NP Clinical Preceptorship is Undervalued and Unfunded (Week #1)

Nurse Practitioners (NPs) are licensed professional registered nurses (RNs) who have advanced training and in many
states practice independently. NPs are one means of increasing the availability of cost-effective healthcare
professionals to meet the impending shortage of primary care providers (Forsberg, Swartwout, Murphy, Danko, & Delaney, 2015).Enrollment in both Masters and Doctorate programs has increased substantially to meet this demand (American Association of Colleges of Nursing (AACN), 2015). However, this increase is stymied by challenges with finding clinical sites and experienced NPs willing to train (or precept) the advanced practice student. Many factors contribute to this problem, including faculty shortages, NPs as employees rather than operators of their own practice, productivity demands, malpractice concerns, and lack of tangible rewards for preceptorship. The increase of on-line education and distance learning has also left NP students searching for their own preceptors, creating even more pressure on an already overwhelmed system (Forsberg et al., 2015). Reviewing professional and general social media sites reveals daily pleas to locate preceptors, and stories of further education halted or resigned entirely due to the lack of preceptors.

The heart, passion, and enthusiasm of nursing is sometimes its own worst enemy; motivating nursing practitioners, faculty, and preceptors to contribute far more to the profession than they are ever remunerated for (Gardenier, Todd & Davis, 2012).  This passion and the ever-evolving regulations and definitions of healthcare providers has created a perfect storm for policy reformation. Storms can be destructive forces or sources of energy for positive change and growth; they are also complex entities comprised of and affecting many factors. One factor that the altruistic nature of nursing struggles with, is the appropriate and equitable financial recognition of its work.

In contrast, the physicians’ well-established system, though also unable to meet the full demand for providers, has relationships with universities and health care systems to provide both training sites and supervised clinical experiences (Dower, 2012). Although The Essentials of Doctoral Education for Advanced Nursing Practice, calls for the establishment of similar relationships for the NP student, as well as stating that program graduates are prepared to “guide, mentor, and support other nurses” (AACN, 2006, p.17); no federal policy or regulation provides the support for the achievement such goals. Physician education goals have federal and state regulatory support in the form of federally funded Graduate Medical Education (GME), which was established as part of the 1965 Medicare amendments to the Social Security Act of 1935 (Centers for Medicare &Medicaid, 2015). The physicians training medical students and residents receive both recognition and reimbursement for their teaching; while physicians and NPs training NP students often receive only the deep gratitude of the student. Via the Centers for Medicare and Medicaid Services (CMS), the GME reimburses hospitals and associated clinics for their direct and indirect costs of educating future physicians (but not NPs), paying out $13.6 billion in 2012 (Eden, Berwick, & Wilensky, 2014). CMS also recognizes that the services “by interns and residents within the scope of their training program are covered as provided services” allowing billing of services provided by physicians in training (CMS, 2016, p. 36). Additional federal monies are appropriated to GME funds through the Veterans’ Health Administration and the Health Resources and Services Administration; additional sources of private funding are substantial but the Institutes of Medicine committee was unable to determine a dollar amount (Eden et al., 2014).

While GME funding is far from perfect or transparent regarding sources and outcomes, it is a substantial acknowledgment to the value of supervised clinical experience. NPs are valuable members of the healthcare team and necessary to address the looming provider shortages. However, to ensure their clinical training is strong and equitable to that of other primary healthcare providers, the organizations and experienced NPs dedicated to teaching in patient care settings need financial recognition and reimbursement for their investment as well. The Affordable Care Act, under section 5509, mandated the development of a Graduate Nurse Education (GNE) demonstration to be operated by the Innovation Center. The CMS’s Innovation Center works in accordance with section 1115A of the Social Security Act to develop new payment and service delivery models for the US healthcare system (CMS, 2012). Considering the annual expenditure for this project is budgeted for LESS THAN 0.3% of the amount of public dollars spent for GME in 2012; it is a very small step, but a step none the less, in the right direction. However, it will be many years before the results of the GNE demonstration are available and applied to regulations. Also, reliance on an already overstretched budget such as that of CMS can limit the options for funding NP preceptorship. Faster, more adaptable solutions to remunerate organizations and experienced NP preceptors are needed if strong NPs are to be available to provide quality healthcare to patients in the United States.

American Association of Colleges of Nursing. (2015, March 9). New AACN data confirm enrollment surge in schools of nursing (Press Release). Retrieved from http://www.aacn.nche.edu/news/articles/2015/enrollment

Centers for Medicare & Medicaid Services. (2012, July 30). Fact sheet: Graduate nurse education demonstration. Retrieved from https://innovation.cms.gov/Files/fact-sheet/GNE-Fact-Sheet.pdf

Centers for Medicare & Medicaid Services. (2015, July). Medicare and medicaid milestones, 1937-2015. Retrieved from https://www.cms.gov/About-CMS/Agency-Information/History/Downloads/Medicare-and-Medicaid-Milestones-1937-2015.pdf

Centers for Medicare & Medicaid Services. (2016, September 16). Medicare general information, eligibility, and entitlement manual, Chapter 5 (CMS Publication No. 100-1). Retrieved from https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/ge101c05.pdf

Dower, C. (2012). Graduate medical education. A debate continues of the size and scope of federal subsidies to support residency training of the nation’s physicians. Health Affairs: Robert Woods Johnson Foundation. Retrieved from http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_73.pdf

Eden, J., Berwick, D. & Wilensky, G. (Eds.). (2014). Graduate medical education that meets the Nation’s health needs. Institute of Medicine of The National Academies. Retrieved from https://www.nap.edu/catalog/18754/graduate-medical-education-that-meets-the-nations-health-needs

Forsberg, I., Swartwout, K., Murphy, M., Danko, K., & Delaney, K.R. (2015). Nurse practitioner education: Greater demand, reduced training opportunities. Journal of the American Association of Nurse Practitioners, 27, 66-71. doi: 10.1002/2327-6924.12175

Gardenier, D., Todd, B.A., & Davis, E.L.  (2016). Do nurse practitioners need postgraduate training? The Journal for Nurse Practitioners, 12, 224-225. doi:10.1016/j.nurpra.2016.01.010