Reflect on your experiences as a member of a clinical team. What makes a team effective or ineffective in terms of achieving expected outcomes for the patients? (Saunders, 2014

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WHITE PAPER

Re-envisioning the Clinical Education of Advanced Practice Registered Nurses

March 2015

SECTION I: Background Recently, there has been a significant increase in awareness regarding the potential contributions that advanced practice registered nurses (APRNs) could make to a reformed healthcare system. In particular, a great deal of attention has been directed to recommendations contained in the Institute of Medicine’s (IOM) 2011 The Future of Nursing report that APRNs be allowed to practice to “the full extent of their education and training” (p. 29). APRNs are poised to deliver care to the additional 30 million individuals who are anticipated to receive health insurance under the Affordable Care Act. Nationwide, APRN education programs are experiencing a number of challenges, including increased demand for APRN education and the national faculty shortage. APRN programs are also particularly challenged to be able to provide adequate numbers and quality of clinical training sites and preceptors. Challenges experienced by each of the four APRN roles – certified nurse midwife (CNM), certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), and nurse practitioner (NP) – are both similar and unique. The current methods of providing educational preparation and clinical training for APRNs present numerous challenges. The model for providing clinical education for all four roles primarily has been a one-to-one preceptor-student model, which is largely unchanged from the original APRN clinical training models developed over 45 years ago, designed to serve a much more limited population of students. With the growing demand for preceptors and clinical sites and the changes in the healthcare environment, this apprenticeship approach may not be sustainable as resources become increasingly scarce. Competition for clinical sites and preceptors is becoming more intense between schools within and outside of the profession, both regionally and for distance programs. APRN students enter clinical training experiences across the curriculum with varied skill levels. Variability among APRN programs, particularly for nurse practitioners and clinical nurse specialists, exists in the clinical competencies expected at various points throughout the curriculum, varied expectations for student performance across programs, and evaluation processes and tools. This variability may hamper efforts to expand the clinical training opportunities for students. Increasingly, new models of care are emerging with a new emphasis on interprofessional practice and education. Regulatory issues for in-state and distance-learning students are mounting. Schools are facing increasingly complex and lengthy processes for addressing administrative requirements, e.g. affiliation agreements and student clearances. A shortage of doctorally prepared advanced practice faculty to provide supervision and guidance for students is also a

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growing issue. All of these challenges require educational programs to explore new and alternative models for providing clinical training for the next generation of APRNs. Competition among programs for both primary care and specialty sites and preceptors continues to grow. The 2013 Multi-Discipline Clerkship/Clinical Training Site Survey—jointly conducted by the American Association of Colleges of Nursing (AACN), Association of American Colleges of Osteopathic Medicine (AACOM), Association of American Medical Colleges (AAMC), and Physician Assistant Education Association (PAEA)—assessed the concerns and factors influencing NP, physician assistant (PA), allopathic physician (MD) and osteopathic physician (DO) clinical training. A majority of respondents from all four disciplines expressed concern regarding the number of sites as well as the quality and availability of preceptors. Concerns regarding the adequacy of clinical sites and qualified preceptors have grown over the last two years, partially fueled by the growth in the number of programs and enrollments. Over 60% of schools with NP programs expressed extreme concern over the limited number of clinical sites, and 59% over an inadequate supply of qualified primary care preceptors (see Figure 1). Figure 1. Percent of Respondents "Moderately Concerned" and "Very Concerned" Regarding the Adequacy of Clinical Opportunities, by Profession (Multidiscipline Clinical/Training Clerkship Survey, 2014)

