You Be the Judge of the Care You Have Received / Will Be Receiving

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"The practice of medicine is a privilege earned by those who have sacrificed more than a decade of their lives---most of it awake.  It is not a right granted by the votes of law makers."

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Is the Training Midlevels Receive Really Adequate?  Marketing does not Take the Place of Years of Education and Training Doctors Undergo.

Below we will demonstrate to you what is occurring on the front end in terms of mass-producing midlevels.  In our opinion, the standards for accreditation are low.  Furthermore, the time required to have the privilege of serving patients is incredibly short.  Because of these factors and because of many others (which we believe apply to the entire industry, not just the named programs), patients, nurses and doctors, alike, are seeing harm occurring to patients each and everyday on the back end.  Our research has led us to the following opinions and conclusions:

• Obtaining a license to have the right to serve patients, prescribe medications and order tests now resembles the days of the wild west chiefly due to lack of patient awareness regarding their "provider's" credentials and due to midlevel lobbying efforts.
• The education and training of a midlevel, by its very nature, can never match that of a doctor.  It is time for more doctors to be educated and trained to phase out individuals representing a dark era in our healthcare system's history.
• It appears the training and education of midlevels is grossly under regulated.
• It appears as though too much power has been delegated to accrediting bodies charged with overseeing schools and/or programs educating and training midlevels.  This self-regulation has led to standards such as those described below, to the potential detriment of patients and society.
• Although only a few examples are provided, the mentioned schools are far from unique in terms of their method of training and lengths of training.
• It appears as though individuals are coming as close to buying a degree and having the right to attempt to practice medicine as is legally allowed rather than earning a degree.
  • According to the American Academy of Nurse Practitioners, there is no limit as to how many times one may take his or her board examination overall (there is a limit of two times per calendar year).  In our opinion, it appears as though it is nearly impossible for one to not become a nurse practitioner based on the unlimited attempts afforded to him or her.
• Even schools and training programs that are considered "reputable" in the midlevel community do not provide an education and training that is as extensive and as rigorous as that of medical schools and medical residency programs that train doctors.
  

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Compare the Education and Training of a Doctor with Midlevels Working in Different Roles
(years of education and training are after completion of high school)

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Doctors

Very few medical students can work during their medical school education and very few doctors can work during their medical residency training (outside of the work they do as a medical resident) due to the rigorous nature of their education and training.  Medical students live around the level of poverty as their only source of financial support (for the majority of students) is student loans.  Medical residents also live around the level of poverty (when adjusting for a 40 hour work week).  Both, medical students and medical residents, must contend with student loans accruing hefty amounts of interest daily.  Medical students and doctors usually move away from their friends and family to pursue a medical education and subsequent training. They miss births, funerals, birthdays, family events, holidays, bar mitzvahs / bat mitzvahs, weddings and many more life events (especially during their 20s and into (at least) the early part of their 30s) as part of their sacrifice for their patients.

To give one a better idea of how difficult it is to be accepted to a medical school (for the sake of ensuring only the most competent candidates are afforded the opportunity to serve patients by providing them with the safest, highest quality of medical care), one may reference a recent article in U.S. News & World Report with the following passages:

"Because of the ultra-low acceptance rates at the highest ranked institutions in the U.S. News Best Medical Schools rankings, some of which accept less than 4 percent of applicants, many aspiring doctors wonder why it is so hard to get into medical school."

"...demand for a medical education is "near an all-time high," so the typical premed student should expect to face stiff competition.  "People really want to become physicians, and now more than ever," he says.  I would say this is especially true of the millennial generation.  And I can tell you that, here at (our school), we hear from high-quality applicants everyday...and these are people with really high MCAT [Medical College Admissions Test] scores and GPAs, that this is their second year, third year or even fourth year applying to medical schools..."

"Experts say that medical schools deliberately have a rigorous vetting process that is designed to ensure that anyone they admit is capable of passing tough medical courses and enduring demanding clinical training.  No matter how many applicants are competing for spots in medical schools, these schools typically have high standards, and they want to identify the best and the brightest students."

"Medical schools set up a great number of hoops for applicants to jump through:  a prescribed undergraduate curriculum with numerous prerequisites, the MCAT exam, a complex and multipart application, traveling to interviews, exhaustive days interviewing, and a constant requirement for professionalism throughout...These hurdles exist for many reasons.  First, med school admissions committees want to establish a mechanism to identify the best applicants in their pool.  It can be challenging to differentiate applicants based solely on objective information like GPA or MCAT score.  Second, the process is designed to be intense to ensure that those going through the steps are willing to endure the trials and hardships inherent in the practice of medicine."
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Nurse Practitioners

-Many, if not most, enrolled nurse practitioners work full time since many courses are offered online, via “distance learning,” at night and/or during the weekends and are lax in nature.
-Your "provider" (nurse practitioner), the individual you are supposed to trust with your health, may have an online degree.
-You may see this for yourself by performing an online search for "100% online nurse practitioner", “100% online rn to msn” or "100% online dnp".
-A nurse practitioner may have obtained his or her nursing degree from a nursing program / school that does not even require any prerequisite courses.

-Doctors (D.O.s and M.D.s) who specialize in family medicine undergo at least 10,000 hours of medical clinical training.  This does not include their 9,000 hours of education during medical school.
-The average nurse practitioner (even ones who may hold a "doctorate") undergoes 1,500 hours of clinical training prior to unsupervised practice (although some may undergo even less than 1,500 hours).
-This means a nurse practitioner undergoes 15 percent of the clinical training alone of a doctor (which does not factor in the difference in years of education).

