Where we are now
As we have been discussing in this blog, the current push for improved healthcare outcomes, cost efficiency, and evidence-based decisions has many private and public sectors examining how we provide healthcare, who provides healthcare, and how we educate those providers. It is crucial that solutions proposed are equitable among providers as well as financial feasible and sustainable. The US spent $3.4 TRILLION on healthcare in 2016 alone; yet is far from the healthiest nation (Keehan et al., 2017). The Graduate Medical Education (GME) fund provided nearly $14 BILLION in education financing in 2012; yet physicians and NPs alike are exiting their training programs with 6-figure personal educational debt (Delisle, Phillips, & van der Linde, 2014). Despite all this spending, we are still not meeting the educational needs of our future providers as well as continuing to face a severe shortage of providers, especially those in primary care. A better utilization of all those dollars must be found.
Private solutions
At one time training of physicians and nurses occurred in hospital-based programs, where healthcare was delivered. As the understanding of bio-physiology deepened and healthcare became more complex, training moved from the hospital to academia; separating education and practice (Institute of Medicine, 2011). The partnership between hospitals, outpatient clinics, and academia must be renewed and cultivated. One partnership that has shown promise is the dedicated educational unit (DEU), in which one unit within the hospital focuses on one school, providing nearly all clinical experiences. Nurses desiring to precept are sponsored by the university and supported in that role as adjunct faculty. The hospital gains a direct contribution to program design needs and access to potential new employees (Institute of Medicine, 2011). It has been continually reiterated since the implementation of Medicare in 1965 that institutions and persons involved with educational activities improve the quality of care and advance the profession and the field of healthcare (Association of American Medical Colleges, 2015).
Funding should not only be sourced from the healthcare organizations. Universities and colleges derive revenue from tuitions, donations, interest, and federal funding. All the various programs offered by the university battle for their share of the budget, which is often focused on campus needs. Nursing faculty must help financial administrators reformulate budgeting to account for educational experiences that occur outside of the boundaries of the university (Horns & Turner, 2006).
Programs that combine educational clinical experience and new employee orientation have provided a smoother transition from the academic world to the work world of the undergraduate nurse. These programs have cost-saving benefits for the hospital and the college, while providing consistent education to the student (Trepainer, Mainous, Africa, & Shinners, 2017). Adapting these for the NP could be developed with minimal investment. Another possibility is combining precepting of undergraduate nurses in order to obtain credits during the pursuit of graduate degrees; similar to the offering of continuing education to licensed NPs for precepting NP students.
Some organizations are offering loan repayment as an employee benefit. This helps to ease the loan burden on providers, is an attractive benefit for many, and offers the organization tax benefits. If tied to precepting students, such as increasing percentage reimbursed based on work with students, it could be one means of indirectly funding NP clinical experiences.
Public solutions
There are many calls for accountability within and revision of the General Medical Education (GME) fund (Eden, Berwick, & Wilensky, 2014). The billions of dollars distributed by this program needs to reflect the balance of healthcare providers and provide evidence of quality outcomes. Current caps on numbers are geographically imbalanced and based on acute-care hospital statistics. To improve healthcare outcomes and reduce costs, the focus of healthcare is moving from the acute setting to prevention within the community; funding must be redirected to cover care provided in these areas.
Another solution is the provision of tax credits to licensed providers for training students. This is one means of offering providers reimbursement for potentially reduced income or increased cost associated with training new providers. Currently, Arizona has a bill (HB 2137) that has initially passed a house committee, but it only offers this incentive to physicians who precept students of medical schools. As this bill is not yet fully implemented, modification to include NPs and NP students should be considered.
Sustainable but responsive
Ensuring that NPs have quality preceptorships in order to become strong, efficient providers requires investments of time and money. Whichever solutions are utilized must be responsive to changes in the healthcare landscape. The current practices have resulted in arbitrary rules and regulations that do not increase the number of NPs or MDs, encourage cost-effectiveness, or promote quality outcomes. The Institute of Medicine’s committee that analyzed the current state and proposed guidelines of the GME stated that future funding should be both operational and transformational; recognizing the need to fund innovative educational models for physicians and other health professionals (emphasis mine) “toward achievement of the “triple aim,” that is, improving the individual experience of care, improving the health of populations, and reducing the per-capita costs of care” (Eden, Berwick, & Wilensky, 2014, p. 14). Policies and plans must be designed to be flexible to address the changing provider mix and educational models of the future.
References:
Association of American Medical Colleges. (2015). Medicare’s graduate medical education policy: Its inception and congress’s clear and persistent commitment. Retrieved from https://www.aamc.org/download/449774/data/medicaresgraduatemedicaleducationpolicyitsinceptionandcongresss.pdf
Delisle, J., Phillips, O., & van der Linde, R. (2014). The graduate student debt review. (Policy Brief). Retrieved from New American Education Policy Program webpage: https://static.newamerica.org/attachments/750-the-graduate-student-debt-review/GradStudentDebtReview-Delisle-Final.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
Horns, P.N., & Turner, P. (2006). Funding in higher education: Where does nursing fit? Journal of Professional Nursing, 22, 221-225. doi: 10.1016/j.profnurs.2006.03.0014
Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine (2011). Transforming education. In The Future of Nursing: Leading Change, Advancing Health. Washington (DC): National Academies Press. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK209885/
Keehan, S.P., Stone, D.A., Poisal, J.A., Cuckler, G.A., Sisko, A.M., Smith, S.D.,…Lizontiz, J.M. (2017). National health expenditure projections, 2016-2015: Price increases, aging push sector to 20 percent of economy. Health Affairs, 36, 553-563. doi: 10.1377/hlthaff.2016.1627
Trepanier, S., Mainous, R. Africa, L., & Shinners, J. (2017). Nursing academic-practice partnership: The effectiveness of implantation of an early residency program for nursing students. Nurse Leader, 15, 35-39. doi: 10.1016/j-mnl.2016.07.010
Quality NP Preceptorships Need $$ 
This was a very informative post on funding for Nurse Practitioner (NP) preceptorships. I agree with your comments regarding the financial obligations of healthcare institutions to assist in funding education. These institutions directly benefit from the education of NP students yet do not generally assist with the funding. Forsberg et al. (2015) discuss how physicians that teach in medical schools typically have joint appointments so that they keep a hand in clinical practice and will assist in training medical students. Nursing education does not allow for this generally. The role of the NP in a hospital to participate in NP education is not clearly identified in job descriptions. Thank you.