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Although this survey specifically focused on NP programs, this growing concern regarding the availability of clinical sites and preceptors is not limited to NP programs. Faculty members representing all four APRN roles have raised similar concerns. The annual AACN survey on enrollment and graduations consistently identifies insufficient clinical sites and preceptors as reasons for not accepting larger numbers of qualified applications for both master’s and doctoral programs. Enrollments and Demand for Clinical Sites Continue to Grow To meet the growing demand for healthcare services, there has been a 17% increase in the number of APRN programs offered in the United States over the past five years (Fang, Tracy, & Bednash, 2010; Fang, Li, Arietti, & Bednash, 2014). Currently, nationwide, 420 institutions offer one or more master’s or DNP entry-level APRN programs. The number of schools offering programs for each of the four APRN roles and student enrollment are shown in Figure 2. Over the past five years, the number of master’s level APRN programs has increased by 8%, and 130 new post-baccalaureate APRN DNP programs have been developed with a 60% increase in enrollment in APRN entry-level programs. The increase in enrollments in entry-level NP programs alone was 81% over the past five years. Figure 2. APRN Enrollment (Fall 2013)1, 2

Program Schools Offering the Program Enrollment Master's NP 368 56,496 Master's CNS 148 2,020 Master's Nurse-Midwifery 40 1,377 Master's Nurse Anesthesia 67 3,532 Post Baccalaureate DNP NP 92 5,064 Post Baccalaureate DNP CNS 18 187 Post Baccalaureate DNP Nurse-Midwifery 7 72 Post Baccalaureate DNP Nurse Anesthesia 13 556 Any Master's or Post Baccalaureate DNP APRN 420 (405 Respondent Schools) 69,304

1 From Tables 24 and 37, Fang, Li, Arietti, & Bednash, (2014) 2 Numbers of schools offering the programs include the schools whose programs were closed since last year. Competition among Nursing Programs for Clinical Sites In many locations, there are multiple APRN educational programs within a relatively small geographic area. In some regions, these programs share clinical resources. Having greater access to in-network clinical affiliates also advantages health systems with multiple clinical sites within a network. In some instances, neighboring APRN educational programs have created consortia to share academic, clinical, and financial resources (Kost, 2010).

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Competition for clinical sites and preceptors in some parts of the country is a growing problem. This challenge has raised concerns that schools may someday need to offer financial compensation to preceptors or clinical sites in order to secure these resources. However, in the 2014 Multi-Discipline Clerkship/ Clinical Training Site Survey, only 4% of nursing schools with an NP program reported paying a fee per student at one or more sites, and only 6% indicated they paid a fee for personnel time at clinical sites. The number, although small, was slightly higher in the Northeast than the rest of the country. While this practice is not widespread, it presents a perceived challenge for universities and schools with restrictions on paying for clinical training sites or without adequate resources to compete for preceptors in this manner, particularly because other health professional schools (allopathic medicine 16%, osteopathic medicine 71%, and physician assistant 20%) may be offering compensation to secure clinical placements at one or more community-based clinical sites. In addition, a majority of nursing schools with NP programs (58%) reported growing pressure to provide financial compensation incentives, particularly in order to recruit new sites for NP training. While similar data for the other three APRN roles are not available, anecdotal reports support similar pressures being placed on these programs as well. Alternative incentives provided by NP programs to preceptors at community-based sites included public recognition (51%), library access (43%), educational opportunities for preceptors (35%), adjunct faculty status at the college or university (34%), continuing education opportunities (34%), and other faculty development opportunities (28%), including preceptor hour documentation for re-certification (Multi-Discipline Clerkship/Clinical Training Site Survey, 2014) . Another emerging phenomenon is that private companies are promising to find and arrange clinical sites and preceptors for students in exchange for payment. The challenge lies in determining how to best encourage preceptors to invest in future APRNs. Regulatory Issues Challenge Schools to Establish Clinical Training Sites Regulatory issues present unique challenges on a state-by-state basis. Outdated state and federal regulations, institutional policies, and misperceptions about provider preparation often prevent APRNs from practicing to the full extent of their education, skills, and expertise (Fitzgerald, 2012). Regulations by many state boards of nursing and federal reimbursement agencies limit the APRN scope of practice by requiring physician oversight of APRN practice. To date, there is no evidence that physician supervision provides any added value to APRN patient outcomes. (Hansen-Turton, 2009; Safriet, 1991, 2011; Newhouse, 2011). Variable regulatory requirements by state boards of nursing and higher education boards can limit schools’ ability to place students in out of state clinical rotations without completing lengthy and expensive approval processes. This is especially true for distance education programs. Also, state regulations change frequently and make institutional compliance difficult. Schools also report growing competition for clinical placements from students attending out-of- state distance programs. Approximately 50% of state boards of nursing regulate graduate nursing education programs; however, a majority of state boards have indicated they expect to be notified when out-of-state graduate students are placed in a clinical training site within the state (NCSBN, August 2013).