For even more information regarding the differences in training and education between doctors who specialize in family medicine and midlevels who work as nurse practitioners, please reference The Texas Academy of Family Physicians' informational webpage titled "Compare the Education Gaps Between Primary Care Physicians and Nurse Practitioners."
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Nurse Anesthetists

-Many, if not most, enrolled nurse anesthetists work full time since many courses are offered online, via “distance learning,” at night and/or during the weekends and are lax in nature.
-Your "provider" (nurse anesthetist), the individual you are supposed to trust with your health, may have an online degree.
-You may see this for yourself by performing an online search for "100% online nurse anesthesia anesthetist".
-A nurse anesthetist may have obtained his or her nursing degree from a nursing program / school that does not even require any prerequisite courses.

Based on statistics, anesthesiologists undergo between 12,000 and 16,000 hours of medical clinical training.  Based on estimates, anesthesiologists undergo between 24,000 and 28,000 hours of total combined medical education and medical training.
-The average nurse anesthetist (even ones who may hold a "doctorate") undergoes 1,651 hours of clinical training prior to unsupervised practice.
-This means a nurse anesthetist undergoes an estimated 10 to 14 percent of the clinical training (alone) of a doctor.  When factoring in the education which precedes clinical training, it appears that a nurse anesthetist may have even less than 10 percent of the total combined hours of education and training of a doctor.

For even more information regarding the differences in training and education between doctors who specialize in anesthesiology (anesthesiologists) and midlevels who work as nurse anesthetists, please reference The American Society of Anesthesiologists' informational webpage titled "Education and Training Can Mean the Difference Between Life and Death."
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Physician’s Assistants

-A physician's assistant may work full time since many courses are offered online, via “distance learning,” at night and/or during the weekends and are lax in nature.
-Your "provider" (physician's assistant), the individual you are supposed to trust with your health, may have an online degree.
-You may see this for yourself by performing an online search for “100% online physician's assistant programs".

-The average doctor (D.O.s and M.D.s) undergoes at least 10,000 hours of medical clinical training prior to unsupervised practice.
-The average physician's assistant undergoes 2,000 hours of training prior to unsupervised practice.
-This means a physician's assistant undergoes 20 percent of the clinical training alone of a doctor (which does not factor in the difference in years of education).
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Putting Things Into Perspective

In addition to the great differences in the quantity of clinical training hours between doctors and midlevels (physician's assistants, nurse anesthetists and nurse practitioners), there are also profound differences in the quality of training hours as well (in addition to the differences in the quantity and quality of educational hours preceding training).

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Doctors are humble enough to acknowledge when they don't know a patient's diagnosis or when they can't find an answer.

Certainly this does not mean they won't keep giving their full efforts to their patients.

However, if they can't diagnose a patient, what hope would a midlevel who undergoes less than a fraction of the education and training of a doctor (as demonstrated above) have?

Sometimes a cough isn't just a cough.

Do you really want to gamble with your health by obtaining care from an individual who has 20 percent or less of the education and training of a doctor?_______________________________________________________________________________________________________________________________________________________
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To Give You a Better Idea of the Requirements and Standards for the Training a Midlevel May Undergo

From the Level of Accreditation

Introduction
The American Association of Colleges of Nursing (AACN) is (according to their website) "the national voice for academic nursing education.  AACN works to establish quality standards for nursing education; assists schools in implementing those standards; influences the nursing profession to improve health care; and promotes public support for professional nursing education, research, and practice."

The Commission on Collegiate Nursing (CCNE) (an autonomous arm of the AACN), according to AACN's website "ensures the quality and integrity of baccalaureate and graduate education programs preparing effective nurses.  Officially recognized by the U.S. Secretary of Education as a national accreditation agency, CCNE serves the public interest by assessing and identifying programs that engage in effective educational practices.  CCNE is the nation's leading accrediting agency for baccalaureate, master's, and DNP programs at schools of nursing and also accredits post-baccalaureate nurse residencies."

The following content is from the American Association of Colleges of Nursing's website's Frequently Asked Questions Clinical Practice Experiences' webpage (in red) along with our opinion and interpretation of the content:
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1.  How does CCNE define clinical practice experiences?

Key Quotes From Their Response:
"Clinical practice experiences are not limited to clinical patient care settings.  Clinical practice experience also refers to any nursing intervention that influences health care outcomes."

Our Opinion and Interpretation:
Clinical practice experiences (plural) is (in our opinion) a bizarre yet delicately worded term used by this organization.  For the sake of introducing culture and background to any individual not in the healthcare field, when one discusses or is asked about his or her experience, the term "clinical practice experience(s)" (when used in a singular or plural form) is not part of common medical parlance.  The commonly employed term is "clinical experience" which is known to be plural and/or all encompassing.  Maybe, one would be asked about his or her "practice experience."  Very few would be asked about his or her "clinical practice experience" (singular).  And finally, it would be exceedingly uncommon for any individual to be asked about his or her "clinical practice experiences" (plural).

However, if we indulge the CCNE's term "clinical practice experiences," for any professional in the healthcare field (whether he or she is a doctor, nurse, pharmacist or any other member of the healthcare team) the term defined is:

Clinical:  "Relating to the observation and treatment of actual patients rather than theoretical or laboratory studies."
Practice:  "The actual application or use of an idea, belief, or method as opposed to theories about such application or use."
Experiences:  "Practical contacts with and observations of facts or events."

• An important point, which will be demonstrated below, is that the word "experience" is countable or uncountable but according to one source, "in more general, commonly used contexts, the plural form will also be experience" (rather than "experiences").

Thus the term "experiences" in the term "clinical practice experiences" reaffirms "clinical practice."

