurse practitioner students are expected to have sufficient skills to use telehealth for provision of care upon graduation. Yet, many programs include no telehealth in the academic preparation of students. To meet this expectation, one program developed evidence-based competencies and curriculum to educate NP students in telehealth. In this paper, the authors described the curriculum development and evaluation of expected competences comparing pretest and posttest means in FNP students. Each competency demonstrated significant increases in FNP student confidence and ability and underscores the importance of including concepts integral to telehealth in NP program curricula. The overall goal of this work is to meet expectations of contemporary health care systems and is particularly relevant in the current COVID pandemic.
Education for the practicing nurse practitioner
The need to learn does not stop upon graduation for the NP. In fact, professional role development demands continuous learning (Berg et al., 2017). In a paper titled "Provider-directed education to reduce unnecessary neuroimaging in uncomplicated headache disorders," Cook and colleagues described a simple provider-directed, evidence-based, practice education session for clinicians. The goal was to reduce unnecessary neuroimaging rates in uncomplicated headache patients. Neuroimaging is costly, and since 1995, there has been dramatic increase in the use of both computed tomography of the head or magnetic resonance imaging of the brain. Prior to 1995, patients with headaches were primarily managed empirically. Despite an initiative to decrease the use of neuroimaging in diagnosis and management of headache complaints by the American Academy of Neurology, the American College of Radiology, and the American Board of Internal Medicine Foundation, only modest decreases in neuroimaging have been realized. The interventional education session described in this paper was developed with the aim to decrease unnecessary neuroimaging orders by clinicians. Using a pretest-posttest design, the 15-minute education session on neuroimaging use in uncomplicated headache resulted in a significantly lower proportion of unnecessary neuroimaging orders at 8-week posteducational intervention. The paper presents a good example of NP learning post graduation, but the intervention could be included in NP education programs.
The collection of papers in this themed issue provides examples of ways to bolster NP curriculum and support NP learning. Whereas, our overall approach to educating NPs to be practice ready upon graduation needs continuous evaluation to determine the match to contemporary health care system and patient needs, including many of the strategies and techniques described in this issue can bolster NP knowledge now. We need not wait until professional organizations change our overall approach to educating competent clinicians. We can, even now, include strategies and learning modules that supplement NPs' ability to provide care needed today.
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