Scope of Practice

What patient-care experience do nurse practitioners have on day one?

Tanya Albert Henry , Contributing News Writer

AMA News Wire

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As lawmakers in state legislatures across the country consider bills that would expand nurse practitioners’ scope of practice, they are likely familiar with the difference in the years and hours that nurse practitioners and physicians put into their training.

For example, the majority of nurse practitioners (NPs) complete a master’s degree in two to three years plus 500–750 hours of clinical training and they aren’t required to complete a residency to graduate or become licensed—very dissimilar to the requirements physicians must complete to become licensed.

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In addition to a bachelor’s degree, physicians must complete four years of medical school to earn a degree as an MD (a doctor of medicine) or a DO (doctor of osteopathic medicine). There are no online medical schools. Physicians rack up at least 16 times as many patient-care hours. Between medical school clinical rotations and residency, physicians get between 12,000 and 16,000 hours of patient-care experience.

But perhaps less talked about are the differences in training among nurse practitioners themselves.

Unlike physician education and training, nurse practitioner programs don’t have standardization or requirements for the practical experience in patient care that they must complete before they are licensed to go out into the health care work force.

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Patients deserve care led by physicians—the most highly educated, trained and skilled health professionals. The AMA vigorously defends the practice of medicine against scope of practice expansions that threaten patient safety.

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Training inconstancies

The lack of standardization among nurse practitioner programs is in stark contrast to physician education and training. Unlike for physicians, the level of exposure to different types of patients, illnesses and practice settings is highly variable among graduating nurse practitioners. Breadth of experience is not guaranteed at the individual level.

In a Journal of Nursing Regulation study that included nearly 4,000 family nurse practitioner students nationwide, researchers discovered that many students reported that their clinical experiences in their training program did not provide patient encounters as outlined by the American Nurses Credentialling Center’s Family Nurse Practitioner Role Delineation Study. That study was used to develop the national certification examination for nurse practitioners.

The Journal of Nursing Regulation study evaluated 84 specific tasks that family nurse practitioners are expected to complete as part of their clinical training. The tasks fell across four domains: assessment, diagnosis, treatment, and evaluation of adult, geriatric and pediatric patients.

Researchers asked nurse practitioner students how many times they performed a given task during their training. 

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“A large number of students reported never experiencing some clinical tasks during their training, including mental health assessment, ordering diagnostic tests, performing primary care procedures (e.g. wart removal, suturing, cerumen removal), and evaluating treatment and educational outcomes related to chronic pain,” according to the study. Reports of not having completed a task were even more prevalent when it came to the pediatric population.

In many instances, just over half of the surveyed students said they completed these clinical tasks more than 10 times during their clinical training. Notably, “more than 10” was the highest number one could select in the survey. For example, among the students surveyed:

  • 64% completed a comprehensive health history on an adult patient more than 10 times in their clinical training; 31.4% only did so seven–10 times. 
  • 69.4% performed a comprehensive physical examination more than 10 times; 10.6% did this task only one or two times.
  • 61.5% prescribed medications more than 10 times; 15% only did this once or twice.
  • 64.1% said they ordered diagnostic tests more than 10 times; 25.6% only ordered such tests three to six times.
  • 60.8 % said they developed differential diagnoses for geriatric patients during their clinical training, while 27.4% completed this task only seven to 10 times.

In addition, many nurse practitioner programs require students to find their own preceptor, contributing to great variability among nurse practitioners when it comes to their clinical experience. By comparison, the Accreditation Council for Graduate Medical Education family medicine residency standards require that physicians complete:

  • A minimum of 1,650 in-person patient encounters at the family medicine program site.
  • 600 hours (or six months), and 750 patient encounters dedicated to the care of hospitalized adult patients.
  • 200 hours and 250 patient encounters dedicated to pediatric patients in the hospital or emergency care setting.
  • 200 hours or 250 patient encounters caring for children and adolescents in an ambulatory setting.
  • 100 hours or 125 patient encounters dedicated to caring for older patients.

“The gaps and inconsistencies in requisite learning experiences for students in programs across the country require a critical conversation among leaders in academic, regulation, and certification,” the authors of the Journal of Nursing Regulation study concluded.

“Working collaboratively, these three groups must examine competency expectations, clinical learning environment availability, and preparation for advanced practice to ensure development of qualified NPs who will provide safe, high-quality care across the lifespan,” the study says.

Learn why allowing nonphysicians, including nurse practitioners, to diagnose and treat patients without any physician oversight is a step in the wrong direction. Find out more about protecting access to physician-led care (PDF).

Fight scope creep