The CCNE's broadening of their definition and use of the term "clinical practice experiences" (plural) as being "not limited to clinical patient care settings" appears to deviate from the formal definition of the term (as provided above).  The CCNE's transposition of this definition of "clinical practice experiences" to include "any nursing intervention that influences health care outcomes" is so vague and so broad that it appears as though a nurse in training to become a midlevel may claim credit for "clinical practice experiences" while having minimal experience with direct patient care (500 hours is the required minimum for master's level programs).  To further demonstrate this (and to demonstrate how broad their criteria is), we will rephrase their statement above for you to judge:

"Clinical practice experience also refers to any nursing intervention that influences health care outcomes."

Quote defined:
"Clinical practice experience also refers to any nursing action or process of coming between, so as to prevent or alter a result or course of events that influences health care outcomes."
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2.  Does CCNE require all degree programs and post-graduate APRN [advanced practice registered nurses (midwives, nurse anesthetists and nurse practitioners)] and post-graduate APRN certificate programs to include clinical practice experiences?

Key Quotes From Their Response:
"Yes, CCNE requires that baccalaureate, master's and Doctor of Nursing Practice (DNP) programs, as well as post-graduate APRN certificate programs, include appropriate clinical practice experiences, considering the roles/areas for which students are being prepared.  This requirement extends not only to the overall degree or certificate program but to each track/program offering within the degree and/or post-graduate APRN certificate program.  For instance, a post-licensure baccalaureate (RN-BSN) program must include appropriate degree level clinical practice experiences.  The same is true for master's, DNP, and post-graduate APRN certificate programs.  The fact that a student is already a licensed or credentialed nurse does not negate this requirement."


4.  Do "online programs" or programs with distance education offerings require inclusion of clinical practice experiences?

Key Quotes From Their Response:
"Yes.  The Standards for Accreditation of Baccalaureate and Graduate Nursing Programs (2013) and the clinical practice experience requirements therein are applicable to all programs that are CCNE-accredited or seeking CCNE accreditation, regardless of the mode of educational delivery."

Our Opinion and Interpretation:
In our opinion, these responses appear to be not entirely factual or misleading because, again, "clinical practice experiences" as CCNE defines it differs from the formal definition of this term, as constructed from its subterms as demonstrated under #1.  Thus, their reference to "clinical practice experiences" as "any nursing intervention that influences health care outcomes" is so vague and so broad that it appears one may have minimal experience with direct patient care to meet this requirement (500 hours is the required minimum for master's level programs).
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5.  Does CCNE have a list of "approved" clinical practice experiences?

Key Quotes From Their Response:
"No.  CCNE does not have a list of "approved" clinical practice experiences and does not prescribe the specific clinical practice experiences a program must offer.  What is important is that the program includes experiences that provide students with the opportunity to integrate new knowledge into practice at the appropriate degree and/or certificate level and to attain the identified professional competencies.  Additionally, the program must be able to provide evidence that the experiences enable students to integrate new knowledge and demonstrate attainment of program outcomes, and that the experiences are evaluated by faculty."

Our Opinion and Interpretation:
In what appears to be a stark contrast to accrediting bodies for osteopathic and allopathic medical schools, CCNE guidelines for "clinical practice experiences" seem so vague that it appears as though there is a lack of any substantive standardization from one program to the next.  Thus, as an accrediting body, CCNE provides only the most minimal of framework to programs accredited by them.
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6.  What is meant by "faculty supervised and evaluated?"  Must faculty be physically present at the clinical location to evaluate and supervise students?

Key Quotes From Their Response:
"All clinical practice experiences must be supervised and evaluated by faculty, according to Key Element III-E for the Standards for Accreditation of Baccalaureate and Graduate Nursing Education (2013).  This can be accomplished through face-to-face meetings at the clinical site, employing the use of technology for the purpose of "visiting" the site, meeting (using various modalities) with the student and preceptor to determine how the student is progressing toward attaining identified student and program outcomes, etc.  Additionally, student performance in all clinical practice experiences, at all educational levels, must be evaluated by faculty, although preceptors may offer input."


"III-E.  The curriculum includes planned clinical practice experiences that:
-enable students to integrate new knowledge and demonstrate attainment of program outcomes; and
-are evaluated by faculty.

Elaboration:  To prepare students for a practice profession, each track in each degree program and post-graduate APRN certificate program affords students the opportunity to develop professional competencies in practice settings aligned to the educational preparation.  Clinical practice experiences are provided for students in all programs, including those with distance education offerings.  Clinical practice experiences involve activities that are designed to ensure students are competent to enter nursing practice at the level indicated by the degree / certificate program.  The design, implementation, and evaluation of clinical practice experiences are aligned to student and program outcomes."

Our Opinion and Interpretation:
There are a number of issues we have with the response provided and the apparent exploitation of the word "supervise."  Before we go any further, we must demonstrate that "Key Element III-E for the Standards for Accreditation of Baccalaureate and Graduate Nursing Education (2013)," in our opinion, offers no further insight whatsoever.

Supervision is defined as "the action of supervising [to observe and direct the execution of (a task, project, or activity)] someone or something."  Although the definition provides no explanation or guidelines for the frequency of observation or direction, when used in an academic and/or clinical setting, many would construe supervision as occurring on a daily or at least a weekly basis.  The statement "all clinical practice experiences must be supervised and evaluated by faculty..." appears, in our opinion, to be misleading since one would have the impression that (in terms of "actual clinical experience" (i.e. direct patient encounters or care) a faculty member will be on staff (at a clinical site if actual clinical learning / training is occurring) or on site to provide observation of or direction to the student.  This may not be the case and, in fact, it may be a preceptor who observes and/or directs the student.  CCNE appears to make this concession by acknowledging the different means by which a student may be "supervised."  In fact, CCNE (in their response above) unilaterally places the word "visiting" in quotation marks which we feel is their acknowledgement of the degree to which they have stretched the definition of that word.

