EDUCATION

Nurse practitioner education: Greater demand, reduced training opportunities Ingrid Forsberg, FNP-BC (Instructor)1 , Kathryn Swartwout, PhD, FNP-BC (Assistant Professor)1 , Marcia Murphy, DNP, ANP-BC, FAHA (Assistant Professor)2 , Katie Danko, MPH (Project Manager)1 , & Kathleen R. Delaney, PhD, PMH-NP, FAAN (Professor)1 1 2

Department of Community, Systems and Mental Health, College of Nursing, Rush University, Chicago, Illinois Department of Adult Health and Gerontological Nursing, College of Nursing, Rush University, Chicago, Illinois

Keywords Education; precepting; primary care; students; nurse practitioners. Correspondence Ingrid Forsberg, FNP-BC, Department of Community, Systems and Mental Health, College of Nursing, Rush University, 600 S. Paulina St, Chicago, IL 60612. Tel: 312-942-5242; Fax: 312-942-6226; E-mail: [email protected] Received: 3 June 2013; accepted: 25 August 2013 doi: 10.1002/2327-6924.12175

Abstract Purpose: To document the factors that are increasing the tension between nurse practitioner (NP) educational programs and the clinical training sites needed for NP students. Data sources: Literature and the faculty experiences garnered over years of placing NP students for clinical training. Conclusions: Several conditions converge to create a situation where sites are increasingly reluctant to precept NP students. The underlying dynamics are diverse and include factors related to the electronic health record, productivity expectations, and the increasing demand for sites as a result of increasing NP enrollments and competing healthcare provider programs. Implications for practice: The nursing community should approach this issue strategically and devise an action and policy agenda to support NP training, including federal monies to support NP training in a design that parallels the Graduate Medical Education; recognition of NPs as licensed professionals in advanced training; and identification of meaningful incentives for NP preceptors.

Nurse practitioners (NPs) are increasingly sought to fill the demand for primary care in all age groups (Robert Wood Johnson [RWJ] Foundation, 2012). Four major healthcare/workforce trends leverage this demand. (a) The increased access to services through health insurance expansion coupled with a shortage of community providers is leading to a national service gap for an estimated 56 million individuals (National Association of Community Health Centers [NACHC], 2012). (b) The need for NPs in the nation’s hospital system is growing, a demand created by the reduction in medical intern and resident training hours as well as the increasing recognition of NP abilities for cost-effective quality care (Larkin, 2003; RWJ Foundation, 2013). (c) Given the recognized need for improved care coordination for older adults and the chronically ill, new models of care are emerging, which utilize NPs in both care coordination and direct service (Stanley, Werner, & Apple, 2009). (d) The anticipated decrease in physicians entering the profession, particularly in primary care (Kirch, Henderson, & Dill, 2012), has increased

66

focus on NPs and physician assistants (PAs) as a solution to workforce practice gaps (Sargen, Hooker, & Cooper, 2011). NPs are also seen as a response to the overarching federal message for cost containment in healthcare services (Poghosyan, Lucero, Rauch, & Berkowitz, 2012). NPs provide quality service that is both effective and cost-efficient, supported by strong consumer satisfaction (Newhouse et al., 2011; Schiff, 2012). This demand for NPs coupled with the greater public recognition of their role in healthcare delivery has contributed to the increased NP enrollments at colleges and schools of nursing (O’Connor 2012). As a result, the graduate nursing programs that educate NPs are experiencing significant increases in student applicants, which should grow the NP workforce significantly and help address the primary care demand (Auerbach, 2012), and ultimately build a workforce focused on health promotion and primary prevention. Unfortunately, NP graduate programs are encountering barriers forcing them to limit enrollment. The

Journal of the American Association of Nurse Practitioners 27 (2015) 66–71  C 2014 American Association of Nurse Practitioners

Nurse practitioner education

I. Forsberg et al.

barriers include an NP faculty shortage, limited clinical training sites, and restrictive state practice laws (Fitzgerald, Kantrowitz-Gordon, Katz, & Hirsch, 2011). Restrictive state practice laws are an issue for potential training sites because such regulations often lead to a reduction in the number of NPs in those states, thus contributing to a limited number of training sites (Lugo, O’Grady, Hodnicki, & Hanson, 2007). While the difficulties securing clinical training sites are often discussed at national NP faculty meetings (Bowen, 2013) and noted as a major barrier to increasing NP enrollment (Cleary, McBride, McClure & Reinhard, 2009; Fitzgerald et al., 2011; Sargen et al., 2011), there is surprisingly scant mention in the literature of the factors that contribute to the increasing imbalance in training site supply and demand. This article discusses the prime reasons identified by our faculty as contributing to the problems in securing training sites for NP students.

