Nurse practitioner report calls for urgent change to NP education to protect patient safety

Rebekah Bernard: ©Rebekah Bernard

John Canion has proudly worked as a nurse practitioner (NP) for the last twenty years, but recent changes to NP education have him deeply concerned about the state of his profession. After spending a decade trying to improve nursing from within, serving on an American Association of Nurse Practitioner (AANP) education committee, working as a nursing professor, and even forming a grassroots organization for change, Canion has become frustrated with a lack of action from the nursing establishment. A few months ago, he decided to make his concerns public, releasing the 2023 Report on Nurse Practitioner Education and the Need for Change.

In his report, Canion outlines a decline in nurse practitioner education following the Institute of Medicine’s 2010 Future of Nursing report, which called for an increase in advance practice nurses. That same year, the Affordable Care Act authorized a major increase in funding for NP education, resulting in a surge of for-profit nurse practitioner programs. “The goal seemed to be to produce as many nurse practitioners as possible,” said Canion, noting that the number of NPs rose from 91,000 in 2010 to 385,000 in 2024.

Competition for federal funding and student tuition dollars by these numerous NP programs led to a decline in entry criteria and educational standards, resulting in new NP graduates who are unprepared to provide quality care to patients. Canion believes that we are now at a tipping point: “Mounting evidence confirms that NPs do not match up well with their physician counterparts regarding patient outcomes,” Canion said, noting that these newer studies contradict prior research from previous decades when NPs received higher quality training and more physician supervision.

Changes in NP education

Traditionally, nurse practitioners entered the field after honing years of experience as a nurse, and training programs were competitive and rigorous. For example, John Canion spent six years at the bedside in multiple hospital departments before entering his NP program, which he says was intense.“I attended in-person lectures and received my clinical training at a critical access rural hospital. I was on call for the whole time I was there. You learned how to work tired, and it was an invaluable part of training.”

With a call to increase the number of NPs in 2010, this training model began to change. To reach more students, many nursing programs converted to online learning, and by 2021, 59% of family nurse practitioner students were enrolled in completely or mostly on-line learning. Entry requirements declined, with some programs boasting 100% acceptance rates. Many NP programs no longer require any nursing experience, with 22% of all family nurse practitioner students in 2019 enrolled in “direct entry”d programs, which allow students with a bachelor’s degree in any subject to become a nurse practitioner in as few as 12 months.

While Canion has worked with qualified nurse practitioners who trained through direct entry programs, he believes that nursing experience is essential to the role. “You need to have spent time at the bedside, and especially working in a critical care setting,” he said, noting that this experience is essential to be able to recognize when a patient is acutely ill and needs to be referred to a physician. “The whole idea of the nurse practitioner role from the very beginning was to take a nurse who had years of experience and was exceptionally good,” said Canion. “Then you just added a little bit of education [500 clinical hours] on top of that to move them to the nurse practitioner level.” Canion says that this same theory cannot be applied to non-nurses. “Now you’re taking people who have no medical training at all and you’re using the same guidelines. You come in with a bachelor’s degree in accounting and we’ll make you an NP in 18-24 months. It just doesn’t make any sense.”

In addition to changes in entry requirements, Canion is deeply concerned about the quality of NP classroom education. “I’ve had students about to graduate that didn’t know how to do a physical examination or develop a differential diagnosis,” he said, noting that these students explained that coursework was not much more than writing papers and reviewing board questions. “Many were never taught or tested on their knowledge.”

Regarding clinical experience, Canion says that NP programs generally require students to find their own preceptors and may fail to ensure that preceptors are providing high quality clinical experience. “We have reports of students paying for hours without ever showing up or going to work as a nurse in an office instead of being trained, and then getting their hours signed off at the end.” Canion is deeply concerned about this lack of training, noting that graduates are being placed in an unfair position. “There are nurse practitioners who finish NP school, start practicing, and go home crying every night because they don't feel prepared,” he said. “I had one text me the other day to say, ‘I went to an online school and now I don't feel like I'm prepared. But I've graduated and passed boards.’”