We find the statement "additionally, student performance in all clinical practice experiences, at all educational levels, must be evaluated by faculty, although preceptors may offer input" to be quite troubling.  The reason this is so concerning is that, it appears, the individual (the preceptor) who will likely have the most direct contact and observation of the student (on-site) will have the possibility of offering input.  But from the statement above, the student is evaluated by the faculty in spite of whether input is or is not provided by the preceptor (the chief observer of the student) and in spite of whether the faculty member chooses to be receptive of or factor in that input.  Although possible (but not likely) a preceptor may be on staff at a program as a faculty member.  However, according to what CCNE has described in terms of roles of the faculty and the preceptor, evaluation would be tantamount to a grade school principle (in this case the faculty) grading a student without having observed him or her while not being obligated to factor in a teacher's (in this case the preceptor's) feedback, if a teacher did offer feedback.

This is terrifying knowing someone who is being evaluated to one day provide patient care could be evaluated in such a manner.
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7.  Can simulation replace "traditional" clinical practice experiences?  How much simulation is acceptable?

Key Quotes From Their Response:
"The CCNE Standards for Accreditation of Baccalaureate and Graduate Nursing Programs, The Essentials of Baccalaureate Education for Professional Nursing Practice (Baccalaureate Essentials), The Essentials of Master's Education in Nursing (Master's Essentials), The Essentials of Doctoral Education for Advanced Nursing 3 Practice (Doctoral Essentials), and Criteria for Evaluation of Nurse Practitioner Programs (NTF Criteria) do not specify or limit the number of hours of simulation that are acceptable.  However, the Essentials documents and the NTF Criteria do offer the following Guidance:" (please see the paragraphs in red below for the referenced guidance)

Our Opinion and Interpretation:
Upon review of CCNE's website, we could not readily find their definition of "'traditional' clinical practice experiences" for which we have a general idea (to mean actual clinical experience (i.e. direct patient encounters or care)), but based on the liberties they have taken above, we did not want to assume their definition would match commonly accepted ones or formal ones.  This is yet another example of an aberrant term they use without providing their definition of it.  By withholding their definition, we do not feel they are being forthcoming with accreditation details and requirements.  After performing much research, we understand 500 hours to be the required minimum for direct patient care for master's level programs.


Key Quotes From Their Response:
""Learning experiences also can occur using simulation designed as a mechanism for verifying early mastery of new levels of practice or designed to create access to data or healthcare situations that are not readily accessible to the student.  These experiences may include simulated mass casualty events, simulated database problems, simulated interpersonal communication scenarios, and other new emerging learning technologies.  The simulation is an adjunct to the learning that will occur with direct human interface or human learning experience" (Master's Essentials, p. 30)."

Our Opinion and Interpretation:
Regarding "The simulation is an adjunct to the learning that will occur with direct human interface or human learning experience," again, this organization employs aberrant terms without providing their definitions for them.  A search of their website (and of the internet) did not yield any results for definitions for their terms.  The reference to "direct human interface or human learning experience" (to us) may span anywhere from classroom learning to self / independent study.  By withholding their definitions, we do not feel they are being forthcoming with accreditation details and requirements.


Key Quotes From Their Response:
""Experiences include in-depth work with experts from nursing as well as other disciplines and provide opportunities for meaningful student engagement within practice environments.  Given the intense practice focus of DNP [doctorate of nursing practice] programs, practice experiences are designed to help students build and assimilate knowledge for advanced specialty practice at a high level of complexity.  Therefore, end-of-of (sic) program practice immersion experiences should be required to provide an opportunity for further synthesis and expansion of the learning developed to that point" (Doctoral Essentials, p. 19)."

Our Opinion and Interpretation:
According to the passage "end-of-of (sic) program practice immersion experiences should be required," it appears "end-of-of (sic) program immersion experiences" are optional or, at the very least, are at the discretion of the specific program being accredited (as witnessed by use of the phrase "should be required").  Again, a search of their website (and of the internet) did not yield any results for definitions for the term "practice immersion experiences."  According to their referenced source, CCNE's Doctoral Essentials, p. 19, "Practice immersion experiences afford the opportunity to integrate and synthesize the essentials and specialty requirements necessary to demonstrate competency in the area specialized nursing practice.  Proficiency may be acquired through a variety of methods, such as, attaining case requirements, patient or practical contact hours, completing specified procedures, demonstrating experiential competencies, or a combination of these elements."  This explanation describes "practice immersion experiences" hopes to accomplish, but it does not define it.  Again, if an individual (or a program) wants to receive / transmit a degree, it appears the language is delicately worded to do so by meeting the most minimal of requirements regarding experience with direct patient care (500 hours is the required minimum).


Key Quotes From Their Response:
""There is an expectation that a minimum of 500 direct patient care clinical hours is needed specifically to address NP competencies in the preparation of the NP role and population-focused area" (NTF Criteria, p. 8)."

Our Opinion and Interpretation:
This statement offers insight into CCNE's selective use of terms and selective use of specificity.  Their use of the term "direct care clinical hours" contrasts with their use of the term "clinical practice experiences" as referenced above.  In fact, most in the healthcare field would assume "direct patient care clinical hours" to mean "clinical practice experiences."  However they use these terms contrary to what many would understand them to mean.  Furthermore, we find it bizarre they use the term "overall" since one would assume (especially if being required, prescribed or recommended by an accrediting body) that a total amount of hours would be equivalent to the total number of hours overall.