Principle issues with securing NP clinical training sites Electronic health record requirements The recent mandate of transitioning to electronic health records (EHRs) has made a sudden and dramatic impact on NP training. Different sites employ different EHR systems and each employed clinician is trained to use that particular system. Often NP students must complete training to be able to use the EHR at their clinical site, training that costs the site, school of nursing (SON), or the preceptor both time and money if the site does not have training classes. Regardless of how it is accomplished, precious time is spent in EHR training, which impacts productivity. A related barrier is the need for students to have their own log-in to have access to the EHR, which can result in extra cost to the site. Naturally some sites pass on this cost to the SON, which can be several thousand dollars per license.

Documentation guidelines Medicare stipulates guidelines for medical student charting in a patient’s record and many sites interpret these guidelines as also applying to NP students. The guidelines require the supervising preceptor to personally document the majority of the history, physical, and medical decision making (Centers for Medicare and Medicaid Services [CMS], 2011). The preceptor cannot copy/paste or refer back to the student note. Of course, student documentation is always reviewed by the preceptor and the note co-signed, but this guideline moves away from allowing students to document the data they accumulate during

their interviews with clients. While not formally discussed within the nursing community or CMS, these restrictions are often applied to NP students even though they are all registered nurses (RNs). These documentation requirements place a significant burden on preceptors and training sites.

Demands for productivity Perhaps the most frequently expressed concern of NP preceptors is the loss of productivity he/she incurs when taking on a student in training. There is little recent data on lost productivity because of precepting (Farwell, 2009), but a student in clinical training needs a certain degree of teaching and oversight to acquire targeted clinical competencies. Precepting and space needs also enter into this productivity equation. Exam room capacity can be compromised when precepting pairs require two exam rooms available for their use. A decrease in productivity may also be generated if the preceptor and student have to share a room and EHR. If NP or MDs’ evaluations and/or salary are based on productivity, they may be understandably reluctant to take on a precepting role. While there are strategies for utilizing NP students that may actually boost productivity, precepting methods are—as they should be—very much the purview of the individual preceptor. In medical education, the issue of lost productivity is addressed by indirect Graduate Medical Education (GME) support for teaching hospitals (Dower, 2012). While the nursing community now has five Graduate Nursing Education (GNE) demonstration projects (CMS, 2013) to explore how funding might address the issue, the findings of these demonstration projects are several years from publication.

Experience level of select NP students As with any profession, students enter into an educational program with varied experiences related to their past work history and education. Some students will learn faster and more efficiently than others. Although each student must master particular NP competencies (such as history and physical exam skills) before starting clinical placements, students will differ in their level of comfort and abilities at initial stages of their practicums. Students with less experience or less comfort in their new role demand more time and support from the preceptor. The SON faculty is often aware of these issues and attempts to place students needing additional support with a seasoned preceptor, a faculty member acting as a preceptor, or one who has the patience and time to train such a student. If such students are not correctly matched to a site and preceptor that can accommodate their needs,

67

Nurse practitioner education

the clinical partnership may fail and be threatened for future placements. Thus matching a preceptor and student is an important component of training, yet one that is difficult to engineer when the number of students needing training is high, the supply of training sites is low, or in situations where students are required to find their own sites.

Preceptor fatigue Training students, regardless of their merit, can become repetitive and tiring and even a seasoned preceptor can experience “burn-out.” Add to this the reality that there are no real incentives to precept. At the current time, most clinical training partnerships are forged on good will, personal relationships, the preceptors’ commitment to educating students, or their desire for the few continuing education units allowed for recertification by select nursing certifying organizations. Willing preceptors are undoubtedly approached continuously year after year to train students. One preceptor told us that after 21 years of training students, he had just grown tired of the role and needed a break.