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In addition, clinical sites are placing greater compliance-documentation demands on students prior to allowing them to participate in clinical rotations, including background checks, drug screens, HIPAA training, OSHA training, verification of health insurance, immunizations and blood titers, and, in some cases, workers’ compensation coverage. Schools are struggling to increase liability-insurance limits and negotiate a variety of political and legislative activities to address physician supervision mandates and licensing requirements for APRN faculty. Additional regulatory challenges that require new approaches include student restrictions on accessing electronic health records (EHR), sites with exclusivity contracts for student placements, and the complexity of processes for establishing affiliation agreements between schools and practice sites, as well as the increased pressure to maintain or increase productivity for preceptors. For NP programs, security and legal issues (81%) (e.g., affiliation agreements, immunizations, and background checks); student access to the EHR (75%); and other administrative elements (74%, e.g., scheduling, coordination, files and forms) were cited as the top three factors influencing the ability to develop new clinical training sites (Multi-Discipline Clerkship/Clinical Training Site Survey, 2014). In an effort to minimize risks to patients and the organization, some sites are restricting student access to certain clinical environments and increasing liability coverage costs to APRN students. This practice can be a barrier to obtaining clinical rotations at rural and underserved sites, as these institutions may be reluctant to incur the additional costs of increasing liability insurance limits to match that of the education institution. Barriers such as these have significant impact on APRN clinical education as rural and underserved clinical sites typically allow APRNs to practice to their full scope of practice and provide excellent opportunities for professional and clinical skill development. Changing Expectations for Preparing Future APRNs Present Challenges and New Strategies The ongoing faculty shortage in schools of nursing also impacts the clinical training of APRN students. A sufficient pool of doctorally prepared faculty with clinical expertise is a prerequisite for programs to be able to grow the number of APRNs available nationwide to address primary care and other healthcare shortages. While these faculty are primarily responsible for educating future APRNs, pervasive faculty shortages continue to limit efforts to increase enrollments (Fang, Li, Arietti, & Bednash, 2014). To meet the IOM’s recommendation of ensuring that nurses practice to the full extent of their education and license, educational opportunities with a sound pedagogical foundation and availability of sufficient numbers of professional role models are essential. Expert nursing faculty are required to plan and implement learning opportunities focused on developing decision-making and problem-solving skills. Increasing numbers of clinical sites and preceptors are requiring that faculty validate students’ competencies prior to entering clinical training and establish a uniform clinical evaluation tool. Program faculty are ultimately responsible for the assessment of students; however, standardized assessment tools for faculty and preceptor use would clarify expectations and evaluation for students, faculty, and preceptors. Early work has begun at several schools to develop clinical assessment tools (personal communications Stone, S., September 2014; Clark, M., October 2013). In addition, other healthcare professions’ education programs, specifically medicine and physical therapy, are far ahead of nursing in developing standardized competencies for trainees and competency-based