Key Quotes From Their Response:
""Direct patient care involves assessment, diagnosis, treatment, and evaluation of a real client/patient-not simulations or lab exercises with trained patient actors" (NTF Criteria, p. 19)."

Our Opinion and Interpretation:
CCNE demonstrates, in this statement, that they are able to be specific and detailed in regards to their requirements, when they choose to be.
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8.  If a program only admits and enrolls licensed nurses, do the licensed nurses need to have clinical practice experiences as part of the completion program?

Key Quotes From Their Response:
"Yes.  All students, regardless of licensure status, must complete clinical practice experiences that provide them the opportunity to integrate new knowledge into practice at the appropriate educational level."

Our Opinion and Interpretation:
No individual in the healthcare field, with which we are associated, would ever refer to their experience as "clinical practice experiences."  Rather, they would refer to their prior experience as "clinical experience" or maybe (but unlikely) "clinical practice experience."  By using the term "clinical practice experiences" CCNE appears to be broadening commonly understood terms to match their arbitrary definition as described above.  Thus, again, based on their verbiage, it appears this accrediting body leaves enough space for one to achieve a degree with only minimal experience in direct patient care (500 hours is the required minimum for master's level programs).
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9.  Can students be awarded clinical practice experience credit based on their licensure and/or certificate status?

Key Quotes From Their Response:
"While students can receive credit for previously earned academically supervised clinical hours,..."

Our Opinion and Interpretation:
One of the most striking observations in the question posed is the use of "clinical practice experience" (singular) when contrasted with CCNE's use of the term "clinical practice experiences" (plural).  We do not feel this is a typo.  Please reference the interpretation for #8 above.

Unfortunately, CCNE chooses not to answer this question (in this location) as, in their response, they do not specify whether students can be awarded clinical practice experience(s) credit based on their licensure and/or certification status.  We conjecture that they would not want this to be a readily publicized fact and we conjecture that this would be the case and thus it would provide yet another shortcut to those pursuing this educational pathway.  Based on their explanation, it does appear that credit earned for a lesser degree may be applied towards earning a greater degree based on the statement "students can receive credit for previously earned academically supervised clinical hours..."  Furthermore, it appears that direct patient clinical training hours from earning of a lesser degree may be applied towards (and potentially circumvent any more direct patient clinical training hours) earning a greater degree.  In fact, in their "2016 Criteria For Evaluation of Nurse Practitioner Programs 5th Edition," "Sample Form F" titled "Gap Analysis For Post-Graduate NP Certificate Or Post-Master's DNP Student" on pages 38 and 39 they appear to provide guidance to programs under their accreditation as to how they may evaluate and grant credit for prior experiences for post-master's students (Criterion III.F).
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10.  Can prior and/or current work experience be used toward the clinical practice experience requirement?

Key Quotes From Their Response:
"For a student to receive credit for prior clinical hours, the experiences must have been academically supervised.  The program decides whether to allow students to engage in clinical practice experiences at their place of work.  CCNE does not prohibit students from completing clinical practice experiences at their place of work.  However, if the students do engage in clinical practice experiences at their workplace, such experiences cannot be "business as usual."  Rather, the experiences must provide the opportunity for students to integrate new knowledge into practice and the experiences must be appropriate to the expected student learning and program outcomes."

Our Opinion and Interpretation:
The programs under CCNE accreditation appear to have an enormous amount of discretion in terms of whether they allow students to engage in "clinical practice experiences" at their place of work.  As mentioned above by CCNE, "Clinical practice experiences are not limited to clinical patient care settings.  Clinical practice experience also refers to any nursing intervention that influences health care outcomes."  It is important to note that a nurse working at the bedside in a hospital (and many other settings) would not necessarily be "academically supervised" in the sense that most would understand this term to mean (as they have already accomplished the requirements to work as a nurse preceding their enrollment into a nurse practitioner program).  A search of CCNE's website did not reveal a definition for the term "academic supervision."  However, if we reference the response for #6 (which is the closest explanation we can find) with regards to "faculty supervised and evaluated:"

"This can be accomplished through face-to-face meetings at the clinical site, employing the use of technology for the purpose of "visiting" the site, meeting (using various modalities) with the student and preceptor to determine how the student is progressing toward attaining identified student and program outcomes, etc."

According to this explanation, we may be able to extrapolate that "supervision" may encompass anything from a meeting (in-person) between the student and their supervisor to an email or text message (without having ever met in person).  Furthermore, we did not see a frequency of encounters between the student and their supervisor which means (extrapolated) "supervision" may also encompass communication (including (but not limited to) emails and text messages occurring less than once a semester or even per year.
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13.  Can students identify their own clinical practice experiences?

Key Quotes From Their Response:
"Neither the CCNE Standards for Accreditation of Baccalaureate and Graduate Nursing Programs (2013) nor the CCNE Procedures for Accreditation of Baccalaureate and Graduate Nursing Programs (2014) prohibits programs from allowing students to identify their own clinical practice experiences.  Regardless of who identifies the clinical practice experience (student or faculty), the clinical practice experience must provide students the opportunity to integrate new knowledge into practice, and be supervised and evaluated by faculty.  Additionally, faculty are responsible for assessing the appropriateness of the clinical practice experience, including preceptor qualifications, types and number of patients, setting/resources, etc."

Our Opinion and Interpretation:
If one reads this response in the context of the interpretations provided for the responses above, they should be deeply troubled.  Students having even the potential to "identify their own clinical experiences" is dangerous in the setting of an unknown or, perhaps, unknowable definition of "supervision" (for which we have not been able to find a definition provided by CCNE).
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From the Level of Education and Training

According to their website, CCNE is the accrediting body for well over 300 programs.  Chamberlain University is listed as one of them.  According to Chamberlain University's website (in blue):

"1.  You Have the Flexibility of Online Learning

"Through 100% online coursework, Chamberlain's MSN-FNP specialty track offers you the flexibility to pursue a degree at your own pace.  You can take as few as one class per session, averaging 12-18 hours per week toward your studies - giving you time to have a life outside of school."

