REVIEW
Nurse practitioner continuing education: Exploring influences JoEllen Wynne, RN, MSN, FNP-BC, FAANP
Keywords Certification; continuing education; patient outcomes; practice gaps; practice improvements. Correspondence JoEllen Wynne, RN, MSN, FNP-BC, FAANP, E-mail: [email protected] Received: 27 December 2012; accepted: 30 December 2013 doi: 10.1002/2327-6924.12199
Abstract Purpose: This article introduces the interrelated concepts of nurse practitioner (NP) continuing education (CE) funding patterns, regulatory guidance surrounding NP CE, and its effect on patient outcomes in the United States. Data sources: A literature review was done by searching online databases: MEDLINE and CINAHL. Searches included review of NP certifying body websites, Institute of Medicine, Josiah Macy Foundation, and the National Council of State Boards of Nursing websites. Conclusions: The nursing literature supports no connection between required CE and improvement in provision of care to patients, nor does it support improvement in individual provider competence. The funding patterns for nursing and medicine indicate a bias toward biomedical and pharmacological interventions. This type of funding stream may contribute to practice gaps rather than improve them. Implications for practice: Understanding factors that influence CE program availability, plus the choices NPs make regarding mandatory CE, can provide planning guidance. This guidance can help reach the goal of improved patient outcomes and decreased healthcare disparities as a result of CE interventions. NPspecific findings may potentially influence regulatory reform relevant to mandatory CE and maintenance of certification. It is important that NPs recognize existing conflicts of interest in order to make informed program choices.
Introduction There are over 167,000 nurse practitioners (NPs) practicing in the United States, with 9500 graduates annually (American Academy of Nurse Practitioners [AANP], 2010– 2011). NPs are the only group of healthcare providers who are increasingly choosing primary care over specialty care (Government Accountability Office, 2008) and practice in rural or frontier settings at twice the rate of physicians (AANP, 2010–2011). This group of healthcare providers is qualified to contribute to improvements in health disparities and patient outcomes in the United States. NPs provide care in a unique fashion, blending nursing and medicine to promote health, manage acute and chronic conditions, and improve patient outcomes across socioeconomic boundaries. The average NP in the United States has been in practice for almost 13 years and the majority of NPs practice in the community (AANP, 2012), removed from the academic environment where content related to both health disparities and educational outcomes is included in the ed-
398
ucational framework. The APRN Consensus Model and LACE (APRN Joint Dialogue Group Report, 2008) outlines detailed guidelines for the primary education of NPs, including curriculum incorporating healthcare disparities. However, guidelines from both these organizations, and national certifying bodies, are minimal and broadly stated surrounding continuing education (CE) requirements for maintenance of certification (MOC), with no clearly identified requirements for specific content of required educational programs (American Academy of Nurse Practitioners Certification Program, 2012; American Nurses Credentialing Center, 2012; National Certification Corporation, 2012; Oncology Nursing Certification Corporation, 2012; Pediatric Nursing Certification Board, 2012). Furthermore, regulatory bodies typically base acceptance of CE for MOC on the program accrediting body, rather than on objectives that guide the content. Practicing NPs’ lack of exposure to recent data surrounding health disparities, or the importance of identifying patient outcomes related to educational interventions, may further contribute to practice gaps. CE programming,
Journal of the American Association of Nurse Practitioners 27 (2015) 398–402 C 2014 American Association of Nurse Practitioners
J. Wynne
designed with measurable educational outcomes, could provide a vital link between practice and education and result in improvement in patient outcomes. The existing funding stream for both CE and continuing medical education (CME) is under scrutiny because of a perception that although CE/CME programming may be free for participants, “Patients and payers, however, may ultimately pay the bill” (Steinbrook, 2008, p. 106). Commercial interests such as pharmaceutical and medical device companies provide millions of dollars in support of CE for all healthcare providers. Yet, there are minimal outcome measures related to the effectiveness of these programs. This type of funding stream supports education on topics of interest to the funder; devices, drugs, and diagnostic testing; missing other topics of huge importance to improving specific patient outcomes, including health disparities. Based on the current funding stream for CE, it may be noted that biomedical interventions are the focus of many, if not most, existing programs (Saxton, 2009). There is scant data surrounding NP choices or outcomes of mandated CE. There is existing literature that highlights the potential conflicts of interest related to current funding patterns for both CME and CE. The purpose of this article is to provide a review of the literature introducing several interrelated topics. These topics include NP CE and its impact on health status and existing CE funding patterns. Current funding patterns have been found to contribute to a unique culture of expectation, related to educational offerings, by consumers of CE programs for health professionals. Additionally, exploration of guidance provided by regulatory bodies regarding specific content requirements of CE for MOC will be presented.