NPs as employees NP preceptors often have restrictions placed on their time and activities by their employer. In our faculty’s experience, some employers limit or even prohibit precepting. In addition to direct patient care, most NPs are expected to participate in other aspects of clinical care delivery such as chart reviews, coding reviews, monthly meetings, quality improvement projects, and supervision of other nursing personnel. If precepting is approved by the employer, these competing time demands may discourage an NP from precepting. With such demands and employers’ control of their time, often it is not within an NP’s decisional control to respond to a precepting request.

Preceptor job mobility Preceptor job changes can disrupt the precepting relationships that have been forged with SONs. NPs change positions for a variety of reasons, including job dissatisfaction, issues of autonomy, and desire for personal growth (De Milt, Fitzpatrick, & McNulty, 2011). Also NPs are usually employees and do not have the opportunity to share in the ownership of a practice, which means the NP may have no “stake” in the business. When an NP changes positions, quite naturally the working relationship with the SON also changes. Even if the SON faculty is informed of the new location of the NP preceptor, the NP preceptor is often unavailable for precepting while they orient to 68

I. Forsberg et al.

their new position or organizational guidelines may prohibit precepting for the first year on a new job. The connection to the SON may be lost during this transition time. Thus a variety of factors exist that destabilize NP preceptor/SON relationships.

Overwhelming sites with requests for training Clinical sites, overwhelmed by the demand for NP student placement, express their frustration with the constant inquiries and their inability to accommodate all the requests. One NP, who coordinates training requests at a site, told us that in addition to the numerous calls at her clinic, students are beginning to call her at home in the evening begging for a placement. The constant inquiries are a nuisance to clinics, and create a sense that there is so great a demand for sites that meeting expectations of area schools is impossible. For a variety of reasons, site frustration is exacerbated by NP students who are in educational programs that require the students to find their own clinical training sites. Students seeking their own sites do not always know what clinical experiences they need (i.e., course objectives) and sometimes do not have a clear understanding of the type of services or patients seen at the site they are calling. This simply adds to the “site frustration.”

Formalized mechanisms to secure training sites As mentioned previously, sites are inundated with requests for NP training. To manage the requests, many hospitals and primary care settings have designated a single “gatekeeper” (often called a clinical site placement coordinator) to be the primary contact for SONs and students inquiring about clinical placements. While a logical, practical, and needed organizational scheme, the clinical site coordinator disrupts the informal mechanism for securing training sites, which relied on relationships with preceptors, sometimes because they were former students of the school. The clinical site placement coordinator is often an NP or administrator who is juggling many other responsibilities at a prospective site. In large organizations with multiple sites, the clinical site placement coordinator’s job is daunting, requiring increasing amounts of dedicated time and continual polling of the potential preceptors at the site regarding their interest and availability. An added burden is their involvement in securing the clinical contract between the site and the school, a process that may be lengthy, as each organization’s legal departments discuss and negotiate specific terms.

Nurse practitioner education

I. Forsberg et al.

Navigating the hierarchy Despite the fact that many clinical sites have a designated Clinical Placement Coordinator, it is sometimes difficult to obtain confirmation of a preceptor’s availability and willingness to accept a student. SON faculty develop relationships over many years with various people who represent the site including both administrators (i.e., CEOs, clinic managers, medical directors) and the clinicians who train the students. These relationships are vital to maintaining a good standing with a partner site. Many different people are involved in laying the groundwork for NP training at clinical sites and many sites have been partners with SONs over many years. Sites often hire graduates from the schools they precept for. The history and complexity of these relationships must be carefully navigated by the SONs seeking placements. A SON accustomed to working with a preceptor over many years may find that they cannot readily navigate the new organizational scheme for securing preceptors.

The fairness dilemma—So many schools, so few sites The need for clinical sites is overwhelming, particularly in regions with many SONs. As enrollments grow, the demand is exponential. Clinical sites understand, but cannot meet the demand. They report that they want to be fair to all SONs who have requested placements. Thus sites must consider all the requests made and determine an equitable way to distribute the openings to all SONs involved. The fairness demand becomes even more complicated with online education. An NP student might be receiving clinical education in one state while formally enrolled in an online program in another. Such students often seek their training where they work or in the hospital system where they are trained for their undergraduate degree. In such situations, the clinical site is faced with the difficult dilemma of prioritizing competing requests.