""My laptop became my best friend and went almost everywhere with me," said Chamberlain MSN-FNP graduate Tia Carrington.  "I still remained busy but wherever my daughter went, that's when I got some work done.  The only thing that changed was my location - I could be at my daughter's dance class or at my mom's, but my work was always with me.""

"Chamberlain NSN-FNP graduate Jaclyn Hamlin was able to go at a faster pace to earn her degree earlier.  "I wanted to go to a school that was going to allow me to continue to work full-time," Jaclyn explained.  "The online aspect of it really appealed to me.  They let me double up my first six months so I could finish my degree in two years instead of two and a half - it was totally doable.""

It appears this university provides their students with the tools to attempt to help themselves when they indicate:

"Preceptors & Practicum Sites

Once you apply, your admission representative will provide you with the information on how to identify a potential practicum site and preceptor.  You are responsible for identifying an appropriate practicum site and preceptor.  Before starting the MSN FNP program, you do not need to identify a preceptor.  However, we require you to identify a potential practicum site before you enroll in your first class."

This program then describes "What is a preceptor?" (see below).  While not specific to this program, we have been aware of multiple instances (if not commonplace) in which an individual serving as a preceptor may rubberstamp their student's checklist.  Not that the program would necessarily have a way of verifying relationships, but one's preceptor very well could be their husband, wife, fiancé, boyfriend, girlfriend, brother, sister, son, daughter, mother, father, friend, an upperclassman from their program "paying forward" a favor or even perhaps someone with which they could enter into a current or future financial relationship with.  According to the website:

"What is a preceptor?

• Serve as a role model for you, while mentoring and directly supervising all aspects of your practicum experience
• Promote your professional development by strategies for remaining current in the field and engaging in ongoing continuing education
• Orient you to the practicum site environment and identify appropriate experiential opportunities that align with course outcomes, student learning agreement and needed skills by the end of the practicum course
• Meet with faculty three times throughout the practicum via conference call to evaluate your progress
• Provide direct supervision of your practicum hours"
  

"Preceptor Criteria

You may use a board certified nurse practitioner, medical doctor, doctor of osteopathy or a physician's assistant as your preceptor.  You will be asked to provide a copy of their CV, a medical license and board certification (for NPs only).

Nurse Practitioner Preceptor Guidelines

• Master's degree in nursing at a minimum
• Nationally board-certified as a nurse practitioner
• Hold an active advanced practice license in the state in which you will conduct your practicum
• Have at least one year of practice as a nurse practitioner
• Is not your current supervisor"

What we find just as troubling as what we perceive to be a lack of organization if one chooses to attempt to find a preceptor is the fact that this program attempts to commission someone who may have never previously served as a preceptor with their "MSN-FNP Preceptor Resource Manual" (https://www.chamberlain.edu/docs/default-source/academics-admissions/fnp/fnp-preceptor-resource-manual.pdf).  Their cycle of instruction (and limited knowledge base) may replicate as the minimum requirement for one to serve as a preceptor is to be a nurse practitioner with "at least one year of practice as a nurse practitioner."

How extensive is the training of a nurse practitioner enrolled in this program?  Extensive is a subjective term when one doesn't have a frame of reference (please see FRAME OF REFERENCE below).  In this program's webpage, listed under "What You Need to Know:" they indicate "Each practicum course contains 125 practicum hours, which must be completed within 7 weeks, or approximately 18 hours per week."  On their webpage, they have listed 5 practicum courses (each of which, again, contains 125 hours).  This appears to be 625 hours (125 hours per practicum x 5 practicums) plus 25 lab hours for a total of 650 hours.  Based on their website's "Sample Curriculum Plan - Online Effective September 2018," their students undergo a total of 45 hours of online courses in addition to the 650 practicum and lab hours.


FRAME OF REFERENCE:

• An osteopathic medical student (a student who becomes a doctor with a D.O. degree) or an allopathic medical student (a student who becomes a doctor with an M.D. degree) completes 650 hours of clinical learning / education well before the 4th week of their 3rd year of medical school.
  
  
• To emphasize the difference in quantity (alone) of training, a nurse in training to become a midlevel at Chamberlain University completes a total of 650 hours of clinical training upon completion of this program.  Medical students, on the other hand, complete this number of hours of clinical training upon completion of 13 to 18 percent of their medical education and medical training.
  
  
• Medical students would complete this quantity of training even earlier in their education if (by virtue of current medical education structure) the majority of clinical rotations were not reserved for the last 2 years of medical school (current medical education structure places an emphasis on building strong academic foundations during the first 2 years with gradual integration of clinical education which occupies the majority of the last 2 years).  This differential in quantity does not factor in the vast difference in quality of education and training.  For even more reference, medical education is comprised of 4 years of medical school followed by 3 to 7 years of medical residency training (and perhaps even longer if one pursues medical fellowship training).
  

Regarding their lab hours, based on our understanding of their website, these 25 hours occur during this program's "Immersion Weekend."  Based on the fact that lodging for at least 1 night is part of the typical costs for this weekend, it appears one may land in Illinois on Saturday morning and have enough time to make it to the airport to fly back home on Sunday afternoon / evening.  It appears, their "weekend" is no more than 1.5 days long.  How immersed are these students?  Below is a general itinerary:

• "Friday
  • You'll arrive leading into the weekend.  This allows you time to check in to your hotel and get situated.
    