Methods A literature review was conducted individually by the author, searching online databases: MEDLINE and CINAHL. The key words used: funding of CME, NP education, nursing CE, MOC, CE outcomes, and regulatory requirements, search dates were 2001 through 2011. The bibliographies of selected journal articles were used to identify other articles of interest and the search was not restricted to nursing. Specific inclusion and exclusion criterion were not established as this is an introduction to the interrelated topics and existing literature is limited. Additional online searches included review of all NP certifying body websites, the Institute of Medicine (IOM), the Josiah Macy Foundation, and the National Council of State Boards of Nursing websites.
Findings The review of the literature consists of two distinct areas, data regarding NP choices, preferences, and patient
Nurse practitioner continuing education
outcomes of NP CE, coupled with NP-specific regulatory requirements and guidance related to mandatory CE. The second area is related to the funding stream and culture surrounding the development, delivery, and funding of CE for health professionals. This area includes a brief review on the identified conflicts of interests related to industry influence on healthcare providers, including NPs. The findings will be presented separately for these two areas.
Regulatory requirements related to NP CE Regulatory bodies, national certification organizations, and state boards of nursing provide varying guidelines regarding mandated CE with few, if any requirements for specific educational content. Each state board has differing requirements surrounding CE for MOC. The five national certification organizations employ varying processes and CE contact hour requirements for the MOC of NPs across roles. Most NP certifying bodies base the acceptance of CE programs on who the accrediting organization is, rather than on objectives that guide educational content or offer the potential of the educational initiative to improve patient care or NP competency (American Academy of Nurse Practitioners Certification Program, 2012; American Nurses Credentialing Center, 2012; National Certification Corporation, 2012; Oncology Nursing Certification Corporation, 2012; Pediatric Nursing Certification Board, 2012).
NP preferences related to CE Innovation has come to the delivery of CE as it has to academic educational programs. The availability of various delivery methods for education, CD ROM, webcast, audio recordings, and interactive online programs, has increased the types and locations of educational offerings. In order to provide state of science educational content and support individual learning styles, CE planners have explored the preferences of target audiences in an attempt to understand what meets the needs and expectations of learners. Many times educational needs assessments include the reporting of the needs of multidisciplinary audiences, typically including NPs as an add-on data point for physician surveys. Another common process is to report aggregate data on nurses, without specific identification of NP responses. However, over the past decade, consistent, if scant, information regarding NP learning preferences has been identified. NPs report a preference for live, in-person educational sessions (Charles & Mamary, 2002; Goolsby & Wynne, 2008; Green, Gorzka, & Kodish, 2005) with clinically focused sessions surrounding 399
Nurse practitioner continuing education
the management of diseases, particularly pharmacologic management (AANP, 2008; Goolsby & Wynne, 2008; Green et al., 2005). NPs complete more CE than is mandated by regulatory bodies (Goolsby & Wynne, 2008; Smith, 2003; Whitehead & Lacey-Haun, 2008) and perceive that CE is important to their professional development and competency (Smith, 2003). Furthermore, it is an NP perception that CE provides a positive change in provision of patient care (Green et al., 2005). Although NPs consistently identify clinical educational topics as the most important factor in choosing specific live programs (Goolsby & Wynne, 2008; Green et al., 2005), there are other identified factors that influence the decision to attend. These include location, length of program, cost, availability of meal at symposium (Goolsby & Wynne, 2008; Green et al., 2005), robust exhibit halls, and contact with pharmaceutical representatives (Ladd, 2011; Ladd, Feeney Malone, & Emani, 2010). Of the four needs assessments included in this review (AANP, 2008; Charles & Mamary, 2002; Green et al., 2005; Smith, 2003) only one included any content related to health disparities (AANP, 2008) and two (Green et al., 2005; Smith, 2003) made an effort to identify the impact or perception of change on practice related to CE. The majority of the literature reviewed consists of quantitative, descriptive studies with data obtained by survey (Charles & Mamary, 2002; Goolsby & Wynne, 2008; Green et al., 2005; Ladd, et al., 2010; Smith, 2003), this includes unpublished work (AANP, 2008). One study included correlation (Smith, 2003). The samples in this study were obtained both by convenience sampling (Green et al., 2005; Charles & Mamary, 2002) and random selection (AANP, 2008; Goolsby & Wynne, 2008; Ladd et al., 2010; Smith, 2003). Qualitative methods were employed in addition to quantitative in one study (Green et al., 2005), with two of the articles included containing literature reviews (Ladd, 2011; Whitehead & Lacey-Haun, 2008).