In his report, Canion explains that NP leadership attempted to solve the lack of clinical experience by a new emphasis on a doctoral degree in nursing, the DNP (Doctor of Nurse Practice). “Initially it was supposed to be a clinical doctorate, and we were told that it would be required for all nurse practitioners,” he said. “But the problem is that the DNP as currently offered does not impart any advanced clinical knowledge.” Canion said as he was considering advancing his education, he began to study DNP curricula. “But every time I look at the programs, I could see that this was not going to benefit me at all.” He believes that the goal of the DNP is to allow nurses to use the title doctor in a clinical setting, which he feels is confusing to patients. “If you walk in the room in a medical setting in the United States and introduce yourself as ‘doctor,’ patients are going to assume you're a physician,” he said. “In an academic or non-clinical setting, that’s fine. But in the clinical setting is just not appropriate, because the DNP is not a clinical doctorate.”

Efforts to improve NP training

When working as a nursing professor and serving on the American Association of Nurse Practitioners Education Enhancement and Sustainability Committee failed to yield positive results, Canion formed a grassroots organization of nurse practitioners. “After talking with others who were seeing the same things, I began to realize how bad the problem was,” he said. His group petitioned the Commission on Collegiate Education (CCNE) to ensure appropriate clinical preceptorships for students, which the CCNE agreed to in January 2019. But Canion said that the CCNE has not enforced the rule.“I’m only aware of one school that the CCNE took action against,” said Canion, noting that it is difficult for students to report concerns because complaints may not be anonymous.

Canion’s group also worked with NP leadership to increase the requirement of clinical hours and expects that an increase from 500 to 750 hours is coming. However, he doesn’t believe that this increase is enough. He is calling for at least 2,000 hours of clinical experience for a foundation in advanced nursing, with another 4,000 hours in a specialty focus such as primary care, acute care, or mental health. “It’s very important for patients, and also for credentialing committees,” he said, “because right now, NP credentials are intentionally vague so that we can be pliable and work in different areas. But we’ve become so nebulous that nobody knows what anyone can do.”

While some NP programs are graduating high quality nurse practitioners, Canion believes that the profession must hold itself accountable for all graduates, including the average and those on bottom. “I ask my academic friends, ‘Are you comfortable with any NP taking care of you, not knowing their background?’ And if the answer is no, then that means we’re not doing what we need to be doing.”

Inaction from the NP establishment

Canion believes that one of the biggest limitations in enacting change is overcoming denial from his academic colleagues. “The whole academic world is based on the literature, so if the literature says one thing, that's what we're going to believe.” But Canion says that the literature is seriously flawed. “I reviewed an article that claimed similar outcomes for emergency patients between NPs, PAs, and physicians,” he said, “but nowhere in the article did they disclose the NP and PA supervision model, so it’s impossible to draw conclusions about independent practice. Were they working independently, or did they have a physician sitting right beside them in every case?” Canion said that there is a lack of data regarding nurse practitioners that are truly functioning independently. “There are states that have allowed independent practice for decades, where you could argue to a review board that it’s ethical based on state laws and do the study, but they’re not done. I don’t know why.”

Noting that nurse practitioner journals often decline to publish articles that oppose independent practice or present a negative view of NP practice, Canion decided to place his report online for the public to review. “So many people reported it for ‘spam’ that the site took it down,” he said, noting that repercussions for nurse practitioners who speak out are not uncommon. “I've had people call me and scream at me and be very upset with me when I put this paper out,” he said. “But the funniest part is that when they’re yelling at me, they often say that everything I’m saying is right. Well, if everything I’m saying is right, why don’t we act?’”

Going public about his concerns was not a decision that John Canion made lightly. “I didn’t want to do it,” he explained. “I wanted to take care of this from the inside because I thought we could switch it. But there are too many people too invested in in full practice authority.” Canion refers to concerns from nurse practitioner leadership that criticizing education will negatively impact political efforts for NPs to practice independently, without physician supervision, which they term ‘full practice authority.’ “This is one of the things they yell at me about,” said Canion. “They say, ‘you’re going to ruin the chance of us getting full practice authority.’” Canion’s reply: “Maybe if our training was good enough, I wouldn't be able to do that. If the training was good enough, it wouldn't be an issue.”

Rebekah Bernard, MD is a Family physician in Fort Myers, Florida. Her most recent book is Imposter Doctors: Patients at Risk. You can find her entire interview with John Canion here.