Nurse practitioner field grapples with question of whether to standardize curriculum nationwide

(InvestigateTV) - Rayne Thoman had watched the 1980s thriller “Fatal Attraction” before. But this time she needed to write a college essay about Glenn Close’s character, a person who was struggling with mental illness.

The paper - worth more than a third of her grade - was part of her 2018 nurse practitioner class on psychiatric mental health for a master’s program at D’Youville College in Buffalo, New York.

“This looks like something I’d do in high school,” Thoman said.

Thoman, a registered nurse for five years, enrolled in D’Youville to get her master’s in nursing with the hopes of working as a nurse practitioner.

But she grew so concerned with what she considered easy class work, she started speaking with and reaching out to other students at different schools having similar issues.

“If it was just me, OK that’s an isolated incident. This is like a crisis almost in my opinion,” Thoman said.

As nurse practitioner programs grow in popularity, especially with online programs during the pandemic, some health experts are growing concerned about the standardization and quality of education.

Currently, while accreditors require certain benchmarks and give guidelines, programs can all use different methods for teaching and measures of student performance.

The standardization of medical programs for doctors happened more than 100 years ago. No such standardization exists for advanced practice nurses like nurse practitioners although attempts have been made.

Some licensed nurse practitioners continue working to change the education model. They have started petitions and social media campaigns.

Nurse practitioners are allowed to diagnose and treat patients, but their power depends on the state in which they practice.

Twenty-two states allow nurse practitioners to practice independently with some running their own medical practices. Other states require a supervising physician to sign off on treatment.

For a registered nurse to become a nurse practitioner, or an NP as they are often called, they typically complete a two-year master’s of nursing program with a combination of class instruction and hands-on hours with patients.

More than 30,000 nurse practitioners graduated last school year, according to the American Association of Colleges of Nursing.

While many graduate from established, well-respected universities, some education models, critics say, are not preparing students for the rigors of being an NP and could be putting future patients at risk.

Further, the variety of state regulations nurse practitioners and schools operate under make it difficult for students to find programs that will lead to licenses in different states – and make it difficult for colleges to keep up with requirements.

The industry’s largest professional organization, the American Association of Nurse Practitioners, declined an interview request. But standardization of NP education is clearly an issue amongst those who study the profession. In the association’s journal, two professors argued for and against whether the curriculum should be standardized.

Physicians for Patient Protection has been an outspoken group of doctors questioning training for nurse practitioners. They invited Thoman to speak at a press conference earlier this year.

“While some nurse practitioners attend high-quality, brick-and-mortar training programs, students are increasingly turning to ‘diploma mills’ with 100% acceptance rates and completely online curricula,” the organization said in an email statement.

Online schools

Online college degrees have become convenient and accessible, especially during the pandemic. They allow nurse practitioner students, many of whom work, flexibility.

There are at least 570 master’s of nursing programs in the United States. One out of six is completely online, according to MastersInNursing.com, a resource site for prospective students.

But critics argue not all online colleges provide the needed experience.

Cristina Naslund was working full-time in Chicago and wanted to start a family, so the nurse practitioner program with 100% online classes attracted her to Maryville University in St. Louis in 2017.

“I didn’t want to do the whole sit down in class thing and just have more flexibility with work-life balance,” she said.

After working nearly a year as a nurse, Naslund wanted to advance her career. She started at Eastern Kentucky State University but had to switch schools when she moved to Chicago.

When Naslund started Maryville classes, she was surprised to see PowerPoints to read instead of live or pre-recorded lectures by professors.

“All of the classes are just a joke,” she said.

Instead of lectures, Naslund read and wrote papers that she describes as “busy work.”

She said learned the most during the 80 clinical hours where she worked under a physician.

More than 800 students graduated from Maryville University’s master’s in nursing programs during the 2019 school year, according to federal data. The university declined an interview request.

Naslund, now the mother of two children, did not finish her degree, but continues to work as an RN care manager, coordinating individual patient’s care.

State licensing

In addition to varying independence for providers in each state, there’s no national standard on licensing nurse practitioners.

For example, Indiana doesn’t require nurse practitioners to pass a national certification exam, a requirement by most states.

States mainly require practitioners to graduate from an accredited school and rely on two national accreditation agencies to set and enforce education standards: Accreditation Commission for Education in Nursing (ACEN) and Commission on Collegiate Nursing Education (CCNE)

ACEN declined an interview request. CCNE did not respond.

But even if a program is accredited, that doesn’t mean a state will accept its graduates.

The master’s of nursing online program at Purdue University Global, an extension of Purdue University, in West Lafayette, Indiana, won’t accept students from at least nine states because graduates wouldn’t be licensed there, according to the school’s website.

The varying state requirements are a challenge to national online programs so the school hasn’t applied for approval everywhere, according to an email statement from the university.

The University of North Dakota, which also offers an online master’s of nursing degree, faces similar struggles. According to its website, it does not admit students from some states because of state nursing board requirements. For the majority of states from which students can be admitted, a few have additional steps a student may have to take.

“The college and program are certainly qualified and can meet the individual educational requirements of any state, but due to the widely varying and continually changing rules and requirements across the nation, the college has made a strategic decision to focus on meeting the needs of students from a select number of states where the requirements are largely consistent,” the college said in an email statement.