Gaps in the research literature In addition to the small number of studies, the most significant gap identified is the lack of educational needs assessments with inclusion of content specific to health disparities and improvement of patient outcomes or practice change related to educational interventions. Descriptive studies to obtain data, using random samples of NPs, will provide more information in this area and identify whether NPs will seek education related to these areas if available. The addition of qualitative methods to gain further knowledge would be beneficial in exploring NPs’ understanding of, and interest in, educational content in these two important areas. A body of literature developed to explore whether MOC indicates competency is 400
J. Wynne
important. Current processes in place appear to support MOC as entry level to practice rather than increasing competency.
Pharmaceutical sponsorship and CE development The existing funding stream for CE/CME is under scrutiny for potential conflicts of interest related to the development and provision of CE to health professionals (IOM, 2009; Ladd, 2011; Saxton, 2009; Steinbrook, 2008). The Josiah Macy, Jr. Foundation sponsored a conference on CE held in 2007, which determined that CE for the health professions in the United States is inadequate. In the report of these proceedings, Steinbrook (2008) documents financial issues related to CME, noting that separate data do not exist for nursing (Appendix). However, because many programs are accredited across disciplines, it is reasonable to expect similar trends. The joint accreditation standards between the Accreditation Council for Continuing Medical Education (ACCME) and the American Nurses Credentialing Corporation (ANCC; Whitehead & Lacey-Haun, 2008) further support this premise. Outlined in this report is the escalation of profit for medical education and communication companies (MECCs) who develop and implement programs. The development of CE for health professionals is a multimillion dollar industry with commercial interests such as pharmaceutical and medical device companies historically providing greater that 50% of funding for program development and implementation (Steinbrook, 2008). All of these financial situations provide cause for concern related to conflict of interests on many levels. Enough so, that in 2003 the Office of Inspector General offered guidance to reduce the risk of fraud and abuse related to educational grants from pharmaceutical companies. The funding patterns related to the development and provision of CE/CME set up an environment of expectation on the part of the participants. As noted in the literature related to NP preferences, participants often look for decreased cost, meals, and interaction with pharmaceutical representatives in the exhibit hall when choosing educational programs to attend. The IOM, (2009) committee formed as a result of findings from Josiah Macy, Jr. Foundation conference. The committee convened stakeholders from each of the health professions, reviewing literature related to educational outcomes and identifying areas for improvement. These areas included concern for commercial funding by device and pharmaceutical companies and a focus on meeting regulatory requirements rather than identifying and minimizing important knowledge gaps. Minimal literature related to NPs and specific conflicts of interest exists, although it has been noted that NPs in
Nurse practitioner continuing education
J. Wynne
practice have a high level of contact with pharmaceutical representatives (Ladd, 2011; Ladd et al., 2010). Additionally, NPs report regular attendance at pharmaceutical supported educational programs that have the potential to increase prescribing of featured drugs (Ladd, 2011; Ladd et al., 2010). This change in prescribing habits may be related to promotion rather than identification of practice gaps or recognition of healthcare disparities requiring individualized treatment. All of the literature reviewed in this section is descriptive, with the inclusion of the proceedings from two meetings that serve as a literature review (IOM, 2009; Steinbrook, 2008). An additional literature review is included, which is in the form of a CE offering, designed to educate NPs regarding marketing versus unbiased education and the potential conflicts that exist (Ladd, 2011). Two opinion pieces are included (Saxton, 2009; Whitehead & Lacey-Haun, 2008) with only one descriptive survey that includes random sampling (Ladd et al., 2010).
