Advanced practice registered nurses (APRNs) are well positioned to make significant contributions to the health of Americans. With increasing demand for services provided by certified nurse-midwives, certified registered nurse anesthetists, clinical nurse specialists, and nurse practitioners, schools of nursing are being challenged to expand enrollment in APRN programs while maintaining high quality standards. The Board of Directors of the American Association of Colleges of Nursing (AACN) convened a task force to offer recommendations on re-envisioning APRN clinical education with a focus on advancing new strategies and models to prepare the growing number of APRNs needed to address current and evolving healthcare needs. Chief recommendations and action steps in the task force’s final report include:
I. Simulation should be used to enhance APRN clinical education, and the use of simulation to replace more traditional clinical experiences should be explored.
A. Seek funding for five demonstration projects that are designed to study the impact of various methods along the continuum of simulation learning approaches as one component of APRN clinical education and assessment.
B. Funding and other resources should be provided at both the national and local levels for the development and use of simulation for learning and assessment, including funding for a national center of faculty innovation and faculty preparation and certification.
C. A national repository should be created and maintained for reliable/valid APRN simulation education materials.
D. Simulations should be developed and tested for assessment of APRN common competencies.
II. AACN-AONE principles for academic-practice partnerships should be adopted by all APRN programs.
A. APRN programs, including face-to-face and distance education programs, should implement expectations described in Section II regarding the development and maintenance of APRN clinical experiences and student oversight.
B. Encourage and support the development of innovative partnerships for APRN clinical education as well as the use of a variety of incentives for practice sites and preceptors, e.g., adjunct faculty status, joint appointments, participation on curricular committees, research support, continuing education credits, academic credit towards graduate degrees.
C. Support the development and testing of innovative APRN academic/practice regional consortia that reflect geographic and institutional diversity.
D. Develop and implement an accessible repository for APRN preceptor orientation materials should be developed and implemented.
III. APRN clinical education and assessment should be competency based.
A. Establish a common language or taxonomy by adopting definitions for competence, competencies, and competency framework that are recognized by APRN organizations and other health professions.
B. Identify common, measurable APRN competencies that cross all four roles and build on or re-affirm the APRN core competencies (AACN, 2006).
C. Progression of competence or milestones should be identified and defined across each of the common competencies.
D. Develop standardized assessment tool to be available to faculty and preceptors to use for formative and summative evaluation of the common APRN competencies.
IV. Support the development of alternative or innovative APRN clinical education models
A. Encourage regulatory bodies to support or allow APRN education programs to develop and test innovative or less traditional clinical models.
B. Encourage APRN programs to explore, implement, and test innovative or less traditional clinical models, including interprofessional learning experiences and use of technology.
C. Seek funding to support the development and evaluation of alternative or innovative APRN clinical training models.
A SHIFT FROM THE APPRENTICESHIP MODEL OF CLINICAL EDUCATION
The current model of clinical education for all four APRN roles primarily has been a one-to-one preceptor-student model, which is largely unchanged from the original APRN clinical training model developed over 45 years ago and designed to serve a much more limited pool of students. With the growing demand for preceptors and clinical sites and the changes in the healthcare environment, this apprenticeship approach is no longer 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.
Across APRN programs, students frequently enter clinical training sites at differing points within the curriculum, with varied skill sets, and diverse expectations for performance. Variability among APRN programs, particularly for NPs and CNSs, exists in the clinical competencies expected at various points throughout the curriculum and evaluation processes and tools. This variability may hamper efforts to expand the clinical training opportunities for students.
INCREASING DEMAND PROVIDES IMPETUS FOR CHANGE
Increasingly, new models of care are emerging with a greater 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 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.
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 (Fang, Li, Arietti, & Bednash, 2014). This rapid increase in the number of APRN students has strengthened the increasing demand for clinical learning sites. Competition among programs for both primary care and specialty sites and preceptors also continues to grow within and between health professions (Multi-Discipline Clerkship/Clinical Training Site Survey, 2013).