Arkansas has fewer requirements than some states.

“Every state has different educational standards. Our standards are put in place to ensure that students meet all academic requirements that we feel are necessary here in the state of Arkansas,” said Tammy Vaughn, program coordinator for the Arkansas State Board of Nursing.

The effort to standardize education and licensing of advanced practice nurses including nurse practitioners was introduced in 2008 by the National Council of State Boards of Nursing with the work of several organizations.

While some states have adopted portions of the standardization recommendations, called the Consensus Model, to date only 18 states have fully adopted all elements.

NPs speak out

Practicing NPs have grown concerned with the education model.

A Facebook group called Clinical Nurse Practitioners for Change has nearly 5,000 members. According to its Facebook page, the group’s mission is, “To provide a voice for nurse practitioners that will promote, stabilize, and standardize Nurse Practitioner education for the improvement of clinical practice promoting improved patient outcomes.”

Listed administers of the group didn’t respond to requests for comment or declined to be interviewed for fear of retribution.

Some NPs would like to see more clinical hours—direct patient care—for nurse practitioner programs. The minimum requirement set by the accrediting organizations is 500 clinical hours.

Physicians are required to complete around 6,000 clinical hours in school and then an additional three years of residency that equate to 9,000 to 10,000 additional clinical hours.

Gabe Westheimer is a family nurse practitioner in San Francisco. The pandemic is highlighting the appreciation for quality care from nurse practitioners, he said.

“We’re an important group of providers to help our neighbors, our communities, during this time of COVID, and certainly the need for good medical care is important,” he said.

He regularly works with NP students to fulfill their clinical hours. He’d like to see NP students get a minimum of 1,500 clinical hours.

“State by state, it kind of varies what’s required, different minimum requirements of clinical hours. I think the state of California is still at a kind of abysmal,” he said.

California requires 500 clinical hours to secure a nurse practitioner license.

Filing Complaints

Thoman’s concerns for the instruction at D’Youville led her to file complaints in 2019 with the New York State Department of Education, the federal Department of Education Office of Civil Rights and D’Youville’s accrediting agency, the Commission on Collegiate Nursing Education.

More than a year later, the state of New York is still investigating the complaint, according to an email sent to Thoman in June.

InvestigateTV contacted the state department about the status of Thoman’s complaint. “We are not able to respond to your query,” an employee emailed.

The complaint filed with the Office of Civil Rights where Thoman alleged disability discrimination when the college did not provide accommodations for a course, resolved in February when D’Youville voluntarily agreed to improvements but did not admit wrongdoing.

Thoman filed a subsequent complaint alleging D’Youville retaliated against her for filing the first complaint by disenrolling her in the program. OCR is still investigating.

D’Youville College declined an interview request. “The college will be responding to the Complaint, denying all allegations of retaliation or other wrongful conduct,” D’Youville wrote in an email statement.

After follow-up reports were filed by D’Youville College, the CCNE board in February determined there were “no compliance concerns.”

Graduates from any program are typically required to pass a national nurse practitioner exam. The passing rate is often a measure of a school’s program. D’Youville’s pass rate was above the national average of 87% percent last year.

“We are proud of all of our nursing programs, and our School of Nursing is in full compliance with our accreditor CCNE,” D’Youville wrote.

Thoman said her education is on hold as she waits to hear from investigators on her two outstanding complaints. In the meantime, she continues to speak out and connect with other students.

“What would concern me would be that when the door closes and I have to be responsible to make decisions that are going to impact another person’s health and wellness.”

News content specialist Peter Buffo contributed to the report.

Additional research conducted by William Savoie from Loyola University New Orleans.

D’Youville Full Statement

In August 2019, the College received a U.S. Department of Education, Office of Civil Rights (“OCR”), Complaint on behalf of the student, Rayne Thoman. On or about February 27, 2020, the College entered into a Voluntary Resolution Agreement with OCR in order to fully resolve the Complaint. As a result, the Complaint was dismissed. In June 2020, the College received a subsequent Complaint filed by Ms. Thoman, alleging retaliation. The College will be responding to the Complaint, denying all allegations of retaliation or other wrongful conduct. Pending complaints filed with OCR by Rayne Thoman, the College will not be able to discuss the details of this case publicly at this time.

Please note, however, complaints filed by Rayne with both the NYSED and CCNE were fully evaluated and D’Youville was found to be in compliance. D’Youville’s School of Nursing successfully graduates over 100 Nurse Practitioner (“NP”) students each year. We are proud of all of our nursing programs, and our School of Nursing is in full compliance with our accreditor CCNE. The complaint filed by Ms. Thoman with CCNE was fully evaluated and D’Youville was specifically found to be in compliance.

The COVID pandemic severely disrupted clinical placements for myriad health professions programs – including nursing programs at all levels – which has impacted colleges and universities throughout our region. However, we are doing everything in our power not only to remain in compliance, but also to find creative opportunities to support student progression and secure clinical placements. This includes:

• Constant outreach to local and regional providers for clinical placements

• Offering housing stipends to students willing to go out of region, such as to a rural community, to obtain a placement

• Appealing to the New York State Education Department to replace some clinical hours with high-impact simulation experiences

In addition to CCNE, D’Youville provided extensive evidence to NYSED regarding Ms. Thoman’s complaint and no additional follow-up was requested.

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