Gaps in the literature There is clear evidence that the culture surrounding CE/CME is one with a potential for bias related to historical funding patterns. NP-specific data in this area are emerging. Further descriptive studies are needed specific to this discipline and the understanding of the impact on practice. It is important to gain an understanding of NPs’ recognition of potential conflicts of interest related to promotion disguised as unbiased CE.
Recommendation for future research and clinical practice The inclusion of options for education including outcomes of programs, performance improvement, and healthcare disparities on educational needs assessments is fundamental. A clear understanding of the choices NPs make regarding mandatory CE programs can provide guidance to those planning NP CE related to healthcare disparities. Practicing NPs, outside academia, may have little exposure to emerging data surrounding outcomes, individual performance improvement, and health disparities. It is important to cultivate a clear picture to develop appropriate educational content. Specific research on NP understanding of the factors that impact CE program availability will further identify areas for educational interventions. NP-specific research related to conflict of interest surrounding commercial support of CE is important. A clear understanding of NPs’ recognition of promotion versus unbiased CE should be developed. The existing funding stream
minimizes CE program choices and NPs may not recognize this influence. Exploration of all these factors has the potential to the development of a CE planning model to be used to assist planners and providers of NP CE, incorporating content that addresses patient outcomes, healthcare provider performance improvement, and healthcare disparities. Additionally, outlining NP-specific recognition of healthcare disparities and practice gaps has the potential to influence regulatory reform relevant to mandatory CE and MOC. Currently, regulatory bodies provide little guidance regarding content of CE choices. MOC requirements, as they exist today, do little to document increasing clinical competence, but appear to support an entry level of competency. Future research has the ability to provide support for increased regulatory input in this area.
Conclusions The nursing literature supports no connection between CE requirements, which meet regulatory standards, and improvement in patient care. The literature on the historical funding patterns for CE/CME indicate a bias toward biomedical and pharmacological interventions, missing other extremely significant gaps in practice such as health disparities. No evidence was found that supports NP choice of specific educational programs related to health disparities, patient outcomes, or performance improvement. Educational needs assessment surveys designed to guide program planning for NPs, typically do not include these topics. At this time it may be concluded that NPs are impacted by the historical culture surrounding the funding, development, and provision of CE. These factors correlate with the historical return on investment that pharmaceutical companies, MECCs, and professional societies have come to expect when providing education to healthcare providers of all disciplines. This convergence of factors results in a lack of CE programs designed to measurably improve patient health across culture, age, and disease state.
References American Academy of Nurse Practitioners (AANP). (2008). [Educational needs assessment]. Unpublished raw data. American Academy of Nurse Practitioners (AANP). (2010–2011). Nurse practitioner facts 2010–2011. Retrieved from http://www.aanp.org/research/aanp-research American Academy of Nurse Practitioners Certification Program. (2012). Recertification CE requirements. Retrieved from http://www.aanpcertification.org/ptistore/control/recert/ce