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clinical assessments. These efforts provide opportunities for nursing to collaborate and build on the work that has been done. Use of Technology and Simulation in Nursing Education Growing In 2004, the IOM suggested that the healthcare workforce was ill-prepared to meet the needs of current and future patients and challenged health educators to expand the use of technology to drive educational innovation. In its work to maintain high quality standards, AACN— through a national, consensus-based process—has delineated the expected outcomes for all graduates of advanced practice nursing programs. The competencies outlined in the 2006 Essentials of Doctoral Education for Advanced Nursing Practice include system assessment and transformation, information management, quality improvement processes and outcome analysis, and organizational leadership, in addition to direct care, diagnostic, and management competencies. APRN programs are further challenged to provide learning experiences that prepare graduates with the full continuum of these expected competencies. The increasing challenges to identify a sufficient number of high quality clinical experiences have spurred a growing interest in the use of simulation, spanning the entire continuum of complexity, from low-fidelity task training to the use of standardized patients and high-fidelity simulation scenarios, both as teaching strategies and evaluation mechanisms. The National Council of State Boards of Nursing (NCSBN) predicts the future of clinical education in pre- licensure nursing will include the increased use of simulation (Kardong-Edgren, Willhaus, Bennett, Hayden, 2012). The NCSBN recognizes that simulation includes screen-based/PC- based simulation, virtual patients, partial task trainers, human patient simulators, standardized patients, and integrated models (Li, 2008). It seems reasonable to suggest that a similar trend can be envisioned for APRN education. There currently is a widespread movement to use simulation of all types (low and high fidelity) in both undergraduate and graduate nursing education. For example, low-fidelity simulation experiences utilize less similar supplies and equipment than those used in practice and include case studies or paper-and-pencil activities. High fidelity simulation includes the use of standardized patients and human patient simulators. Increased demand for simulation is driven by decreasing numbers of clinical practice sites, a national nurse educator shortage, the need for student opportunities to develop decision-making and problem-solving skills, gaps between academia and practice, and the search for a new model of education, which includes technology, realism, and diagnostic reasoning skills (Kelly, & Jeffries, 2012). Development of effective and innovative higher education models will require a paradigm shift from focusing on teaching to focusing on learning. Definitive research findings on the efficacy of high-fidelity simulation to facilitate learning are emerging. In a systematic review of 109 research articles with varying quality, the use of high- fidelity patient simulation was shown to facilitate learning under certain conditions such as providing feedback, repetitive practice, curriculum integration, multiple learning strategies, simulators that capture a wide variety of clinical conditions, a range of task difficulty, controlled environments where learners can make mistakes without consequences, individualized learning, defined outcomes, and simulator validity (Issenberg et al., 2005). In an update on simulation

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published in 2011, a review of over 600 studies enrolling over 35,000 medical student participants attempted to answer the question: To what extent are simulation technologies for training healthcare professionals associated with improved outcomes in comparison with no intervention? In these comparisons, both virtual patients and technology-enhanced simulation were consistently associated with large, statistically significant benefits in the areas of knowledge, skills (instructor ratings, computer scores or minor complications in a test setting), and behaviors (similar to skills, but in the context of actual patient care; Cook, 2010, 2011). The NCSBN National Simulation Study (Hayden et al, 2014) that focused on pre-licensure programs demonstrated that the use of up to 50% simulation in lieu of traditional clinical experiences showed no significant impact on NCLEX pass rates, clinical competency, and nursing knowledge. When evaluating the direct effects of simulation-based clinical experiences on patient outcomes such as major complications, increased mortality, or length of stay, the benefits are smaller but significant (Zendejas, 2013). Clearly, simulation-based education is effective at least when compared to no instruction at all. However, correlations between receiving frequent feedback, repetition, cognitive interactivity, clinical variation, individualized training, and longer training time also significantly improve skill outcomes (Cook, 2013). Cook concluded that, although simulation effectiveness is now established, value judgments require consideration of costs, including price of the simulator, faculty time, training expenses, facility fees, and opportunity costs. To date, few studies have enumerated these costs and none has offered a definitive position. There are examples illustrating that low-fidelity, low-cost training modules can lead to outcomes equal to much more expensive simulators (Tosterud, 2013; Tan, 2012; Finan, 2011; Levett-Jones, 20122; Friedman, 2009; Hoadley, 2009). Current curriculum standards limit or restrict the increased use of simulation in APRN education programs, particularly for NP and CNS programs (NTF, 2012; NACNS, 2011). However, the nurse anesthesia doctoral program standards currently being piloted require the use of simulation to prepare students for delivery of safe and effective patient care (COA, 2014). Strategies and Opportunities for Enhancing and Expanding Clinical Experiences In addition to the increased use of technology, education programs and practice settings have developed or are experimenting with innovative approaches and strategies to address the growing demand for APRN clinical training opportunities. The following is a sampling of the work underway:

• One approach has been the establishment of regional academic consortia to assign preceptors via a centralized database and matching process. Pooling and coordination of resources have been suggested to lessen competition for clinical sites and preceptors and maximize the use of all sites and preceptors within a region.

• Faculty-practice partnerships have emerged that allow a preceptor to supervise multiple students from one or more disciplines or roles and increase student access to clinical sites.

• A similar strategy has been to develop interprofessional or team-based practica experiences, which expand clinical opportunities but also facilitate the acquisition of interprofessional and role specific competencies.

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• Increased use of standardized patients and other forms of simulation training are providing expanded clinical training opportunities, and emerging evidence is showing that simulation methodologies can be used to enhance or expand the preparation of students prior to entering clinical sites.

Other schools are developing new clinical education models and placement of clinical experiences by front-loading didactic content followed by clinical coursework at the end of the curriculum; developing end-of-program immersion or practice intensive experiences when students have attained increased clinical expertise/knowledge; and placing students within one healthcare system for their entire clinical experience, which not only provides a longitudinal experience, but also allows the student to develop a relationship with and understanding of one system. Specific Clinical Education Challenges and Perspectives for the Four APRN Roles Certified Nurse-Midwives The Accreditation Commission for Midwifery Education (ACME) requires that all midwifery education programs incorporate the following competencies into their curricula: the American College of Nurse-Midwives (ACNM) Standards for Practice of Midwifery and the ACNM Core Competencies for Midwifery Practice (2011), and if a doctoral program, the ACNM Competencies for the Practice Doctorate in Midwifery. These documents address the expected educational outcomes of midwifery education. Each program is expected to provide evidence that graduates have achieved these outcomes. These competencies are examined and revised every five years. Accreditation of CNM and CM programs is accomplished by the Accreditation Commission for Midwifery Education through a peer review accreditation process. Graduates of accredited programs are eligible to take the national certification exam administered by the American Midwifery Certification Board (AMCB). Nurse-midwifery clinical education is based on the concept of competency-based education. Therefore, no required number of clinical hours or experiences is included in the ACME accreditation standards. Education programs are charged with adequately describing to ACME how they assure that graduates attain the basic core competencies. Although most educational programs have adopted policies which do require a number of hours in a one-to-one preceptor site and many require a certain number of different experiences, this policy does leave the door open to exploring the idea of replacing some direct one-to-one preceptor experiences with simulations or other learning approaches. Early research with midwifery students has shown that simulations are an effective way to teach students how to manage rarely encountered emergency situations such as shoulder dystocia methods (Lathrop, Winningham, & VandeVusse, 2007). Competency-based education also allows programs the flexibility to adopt policies that award students credit for previous experiences through successful demonstration of a skill/competency. Nurse-midwifery educators face a number of challenges in achieving the goal to graduate well- prepared midwives. Ideally, educators believe that students should have exposure to both in- hospital and out-of hospital experiences such as free-standing birthing centers or home birth practices. This is difficult due to the low number of out-of-hospital birthing sites. Another