    
• Saturday
  • The immersion itself starts on Saturday morning.  The Dean welcomes everyone with an opening keynote before you break out to the skill sessions with your professors.
  • During the first day, you will spend time with your professors going through five skill stations learning to gather history and physical exam data pertinent to patient complaints that might be seen in a primary care setting.  The following are complaints you will learn about:
    • Generalized abdominal pain
    • Cough
    • Non-specific headache
    • Sore throat
    • Sinus pain
    • Ear pain
    • Skin rash
  • The day ends with dinner and leaves ample time for you to prepare for your demonstration the next day.
    
    
• Sunday
  • On Sunday, you perform a full head to toe assessment of a partner in order to advance to practicum courses.  Once through, your immersion is complete."

Our summary and understanding of their itinerary is as follows:

• Friday
  • No clinical work.
    
    
• Saturday
  • Some clinical work, but enough time for dinner and plentiful ("ample") time is left to prepare for Sunday.
    
    
• Sunday
  • Some clinical work, but we assume there is enough time left to commute to the airport and arrive two hours early for one's flight (based on lodging for at least 1 night as mentioned in the "typical costs" on this institution's website).  In fact (based on our estimates based on experience), if (as the website indicates) performing "a full head to toe assessment of a partner in order to advance to practicum courses" is all that is performed on that day, it is likely that not more than 3 hours (which is being generous in terms of time for this task) comprises that day's worth of "immersion."
    

According to a representative from this institution, "Friday is set as for just travel, Saturday is a full day of class (example 8 to 5), and Sunday is a half day."  When an institution specifies a weekend, words matter.  It appears it is important to query what their definition of a weekend is and how many hours their definition encompasses.  According to the dictionary, the word "weekend" is defined as "the period from Friday evening through Sunday evening..."  To be clear, the word "evening" is defined as "the period of time at the end of the day, usually from about 6 p.m. to bedtime."  According to one source, the average American bedtime is approximately 11:00 P.M.

According to all of the facts and definitions above, a weekend is defined as the timespan from approximately 6:00 P.M. on Friday until approximately 11:00 P.M. on Sunday.  According to Chamberlain University's use of the word "weekend" when they refer to their "Immersion Weekend," this is the timespan from Saturday morning until, perhaps, Sunday afternoon.  To be more specific, in one of their student resources, they provide the following instructions, "Do not book your return flight before 5:00pm on Sunday."  If one needs to check-in at the airport 2 hours before his or her flight and travel 36 miles to the nearest airport, he or she would need to depart Chamberlain University's Q Center Training Facility by 2:00 P.M. if he or she booked a flight which departs at 5:00 P.M.  If a student rented a car, he or she would need to depart even earlier to factor in the time of returning the rental car.

Please let these facts sink in:

• A nurse, who obtains an online degree from this school, is 695 hours away from becoming a nurse practitioner (master of science in nursing (M.S.N.)) and having the ability to prescribe medications, order tests and make life and death decisions based on his or her online degree.
  
  
• If one strictly pursued courses offered by this school, it appears he or she could become a nurse practitioner by the age of 23 (assuming he or she graduates from high school at the age of 18) and serve as a patient's "provider."  One of the requirements for acceptance to their B.S.N. (Bachelor of Science in Nursing) program to become a nurse is for one to have a 2.75 grade point average or (depending on the year taken) a G.E.D. test score of at least 551.  According to their website, a B.S.N. degree offered by them may be earned in 3 years' time.  From there, a student may earn their m.s.n. degree in 2 years' time.
  
  
• No doctor (D.O. or M.D.) has the capability of prescribing medications or ordering tests prior to the age of 26 (assuming he or she graduates from high school at the age of 18) even after undergoing 8 years of education.  The earliest age at which the majority of doctors would serve as a patient's primary care physician is 29.

"4.  You Collaborate with Faculty and Students"

""Something I really took advantage of was the first-week phone call with faculty," Jaclyn said.  "Every eight weeks you get a new teacher, and they may want your notes to be different from the one before.  So I would use that phone call at the beginning to say this is who I am and tell me what you want out of me in this class.""

"To provide additional opportunities for real-time contact with faculty (via WebEx or phone), collaborative sessions have been built into the FNP courses that may include debriefings for class assignments or virtual interactive student evaluations depending on the course."

"Through Facebook groups, discussion boards and study groups, you can connect with fellow students throughout your time in the program.  "I connected with other students in my cohort and I formed a Facebook group specifically for our class," said Chamberlain MSN-FNP graduate Jaime Henson.  "It was fantastic to bounce ideas off of each other and share our experiences.""

If an individual who wants to become a nurse practitioner finds that 5 years is just too much time to dedicate to education and training to best serve one's patients, he or she may become a nurse practitioner in as little as 4.5 years' time.  According to Rasmussen College's website, "With Rasmussen College, you can earn your Professional Nursing Associate's degree (ADN) in as few as 18 months.  This college, too, has an online learning option.  Upon completion of that program, one could enroll in California Southern University's School of Nursing to become a nurse practitioner in 3 years' time.  According to their website, "With CalSouthern's ADN-to-MSN program, registered nurses holding an Associate Degree in Nursing can earn their Master of Science in Nursing (MSN) directly, without having to first complete their Bachelor of Science in Nursing."

In our opinion, being enabled to obtain a master's degree (even as a nurse practitioner) directly from an associate's degree (without first obtaining a baccalaureate degree) is tantamount to assuming an individual can run straight from crawling (without taking the intermediate step of learning how to walk).  In our opinion, it is illogical and counterintuitive.