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American Nurses Credentialing Center. (2012). Renewal requirements. Retrieved from http://www.nursecredentialing.org/RenewalRequirements. aspx APRN Joint Dialogue Group Report (2008). APRN Consensus Work Group, & National Council of State Boards of Nursing APRN Advisory Committee. Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved from http://www.aacn.nche.edu/education-resources/APRNReport.pdf Charles, P. A., & Mamary, E. M. (2002). New choices for continuing education: A statewide survey of the practices and preferences of nurse practitioners. Journal of Continuing Education in Nursing, 33(1), 88– 91. Goolsby, M. J., & Wynne, J. E. (2008). Interprofessional education: Educational needs of U.S. nurse practitioners. Abstracts from CME Congress 2008, Vancouver, British Columbia. Journal of Continuing Education in the Health Professions, 28(S1), 33–46. doi: 10.1002/chp Government Accountability Office. (2008). Testimony before the Committee on Health, Education, Labor, and Pensions, U.S. Senate. Primary care professionals: Recent supply trends, projections, and valuation of services. GAO-08–472T. Retrieved from http://www.gao.gov/new.items/d08472t.pdf Green, R., Gorzka, P., & Kodish, S. (2005). Achieving excellence in practice: A model for continuing education for nurse practitioners. Journal of the American Academy of Nurse Practitioners, 17(11), 452– 459. Institute of Medicine (IOM). (2009). Redesigning continuing education in the health professions. Retrieved from http://www.iom.edu/Reports/2009/ Redesigning-Continuing-Education-in-the-Health-Professions. aspx
Ladd, E. (2011). Pharmaceutical industry sponsorship and the NP prescriber: Policy and practice implications. Journal for Nurse Practitioners, 7(2), 102–108. Ladd, E. C., Feeney Mahoney, D., & Emani, S., (2010). “Under the radar”: Nurse practitioner prescribers and pharmaceutical industry promotions. American Journal of Managed Care, 16(12), 358–362. National Certification Corporation. (2012). Maintain your certification. Retrieved from http://www.nccwebsite.org/Certification-maintenance/OnlineApplicatoinInformation.aspx Oncology Nursing Certification Corporation. (2012). Renew your certification. Retrieved from http://www.oncc.org/Renew/ONC-PRO Pediatric Nursing Certification Board. (2012). Recertify. Retrieved from http://www.pncb.org/ptistore/control/certs/cpn-cpnp/index. Saxton, M. (2009). A view from industry: The foundations of future commercial support and a call for action. Journal of Continuing Education in the Health Professions, 29(1), 71–75. doi: 10.1002/chp.20010 Smith, J. (2003). Report of findings exploring the value of continuing education mandates (NCSBN Research Brief). Retrieved from National Council of State Boards of Nursing website: https://www.ncsbn.org/CEStudy.pdf Steinbrook, R. (2008). Financial support of continuing education in the health professions. In M. Hager, S. Russell, & S. W. Fletcher (Eds.). Continuing education in the health professions: Improving healthcare through lifelong learning, Proceedings of a Conference Sponsored by the Josiah Macy, Jr. Foundation, Bermuda, November 28 to December 1, 2007 (pp. 103–137). New York: Josiah Macy, Jr. Foundationital. Retrieved from http://macyfoundation.org/docs/macy pubs/pub ContEd inHealthProf.pdf Whitehead, T. D., & Lacey-Haun, L. (2008). Evolution of accreditation in continuing nursing education in America. Journal of Continuing Education in Nursing, 39(11).
Appendix: ACCME funding charts
Table A1 Income and expenses for continuing medical education in the United States, 1998–2006
Year
ACCME accredited organizations
Total income
Commercial support
Ad and exhibit income
Registration fees and other income
Total expenses
Profit margin
1998
632 655
2000
680
2001
674
2002
686
2003
697
2004
716
2005
716
2006
729
$302 million $388 million $467 million $569 million $746 million $971 million $1.07 billion $1.12 billion $1.2 billion
$125.9 million $148.2 million $168.9 million $160.0 million $187.3 million $183.3 million $197.0 million $235.7 million $244.9 million
$457.7 million $574.6 million $635.4 million $665.2 million $662.9 million $620.1 million $784.5 million $899.2 million $940.3 million
$842.1 million $920.9 million $1.05 billion $1.18 billion $1.33 billion $1.54 billion $1.61 billion $1.72 billion $1.82 billion
5.5%
1999
$888.5 million $1.11 billion $1.27 billion $1.39 billion $1.60 billion $1.77 billion $2.05 billion $2.25 billion $2.38 billion
20.5% 20.6% 18.1% 20.3% 15.2% 27.4% 31.0% 31.0%
Data are from the 2006 annual report of the ACCME. Of the 729 ACCME accredited providers, 718 reported data on total income, 601 on commercial income, 446 on advertising and exhibits, 650 on registration fees and other income, and 721 on total expense. Data on providers that are accredited by state medical societies are not included. Adapted from Steinbrook (2008, p. 105).