Lack of academic structures and funding stream to support NP training Many physicians have joint appointments with a university, and being on a university faculty adds value to their practice role. Often with a joint appointment comes the expectation of participating in the education of those coming into the profession. In most instances, attending physicians are tasked with the job of training medical residents and fellows in clinical settings. In fact, training residents/fellows might be written in as an element of the attending physician’s position. Whether it is included as part of their job description and/or they are compensated for

it, the traditions and mechanisms of medical student training are deeply embedded in a teaching hospital and the GME reimbursement structure (Dowers, 2012). Unfortunately, the same mechanisms of this very successful training model are not established for NP training. The GME system has been in existence nationally for 30 years, but there has never been a similar, formalized route to systematically plan for NP training. The responsibility of NPs employed in teaching hospitals to participate in the education of their NP students is rarely delineated. There are even instances when an NP is considered an employee of a medical department and the priority is for the NP to train medical students. Additionally, a joint appointment structure for NPs, which would support a formal relationship for precepting rarely exists.

Discussion Considered together, the multiple factors impacting NP clinical training opportunities pose a significant threat to sustaining quality NP clinical education. At the current time these barriers have not been examined in the literature. A dialogue needs to begin on both the issues and the action steps to address them. Four priority issues that particularly warrant policy discussion and organized action are federal support for NP education, recognition of RN scope of practice as defined in each state’s nurse practice act, preceptor/site compensation, and a strategic plan for broader inclusion of NPs in federal workforce planning groups. Recognizing the need for more primary care providers, the Affordable Care Act funded the GNE demonstration project. Currently, CMS is conducting a pilot at five GNE sites. The demonstration will provide information on whether federal support for Advanced Practice RN (APRN) clinical training facilitates a graduate nursing program’s ability to secure clinical training sites and thus increase their enrollment of APRN students particularly NPs for primary care. The findings from the GNE will inform policy discussion on how to systematize reasonable levels of federal support for APRN training. A plan for federal support for APRN training could be modeled after GME support for medical education. In such a plan, the GME preceptor support provided by Medicare Part A could be extended to NP training, a solution supported by the Medicare Payment Advisory Commission (MedPAC; O’Grady & Ford, n.d.). A GNE model would not duplicate every provision of the GME; it is an expensive program that soon may be trimmed by the federal government (Iglehart, 2013). Reasonable support for NP training would not necessarily seek salaries for trainees (the bulk of the GME costs) but equalize GNE and GME incentives in the area of

69

Nurse practitioner education

monies that provide salary compensation to preceptors. For SONs that are not affiliated with academic medical centers, partnerships with large hospital systems that care for federally insured patients might be created and a mechanism established whereby training pass-through dollars provide support for a portion of NP preceptor salaries. A proposed bill for federal support of medical education for community training would allocate a portion of GME payments to community-based primary care residency programs (AAFP, 2013). Support of NP training at community sites, particularly those addressing the needs of the underserved, could also be structured along the lines of the proposed GME reimbursement system. The GME system represents the federal government’s belief in their duty to support the training of the workforce who will provide for the health of the nation and the related hospital commitment to train that workforce. The GNE marks an important step in the federal government’s recognition that APRNs are critical to advancing the health of U.S. citizens. It has provided the profession a new level of inclusion in federal healthcare workforce planning. Nursing organizations such as the American Nurses Association (ANA), American Association of Colleges of Nursing, American Academy of Nurses, and the American Association of NPs need to forward policy initiatives that maintain the dialogue. As the role of APRNs in federal workforce planning has enlarged, the interprofessional discourse on their education and scope of practice has intensified. The dialogue often defaults into comparisons of the educational path of APRNs versus physician providers. What often becomes lost in the discussion is that APRN students are licensed professionals in advanced training. Failure to recognize this point has subtle ramifications; our concern is its impact on CMS policies around training. Here APRN students are often included in regulations designed for unlicensed trainees such as medical students and PAs. This practice is carried into the interpretation of CMS documentation guidelines, which then become applied to APRN students, medical students, and PAs (Schaffer, 2002). Thus to appropriately apply these guidelines to APRN students, a dialogue needs to begin on how the clinical scope of practice and documentation of an NP student interfaces with the scope and documentation of a licensed RN. Perhaps NP preceptors would follow CMS guidelines for medical residents, who are also licensed professionals. In this instance, preceptors would amend and attest to the documentation of the trainee. Of course training efficiencies, patient safety, and quality care need to be carefully considered. But in this era of improving access to care and productivity monitoring, it is important that NP trainees can contribute to the extent of their license to the patient 70

