Increase in Clinical Education Hours for Nurse Practitioner Programs Harms Efforts to Address the Nursing Shortage

Increase in Clinical Education Hours for Nurse Practitioner Programs Harms Efforts to Address the Nursing Shortage

“One Size Fits All” Model of Nursing Education Could Cause Some Programs to Close & Create a Roadblock to Competency-Based Education in Nursing Workforce Development

Washington, DC — The National League for Nursing, the nation’s first nursing association and the leading voice for nursing education, continues to strongly oppose the increase in the required clinical practice education hours to 750 from 500 for Nurse Practitioner (NP) graduate programs. This increase has created a burden on nursing programs that may cause some of them to close, further reducing the number of nurse educators available to teach the tens of thousands of prospective nursing students who apply each year, and therefore worsen the already alarming shortage of nurses.

Since first addressing this issue in November 2022, the League believes there remains a lack of peer-evaluated documented scholarship to substantiate the mandate for a revised requirement to increase those clinical practice hours. According to studies conducted of nurse practitioner competence, the previous 500-hour clinical requirement resulted in patient care that equaled or even exceeded the quality and safety standards demonstrated by physicians across a variety of health care settings and in specialty care environments (Carranza, et al, 2020; Stanik-Hutt et al, 2013; Mundinger et al, 2000).

The National League for Nursing has long supported the transformation of nursing education to better meet the needs of a dynamic, diverse health care environment. The League, though, strongly decries a “one size fits all” model of education that puts in place an unnecessary 750-hour clinical requirement for all new graduates of nurse practitioner advanced degree programs. Clinical education placements are already tough to come by; this requirement has made access to them more difficult with little to no benefit in patient care.

With a persistent nursing shortage that disproportionately affects equitable access to quality care by residents in underserved and rural areas and by a diverse range of communities, this inflexible standard has had unintended consequences contrary to the goal of universal health care access and of creating a more diverse cohort of nurse practitioners, reflective of the populations they serve. This new standard imposes undue burdens of cost, time and staffing on NP education programs, academic clinical sites, faculty and clinical mentors, and qualified candidates for entry into advanced nursing practice.

Many graduate programs are already at risk of closure due to financial instability in institutions of higher education. Those programs also serve vital roles in the economies of their communities, and their closure could further threaten the health of people living in those areas. Additionally, a shrinking number of clinical sites and nursing staff stretched to their limits are all realities that have been worsened by the increase in clinical practice hours. With nurse practitioners providing more and more of the primary and preventative care within communities, it is vital for all of us to do everything possible to ease the crisis while safeguarding the path to graduation for nurse practitioners, not extend the time it takes for them to earn that required credential.

Indeed, the National League for Nursing has long opposed the clinical practice hours mandate applying to the curricula of graduate nursing education programs. Requiring a set number of clinical practice hours—which focus on the provision of expanded licensure nursing care rather than on gaining experience in areas such as nursing administration or nursing education—ends up creating just one path to graduate nursing education whereby all graduate educated nurses are expanded practice clinicians. This is contrary to the longstanding system that graduate nursing degrees do not all lead to expanded licensure, such as nurse practitioner, clinical nurse specialist, midwife, and anesthetist. 

There are also graduate nursing degrees that lead to expertise in areas such as nursing education, public health, and nursing administration/leadership, which are areas of advanced practice yet not clinical. When graduate nursing education curricula must add clinical nursing hours to support expanded nursing practice, it further decreases the numbers of nurses that are seeking advanced nursing degrees without any intent of obtaining an expanded nursing license. 

In the League’s view, the number of clinical practice hours required to earn an advanced practice degree is but one factor among many that determines competency. The National League for Nursing considers clinical practice hours from the perspective of a holistic approach to education that is best reflected in the highly regarded, evidence-based model of Competency-Based Education (CBE). 

This methodology understands competencies as specifically defined elements of an integrated whole encompassing mastery of knowledge, skills, and abilities. Competencies are observable and measurable and promote a consensus of what individuals must know and be capable of executing. With an emphasis on assessment, evaluation, and demonstrated performance of key competencies—behaviors, decision-making, actions, outcomes—CBE prioritizes individual student development, capability, and occupational readiness over delivery of content and theoretical understanding divorced from practical application.

The League also strenuously disagrees with the standard of approving simulation to support but not replace any portion of the 750 clinical practice hours, given there is a lack of evidence for this restriction. Increasingly sophisticated in design and implementation, simulation has become an effective and useful tool in nursing, medical and other health-related education, decreasing the immense strain on clinical sites. Another positive outcome of simulation has been the rise in innovative academic-practice partnerships and interprofessional educational initiatives.

To understand the true effect of any change to current NP requirements, the League renews its recommendation for the development of rigorous research to investigate the evaluation of competency as the gold standard of NP graduate education. Rather than contribute to an unwarranted burden on our current health care system that threatens to adversely impact an already overwhelmed workforce, nursing education leadership should support evidence-based research to examine:

• Identification of the impact of the additional 250 clinical practice hours on enrollment, clinical learning access, and long-term effects on program viability, particularly in rural and underserved areas
• Projections of workforce demand for diverse nurse practitioners by clinical and role specialties
• Economic impact on prospective students and families, especially those of diverse backgrounds who would reflect the populations they would serve
• Impact of simulation on NP learning
• Evaluation and effect of prior clinical experience on required clinical practice hours for NP preparation
• Impacts on master’s level and liberal arts-based colleges in serving their communities
• Projected impact on care in communities where nurse practitioner graduate programs serve as the primary source of health care providers
  

Working together, the nursing education community and stakeholders must forge ahead to facilitate nursing workforce development and widen, not narrow, the pathways for graduates of NP and other nursing education programs to seamlessly transition to practice, thus reducing the nursing shortage and providing needed care to patients.

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