402
Nurse practitioner continuing education: Exploring influences JoEllen Wynne, RN, MSN, FNP-BC, FAANP
Keywords Certification; continuing education; patient outcomes; practice gaps; practice improvements. Correspondence JoEllen Wynne, RN, MSN, FNP-BC, FAANP, E-mail: [email protected] Received: 27 December 2012; accepted: 30 December 2013 doi: 10.1002/2327-6924.12199
Abstract Purpose: This article introduces the interrelated concepts of nurse practitioner (NP) continuing education (CE) funding patterns, regulatory guidance surrounding NP CE, and its effect on patient outcomes in the United States. Data sources: A literature review was done by searching online databases: MEDLINE and CINAHL. Searches included review of NP certifying body websites, Institute of Medicine, Josiah Macy Foundation, and the National Council of State Boards of Nursing websites. Conclusions: The nursing literature supports no connection between required CE and improvement in provision of care to patients, nor does it support improvement in individual provider competence. The funding patterns for nursing and medicine indicate a bias toward biomedical and pharmacological interventions. This type of funding stream may contribute to practice gaps rather than improve them. Implications for practice: Understanding factors that influence CE program availability, plus the choices NPs make regarding mandatory CE, can provide planning guidance. This guidance can help reach the goal of improved patient outcomes and decreased healthcare disparities as a result of CE interventions. NPspecific findings may potentially influence regulatory reform relevant to mandatory CE and maintenance of certification. It is important that NPs recognize existing conflicts of interest in order to make informed program choices.
Introduction There are over 167,000 nurse practitioners (NPs) practicing in the United States, with 9500 graduates annually (American Academy of Nurse Practitioners [AANP], 2010– 2011). NPs are the only group of healthcare providers who are increasingly choosing primary care over specialty care (Government Accountability Office, 2008) and practice in rural or frontier settings at twice the rate of physicians (AANP, 2010–2011). This group of healthcare providers is qualified to contribute to improvements in health disparities and patient outcomes in the United States. NPs provide care in a unique fashion, blending nursing and medicine to promote health, manage acute and chronic conditions, and improve patient outcomes across socioeconomic boundaries. The average NP in the United States has been in practice for almost 13 years and the majority of NPs practice in the community (AANP, 2012), removed from the academic environment where content related to both health disparities and educational outcomes is included in the ed-
398
ucational framework. The APRN Consensus Model and LACE (APRN Joint Dialogue Group Report, 2008) outlines detailed guidelines for the primary education of NPs, including curriculum incorporating healthcare disparities. However, guidelines from both these organizations, and national certifying bodies, are minimal and broadly stated surrounding continuing education (CE) requirements for maintenance of certification (MOC), with no clearly identified requirements for specific content of required educational programs (American Academy of Nurse Practitioners Certification Program, 2012; American Nurses Credentialing Center, 2012; National Certification Corporation, 2012; Oncology Nursing Certification Corporation, 2012; Pediatric Nursing Certification Board, 2012). Furthermore, regulatory bodies typically base acceptance of CE for MOC on the program accrediting body, rather than on objectives that guide the content. Practicing NPs’ lack of exposure to recent data surrounding health disparities, or the importance of identifying patient outcomes related to educational interventions, may further contribute to practice gaps. CE programming,
Journal of the American Association of Nurse Practitioners 27 (2015) 398–402 C 2014 American Association of Nurse Practitioners
J. Wynne
designed with measurable educational outcomes, could provide a vital link between practice and education and result in improvement in patient outcomes. The existing funding stream for both CE and continuing medical education (CME) is under scrutiny because of a perception that although CE/CME programming may be free for participants, “Patients and payers, however, may ultimately pay the bill” (Steinbrook, 2008, p. 106). Commercial interests such as pharmaceutical and medical device companies provide millions of dollars in support of CE for all healthcare providers. Yet, there are minimal outcome measures related to the effectiveness of these programs. This type of funding stream supports education on topics of interest to the funder; devices, drugs, and diagnostic testing; missing other topics of huge importance to improving specific patient outcomes, including health disparities. Based on the current funding stream for CE, it may be noted that biomedical interventions are the focus of many, if not most, existing programs (Saxton, 2009). There is scant data surrounding NP choices or outcomes of mandated CE. There is existing literature that highlights the potential conflicts of interest related to current funding patterns for both CME and CE. The purpose of this article is to provide a review of the literature introducing several interrelated topics. These topics include NP CE and its impact on health status and existing CE funding patterns. Current funding patterns have been found to contribute to a unique culture of expectation, related to educational offerings, by consumers of CE programs for health professionals. Additionally, exploration of guidance provided by regulatory bodies regarding specific content requirements of CE for MOC will be presented.