I. Forsberg et al.

care performed at the site. Nursing organizations should work with CMS to identify how APRN trainees as licensed professionals might document to their current scope of RN practice. The issue of preceptor/site compensation must also be examined. This subject has often been approached as a dichotomous question of “to pay or not to pay” preceptors. Considering the financial strains on SONs as well as the productivity demands on preceptors, a more viable approach might be to develop a meaningful package of preceptor/site compensations that fit site needs and SON compensation avenues. For instance, a site or preceptor might value adjunct faculty appointments, which would allow them some benefits from the university such as library Internet services, faculty development programs, and research opportunities with members of the faculty. For NP preceptors, additional incentives might include tuition allowances for further education and mentoring by faculty for publications/presentations at local and national conferences. Models should also be considered for compensating a clinic site rather than individual preceptors. In this scheme, sites and SONs might become partners in supporting the site’s quality initiatives or implementation of new models of care at the site. Doctor of Nursing Practice (DNP) students would be particularly useful in these initiatives. Alternately a SON might enter into arrangements to place a faculty 1 or 2 days a week at a site where they would provide services and precept students. Testing such models, the site and SON could arrive at a cost-sharing scheme where the patient revenue covers a portion of the faculty salary. Finally, the workforce dialogue must continue and that will require nursing representation on the federal workforce committees that are steering the process. These nursing representatives need to be armed with data on how in each state the SONs and the state ANA chapter are coordinating to examine and plan for meeting the healthcare needs of the citizens of that state. For example, the recent report on the care provided by NPs to patients with Medicare insurance (state by state) helps support how NPs address access issues (Kaplan, Skillman, Fordyce, McMenamin, & Doescher, 2012). Another piece of data that would support workforce planning and access would be a prospective planning report from each state, substantiating medical need, the current supply of providers (including NPs), and the projected graduates from the current NP schools in the state. The state action coalitions supported by recent RWJ and American Association of Retired Persons (AARP) initiatives might assist with these data (Campaign for Action, 2013). The APRN consensus model has demonstrated nursing’s capacity to create dialogue and a model for consistency and quality in APRN

I. Forsberg et al.

training across licensure, accreditation, certification, and education. A similar effort should be mounted in state by state workforce planning for the future of health care.

Conclusion The traditions of negotiating NP preceptors via relationships and good will are no longer the only viable methods for securing NP training sites. A sustainable method of garnering and maintaining quality preceptors must be created in order bring NP clinical training to the next level of professionalism.

References AAFP. (2013). Bipartisan bill would create community-based primary care training models. Retrieved from http://www.aafp.org/news-now/governmentmedicine/20130314gmebillreintroduced.html Auerbach, D. I. (2012). Will the NP workforce grow in the future? New forecasts and implications for healthcare delivery. Medical Care, 50, 606–610. Bowen, F. (2013). Educating primary care NPs: Overcoming the challenges of practicum placements. NONPF 39th Annual Meeting. Lecture conducted from Pittsburg, PA. Campaign for Action. (2013). Future of nursing: Campaign for action. Retrieved from www.campaignforaction.org Centers for Medicare and Medicaid Services (CMS). (2011). Fact sheet: Guidelines for teaching physicians, residents and interns. Retrieved from http://www.cms.gov/Outreach-and-Education/Medicare LearningNetworkMLN/MLNProducts/downloads/gdelinesteachgresfctsht.pdf Centers for Medicare and Medicaid Services (CMS). (2013). Graduate nurse education demonstration. Retrieved from http://innovation.cms. sgov/initiatives/gne/ Cleary, B. L., McBride, A. B., McClure, M. L., & Reinhard, S. C. (2009). Expanding the capacity of nursing education. Health Affairs, 28(4), w634–w645. De Milt, D. G., Fitzpatrick, J. J., & McNulty, S. R. (2011). Nurse practitioners’ job satisfaction and intent to leave current positions, the nursing profession, and the nurse practitioner role as a direct care provider. Journal of the American Academy of Nurse Practitioners, 23, 42–50. Dower, C. (2012). Graduate Medical Education. A debate continues over the size and scope of federal subsidies to support residency training of the nation’s physicians. Health Affairs, Health Policy Brief. Retrieved from http://healthaffairs.org/ healthpolicybriefs/brief˙pdfs/healthpolicybrief 73.pdf Farwell, A. L. (2009). Practitioner preceptors: A shortage of willing mentors. Journal of Pediatric Health Care, 23, 198–200. doi: 10.1016/j Fitzgerald, C., Kantrowitz-Gordon, I., Katz, J., & Hirsch, A. (2011). Advanced practice nursing education: Challenges and strategies. Nursing Research and Practice, 2012. doi: 10.1155/2012/854918