THE ROLE OF TECHNOLOGY AND SIMULATION
Advances in technology both within healthcare delivery and education have created opportunities for APRNs to lead the effective integration of technologies into healthcare delivery. As such, maximizing the use of these technologies during clinical education is essential in the preparation of the contemporary APRN workforce. New technologies also provide opportunities for developing new models of professional education, including the use of a wide array of simulation and other strategies for learning and assessment. Growing evidence in nursing and other disciplines appears to support the increased use of diverse forms of simulation with positive learning outcomes. However, the evidence on the most relevant and effective application to APRN education is not yet available. Other strategies or innovative models of APRN clinical education are being implemented in limited situations; these innovations appear to provide ways to address some of the challenges being faced as well as reflect the changes in practice, including the focus on interprofessional team practice.
ACADEMIC PRACTICE PARTNERSHIPS FOR APRN CLINICAL EDUCATION
The growing challenges for establishing and maintaining quality clinical experiences for APRN students require concerted collaborative efforts from all stakeholders to collaborate, rather than compete, for increasingly scarce resources. One way to achieve this is through the establishment of academic-practice partnerships between schools of nursing and healthcare institutions. These partnerships should engage stakeholders both within the nursing profession, with other health professions and the larger community. Principles or characteristics of academic-practice partnerships are clear for establishing and sustaining effective partnerships (American Association of Colleges of Nursing-American Organization of Nurse Executives Task Force on Academic-Practice Partnerships, 2012). These partnerships are important to all APRN clinical education to ensure that students have access to patients, healthcare professional teams, and current data and experiences. Partnerships are increasingly important when considering interprofessional education, transition to practice for new graduates, implementation of new clinical education models, and the rapid changes that are occurring in healthcare systems.
ADDRESSING COMPETENCY-BASED EDUCATION AND ASSESSMENT
Across higher education, there is an increased interest and emphasis on examination and implementation of competency-based education and assessment models in a variety of disciplines and more specifically in the health professions (Carraccio, 2002, 2013). There is considerable discussion around and support for the need to reduce dependence on more traditional measures, including seat time or credit hours as metrics of student achievement to the identification of observable, measurable competencies as a basis for both teaching and assessment of learner outcomes.
Nursing, including APRN education, has considered the use of competency-based education for over three decades. Various professional nursing organizations have identified education competencies or expected outcomes that have provided a foundation for both curricular development and individual student assessment for each of the four APRN roles. However, these competencies vary widely in both scope and the ability to be measured. Much of this variation occurs because the profession has not, as yet, adopted common definitions of competence and competency or a common framework for competency-based education. The use of a common taxonomy would allow the multiple stakeholders involved in nursing education to truly “speak the same language”. As the move to IP education and practice advances, the use of common definitions across health professions also becomes even more imperative.
ENVISIONING A REDESIGNED SYSTEM OF CLINICAL EDUCATION
The four APRN roles share many common challenges in delivering clinical training. Competition for clinical sites and preceptors is becoming more intense between schools both within and outside of the profession. These same challenges exist for programs within the same geographic region as well as for distance programs. The growth in number of APRN programs as well as the increase in enrollments has created additional challenges for developing clinical opportunities. The scarce supply of clinical sites and preceptors, accentuated by increasing competition for these resources, is a common theme for all four APRN roles. Also, regulatory restrictions on scope of practice in some states create challenges for identifying role models or preceptors that practice to the full scope of the APRN role. State and local regulatory requirements for in-state and distance-learning programs are mounting and present frequently changing requirements and barriers for schools. Preceptor expectations of APRN students entering their clinical training sites vary as well as evaluation criteria and assessment tools used by APRN programs. A shortage of doctorally-prepared advanced practice faculty to provide supervision and guidance for APRN students is an ongoing issue.
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