Forsberg, I., Swartwout, K., Danko, K., Delaney, K. R., & Murphy, M. (2015). Nurse practitioner education: Greater demand, reduced training opportunities. Journal of the American Association of Nurse Practitioners, 27(2), 66-71. doi:10.1002/2327-6924.12175
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Yes, NPs need education of those entering the profession in all of our job descriptions. As I stated in my 1st week’s blog, while “The Essentials of Doctoral Education for Advanced Nursing Practice”, states program graduates are able “guide, mentor, and support other nurses” (AACN, 2006, p.17 – http://www.aacn.nche.edu/dnp/Essentials.pdf); there is not the formalized and financed partnership that physicians have with medical colleges. The funding for that comes from many different sources, such as alumni giving programs, the GME, hospital foundations, etc. While this complex situation doesn’t have a one-stop or one payment fix, I think keeping it on the front burner as our healthcare system undergoes change will provide solutions that work both financially and educationally.
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Since Arizona is exploring the idea of using tax credits as an incentive for providers to act as preceptors, it may be informative to examine what was already accomplished in other states. Maryland recently initiated a program offering a $1000 tax incentive for primary care physicians and nurse practitioners taking on students and early results have been promising. Additionally, the incentive applies equally to both urban- and rural-based providers, so Maryland expects to see an increase in the number of providers willing to work in rural and frontier areas. The initiative has support from the state’s primary care specialty societies, allied health professional associations, and the state medical association
http://www.aafp.org/news/education-professional-development/20160614preceptorcredits.html
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Thanks for your information on the states that have already passed this type of legislation. I was glad to see that all 3 states extend the credit to a variety of provider types as well as place restrictions on types of practices eligible. This article also reflected what I have found, that this option is acceptable across professional organizations. Although from the comments, I see one MD wasn’t happy with the amount offered – “You guys are kidding, right? Did you forget a zero or two?? $1000/160 hours = $6.25/hour. I think they pay a LOT better at McDonalds… “ (blog comment by David Mark Grganto, MD at http://www.aafp.org/news/education-professional-development/20160614preceptorcredits.html). I guess he missed the comment about passion for teaching and an acknowledgement of the efforts by the public sector.
While I can see where Colorado felt providing this only to rural providers would increase those that serve in rural areas, I think it is unfair to those working with underserved urban populations. In my research for this blog, as well as replying to others, underserved areas can’t be strictly determined by population to provider numbers, specific populations can also be underserved. Here’s a couple of great links to start learning more about how the government determines HPSAs (Healthcare Provider Shortage Areas), MUA/P (Medically Underserved Areas/Populations). I feel that this type of incentive could address a couple of very big issues with provider availability and quality preceptorships with minimal direct financial investment. I am sure the amount of healthcare provided in the long-run and exposure of students to working in underserved areas more than covers the tax dollars not collected by the state.
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Being a preceptor as a nurse and for a nurse practitioner does take a lot of time and energy for the student and the preceptor. Many of the preceptors chosen are experienced professionals who have good sense of judgement, been in their field for numerous years and have the ability to teach and a part of process improvement in their own unit (Dziedic, 2010). Having a person who has the responsibilities for caring for patients, unit duties and then having to precept (often times having harder assignments to give the student exposure) can lead to burnout. Burnouts occur due to the preceptor being stretched too thin, management not consistent with assignments when precepting, and failure to formalize a preceptor program (Dziedic, 2010). I know from my experience as a preceptor for my unit, I had to ensure that we had an assignment that was commensurate to the skill level of the student as well as making sure that I knew my information. If I didn’t, I found myself studying more to ensure I can give my student the best opportunity possible. It definitely is a lot more work and having compensation for precepting would entice others to want to precept as well. Just as your blog stated, the compensation can be in various forms, whether school loan forgiveness, financial compensation or even time off, that could be very beneficial and an incentive to have more preceptors.
Dziedzic, M.E., (2010). Preventing preceptor burnout. American nurse today. 5(6). Retrieved https://www.americannursetoday.com/preventing-preceptor-burnout/
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You bring up many good points from the preceptor view. Your post also made me think more about the need for organized preceptor programs; not just in the hospital or healthcare center, but in NP education overall. Medical students and residents have the advantage of well established programs in partnerships with hospitals and physician practices. In part these partnerships were formed and solidified through the CMS programs. This course has made it very clear to me that to get NP education to have the same respect and options as medical education, we need to be aware of the policies and politics out there, so that when that “perfect storm” of opportunity arises we don’t miss it. Although it won’t be me personally doing that work, I did up my AANP contribution and do read the legislative updates with a little more interest.
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Excellent suggestions for possible solutions. Very well worded! Thank you
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