Nurse practitioner education

Iglehart, J. K. (2013). Financing Graduate Medical Education—Mounting pressure for reform. New England Journal of Medicine, 366, 1562–1563. Kaplan, L., Skillman, S. M., Fordyce, M. A., McMenamin, P. D., & Doescher, M. P. (2012). Understanding APRN distribution in the United States using NPI data. Journal for Nurse Practitioners, 8(8), 626–635. doi: 10.1016/ j.nurpra.2012.05.022 Kirch, D. G., Henderson, M. K., & Dill, M. J. (2012). Physician workforce projections in an era of health care reform. Annual Review of Medicine, 63, 425–445. doi: 10.1146/annurev-med-050310-4634 Larkin, H. (2003). The case for nurse practitioners. Hospitals & Health Networks, 77(8), 54–58. Lugo, N. R., O’Grady, E. T., Hodnicki, D. R., & Hanson, C. M. (2007). Ranking state NP regulation: Practice environment and consumer healthcare choice. American Journal of Nurse Practitioners, 11, 8–24. National Association of Community Health Centers (NACHC). (2012). The state of unmet need for primary health care in American. Retrieved from http://www.nachc.com/client//HealthWanted.pdf Newhouse, R. P., Stanik-Hutt, J., White, K. M., Johantgen, M., Bass, E. B., Zangaro, G., . . . Weiner, J. P. (2011). Advanced practice nurse outcomes 1990–2008: A systematic review. Nursing Economics, 29, 1–21. O’Connor, B. (2012). New American Association of Colleges of Nursing data show enrollment surge in baccalaureate and graduate programs amid calls for more highly educated nurses. Journal of Professional Nursing, 28, 137–138. O’Grady, E. T., & Ford, L. C. (n.d.). The 5 NP political issues and the one solution. WebNPonline. Retrieved from http://www.webnponline.com/ Poghosyan, L., Lucero, R., Rauch, L., & Berkowitz, B. (2012). Nurse practitioner workforce: A substantial supply of primary care providers. Nursing Economic$, 30, 268–274, 294. Robert Wood Johnson (RWJ) Foundation. (2012). How nurses are solving some of primary care’s most pressing challenges. Charting Nursing’s Future (July). Retrieved from http://www.rwjf.org/content/dam/files/file-queue/ cnf20120810.pdf Robert Wood Johnson (RWJ) Foundation. (2013). Improving patient access to high quality care. How to fully utilize the skills, knowledge, and experience of Advanced Practice Registered Nurses. Charting Nursing’s Future (April). Retrieved from http://www.rwjf.org/content/dam/farm/reports/ issue briefs/2013/rwjf405378 Sargen, M., Hooker, R. S., & Cooper, R. A. (2011). Gaps in the supply of physicians, advance practice nurses, and physician assistants. Journal of the American College of Surgeons, 212, 991–999. Schaffer, S. D. (2002). How NP preceptors can comply with Medicare requirements. Nurse Practitioner, 27, 10. Schiff, M. (2012). The role of nurse practitioners in meeting increasing demand for primary care. National Governors Association for Best Practices. Retrieved from http://www.nga.org/cms/home/nga-center-for-best-practices/centerpublications/page-health-publications/col2-content/main-content-list/therole-of-nurse-practitioners.html Stanley, J. M., Werner, K. E., & Apple, K. (2009). Positioning advanced practice registered nurses for health care reform: Consensus on APRN regulation. Journal of Professional Nursing, 25, 340–348.

71

Copyright of Journal of the American Association of Nurse Practitioners is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Nurse practitioner education: greater demand, reduced training opportunities.

To document the factors that are increasing the tension between nurse practitioner (NP) educational programs and the clinical training sites needed fo...
114KB Sizes 0 Downloads 6 Views