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challenge is the competition with medical schools for clinical sites. Obstetrics/gynecology sites were identified as the second most difficult sites to find by allopathic (49%) and osteopathic (74%) schools (Multi-Discipline Clerkship/Clinical Training Site Survey, 2014). In health science centers, the hospital frequently will not sign an agreement to have nurse-midwifery students as they want to reserve the experiences for medical students or residents. They often cite the fact that the hospital is reimbursed through Graduate Medical Education (GME) funds for these types of students but not for nursing students. A third challenge is the gap in theory-based learning (midwifery philosophy of care) and the reality of non-evidence based clinical practices frequently seen in clinical sites. This can cause confusion and sound mentoring is required to help the student learn concepts such as therapeutic presence and non-intervention in the absence of complications (Jordan & Farley, 2008). This discrepancy, however, could present an opportunity to develop simulations and case scenarios to solidify these concepts. Certified Registered Nurse Anesthetists The nurse anesthesia (NA) clinical education model is unlike that of other APRNs in that students are assigned to clinical sites rather than clinical preceptors. Nurse anesthesia clinical education experiences are obtained at a variety of clinical sites rather than a single institution. While on rotation to a particular clinical site, nurse anesthesia students typically work with different preceptors from day to day. The ratio of nurse anesthesia student(s) to CRNA or MD clinical preceptor oversight is 1:1 or 2:1. Novice students typically work 1:1 with a clinical preceptor while more experienced or senior students may be supervised using a 2:1 ratio. During the course of a nurse anesthesia education program, students may work with hundreds of clinical preceptors. Certain clinical site rotations focus on specific specialty requirements, such as cardiovascular, pediatrics, obstetrics, or pain management, while rotations to other sites provide a more general exposure to patients from different populations who present for a variety of surgical or interventional procedures. The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) sets the standards for nurse anesthesia education and mandates required clinical experiences, including specialty experiences focusing on cardiovascular, pediatric, obstetrics, and pain management. Currently, a minimum 550 clinical cases in specifically defined categories are required to meet nurse anesthesia program clinical education requirements. However, current nurse anesthesia students far exceed this requirement by averaging over 800 cases and more than 2,500 total clinical hours. In 2015, the minimum case requirement for all nurse anesthesia programs will increase to 600 cases (COA, 2014). There is no option for part-time study according to COA program accreditation requirements. Other changes in nurse anesthesia education may impact clinical education opportunities for students. The COA has mandated that by January 2022, all nurse anesthesia education programs will transition to the doctoral degree as the entry to practice (COA, 2012). Nurse anesthesia doctoral programs will encompass a minimum of 36 months and include a requirement for anesthesia practicum clinical hours as well as additional hours needed to meet the clinical practicum requirement for completion of a capstone or terminal project. The number of

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educational credits required for CRNA students to complete the new doctoral program requirements will increase as will tuition costs. In academic health centers that house both nurse anesthesia and anesthesiology programs, sharing clinical site experiences and locations is commonplace. However, priority in choosing clinical experiences is many times given to the anesthesiology resident. As a result, nurse anesthesia students must attend rotations outside of their primary health system to access specialty clinical experiences. Competition for clinical sites also exists with anesthesiologist assistant programs and may increase as anesthesiologist assistant programs increase. While clinical rotation experiences outside of the primary institution have many advantages, including the opportunity to provide care to a highly diverse patient population in a variety of settings, nurse anesthesia students must incur the additional expense associated with travel, housing, and the recurring stress of rotating to different clinical sites. The quality of clinical preceptor expertise and degree of student oversight is also varied and more difficult to monitor, which creates a greater challenge for evaluating the student’s clinical performance. Financial reimbursement of APRN clinical preceptors varies by specialty and by institution. Nurse anesthesia educational programs do not typically reimburse clinical preceptors. The costs associated with financial reimbursement of a large number of nurse anesthesia clinical preceptors are cost prohibitive. The problem with creating financial incentives is that there are no guarantees that they can be maintained. The concern is that—with the economic difficulties of recent years and the push to create a more cost-efficient and effective healthcare workforce— incentivizing preceptors is likely not an institutional priority, and therefore, subject to withdrawal of funding where money for other projects is needed. This could create a negative situation between the clinical preceptor and the educational program and may result in loss of clinical education experiences. Clinical Nurse Specialist The National Association of Clinical Nurse Specialists (NACNS) used a national consensus-