Another nurse practitionry program indicates they have "Saturday residencies."  According to the dictionary, residency is defined as "a period of advanced training in a medical specialty that normally follows graduation from medical school and licensing to practice medicine."  We query why a program of nurse practitionry may mislead individuals with the use of this term (as theirs is not a medical school).  Furthermore, no one in the medical (let alone the healthcare) community with which we have spoken has ever heard of a one-day-a-week residency.  Residency, according to medical tradition, is a continuous time of rigorous training a Doctor undergoes to obtain a medical specialty.  It is not a one-day-a-week course one takes to become a midlevel.
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"The American Association of Nurse Practitioners has employed the slogan "We choose NPs" as part of their marketing agenda.  The Patient Safety Guide and the doctors of America would like to remind you that misinformed choices can have lifelong consequences.  Always demand to receive medical care from the most highly educated and trained professionals in the medical field.  Always demand a doctor."

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The American Academy of PAs (AAPA) has employed the slogan “Your PA Can Handle It”
as part of their marketing agenda.
Some things they (or this organization representing them) can’t handle or are unwilling to handle are:

 
Clearly identifying themselves:
On their webpage for their marketing agenda, this organization does not clearly identify themselves as one representing physician's assistants.  They exclusively use the term “PA” (54 times).  The term “physician assistant” is only used once and it is in fine print to cite a statistic.  We are curious as to why they refuse to fully and clearly identify themselves. We find it bizarre that an organization would use an abbreviation for an abbreviation.  For example, if there was an organization with the abbreviated name "A.A.M.D.," they would declare their full name as the "American Association of Medical Doctors."  They would not use an abbreviation for an abbreviation and indicate their full name was the "American Association of M.D.s."  Many individuals in the medical community view this attempt at rebranding the name "physician's assistant" to "pa" akin to Kentucky Fried Chicken's transition to the name "K.F.C." (which some believe is to minimize the emphasis on the frying process (and its negative connotation) employed in many of their menu items).
Please refer to paragraph #8 under the tab titled “Key Points.”  Please also refer to the paragraph titled “A Doctor?  Or A Case of Renaming, Remarketing and/or Rebranding?” under the tab titled “Are They a Doctor?”

Providing a frame of reference:
Numbers can sound impressive when no scale or frame of reference is provided.  Does 29 feet sound like a long distance?  It doesn't until you learn that this is the distance someone jumped to set the Olympic record for the longest distance ever jumped at the long jump event.

The American Academy of PAs cites “2000+ hours of clinical rotations.”  This would sound impressive but (as mentioned above) doctors undergo 18,000 to 33,000 hours of clinical training.  In fact, according to the United States Department of Labor’s Bureau of Labor Statistics, physician’s assistants undergo no on-the-job training.  In contrast to this, The Bureau of Labor Statistics has listed internship/residency for on-the-job training for doctors.  Their website describes on-the-job training as “additional training needed (postemployment) to attain competency in the skills needed in this occupation.”

Readily providing more details about their sampling methods and the statistics they provide:
According to their marketing website, AAPA indicates a 2014 Harris online survey was conducted.  According to the Better Business Bureau, 72 complaints have been registered against Harris Poll Online.  It appears many of them pertain to some sort of points or rewards program offered to respondents.  If this survey was conducted like others whereby a points or rewards program was employed, in our opinion, it can hardly be construed as objective.  Based on the information available online, it appears respondents were given 4 choices when responding to a question:

1. Strongly agree.
2. Somewhat agree.
3. Somewhat disagree.
4. Strongly disagree.

On their marketing website, AAPA indicates 93% for “PAs are trusted healthcare providers.” For this specific question:

48% indicated they strongly agree.
45% indicated they somewhat agree.
5% indicated they somewhat disagree.
1% indicated they strongly disagree.

For something like trust (which is quantized), it is difficult to accept that a patient may somewhat agree PAs are trusted healthcare providers.  Either one trusts a pilot’s skill and experience (and decides to board a flight) or he or she doesn’t and deplanes (or doesn't board in the first place).  AAPA, however, took the liberty of aggregating “strongly agree” (48%) and “somewhat agree” (45%) to present the statistic of 93%.  Please refer to the paragraph titled “False and Questionable Statistics” under the tab titled “Tools Midlevels Employ which May Mislead Patients.”

While it is this organization’s prerogative to choose which statistics to present, we feel it is important to demonstrate statistics we find to be of incredible importance:

• Regarding the question, “The PA/PAs I/my loved one have seen have educated me about how to stay well and prevent illness,” only 35% strongly agreed.
• Regarding the question, “PAs increase my satisfaction as a patient/loved one’s satisfaction as a patient,” only 34% strongly agreed.
• Regarding the question, “The PA/PAs I/my loved one have seen have educated me about how to stay well and prevent illness,” 18% disagreed.  This is almost 1 out of every 5 patients.
• When one averages the responses for all of the questions (based on information provided online), the majority of the responses are “somewhat agree.” 

We found some of the questions posed to respondents to be beyond what they could possibly know.  Some of the questions appeared tantamount to asking a new car buyer what he or she feels about an automotive manufacturer’s layout of their assembly line.  The healthcare industry is not like other industries as many patients are unaware and/or can’t be aware of its inner workings. Because of this, many patients focus on their “customer service” experience.  Please refer to the paragraph titled “Customer Service” under the tab titled “Tools Midlevels Employ which May Mislead Patients.”  As previously mentioned, according to one article describing a landmark study, “patients who had the highest satisfaction were more likely to be admitted to the hospital, spent more on healthcare, spent more on prescription drugs, and were 26% more likely to die than those who had the lowest satisfaction.”

Don’t gamble on what a physician’s assistant (PA) thinks he or she can handle.  Always demand to receive medical care from the most highly educated and trained professionals in the medical field. Always demand a doctor.

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