Methods A literature review was conducted individually by the author, searching online databases: MEDLINE and CINAHL. The key words used: funding of CME, NP education, nursing CE, MOC, CE outcomes, and regulatory requirements, search dates were 2001 through 2011. The bibliographies of selected journal articles were used to identify other articles of interest and the search was not restricted to nursing. Specific inclusion and exclusion criterion were not established as this is an introduction to the interrelated topics and existing literature is limited. Additional online searches included review of all NP certifying body websites, the Institute of Medicine (IOM), the Josiah Macy Foundation, and the National Council of State Boards of Nursing websites.
Findings The review of the literature consists of two distinct areas, data regarding NP choices, preferences, and patient
Nurse practitioner continuing education
outcomes of NP CE, coupled with NP-specific regulatory requirements and guidance related to mandatory CE. The second area is related to the funding stream and culture surrounding the development, delivery, and funding of CE for health professionals. This area includes a brief review on the identified conflicts of interests related to industry influence on healthcare providers, including NPs. The findings will be presented separately for these two areas.
Regulatory requirements related to NP CE Regulatory bodies, national certification organizations, and state boards of nursing provide varying guidelines regarding mandated CE with few, if any requirements for specific educational content. Each state board has differing requirements surrounding CE for MOC. The five national certification organizations employ varying processes and CE contact hour requirements for the MOC of NPs across roles. Most NP certifying bodies base the acceptance of CE programs on who the accrediting organization is, rather than on objectives that guide educational content or offer the potential of the educational initiative to improve patient care or NP competency (American Academy of Nurse Practitioners Certification Program, 2012; American Nurses Credentialing Center, 2012; National Certification Corporation, 2012; Oncology Nursing Certification Corporation, 2012; Pediatric Nursing Certification Board, 2012).
NP preferences related to CE Innovation has come to the delivery of CE as it has to academic educational programs. The availability of various delivery methods for education, CD ROM, webcast, audio recordings, and interactive online programs, has increased the types and locations of educational offerings. In order to provide state of science educational content and support individual learning styles, CE planners have explored the preferences of target audiences in an attempt to understand what meets the needs and expectations of learners. Many times educational needs assessments include the reporting of the needs of multidisciplinary audiences, typically including NPs as an add-on data point for physician surveys. Another common process is to report aggregate data on nurses, without specific identification of NP responses. However, over the past decade, consistent, if scant, information regarding NP learning preferences has been identified. NPs report a preference for live, in-person educational sessions (Charles & Mamary, 2002; Goolsby & Wynne, 2008; Green, Gorzka, & Kodish, 2005) with clinically focused sessions surrounding 399
Nurse practitioner continuing education
the management of diseases, particularly pharmacologic management (AANP, 2008; Goolsby & Wynne, 2008; Green et al., 2005). NPs complete more CE than is mandated by regulatory bodies (Goolsby & Wynne, 2008; Smith, 2003; Whitehead & Lacey-Haun, 2008) and perceive that CE is important to their professional development and competency (Smith, 2003). Furthermore, it is an NP perception that CE provides a positive change in provision of patient care (Green et al., 2005). Although NPs consistently identify clinical educational topics as the most important factor in choosing specific live programs (Goolsby & Wynne, 2008; Green et al., 2005), there are other identified factors that influence the decision to attend. These include location, length of program, cost, availability of meal at symposium (Goolsby & Wynne, 2008; Green et al., 2005), robust exhibit halls, and contact with pharmaceutical representatives (Ladd, 2011; Ladd, Feeney Malone, & Emani, 2010). Of the four needs assessments included in this review (AANP, 2008; Charles & Mamary, 2002; Green et al., 2005; Smith, 2003) only one included any content related to health disparities (AANP, 2008) and two (Green et al., 2005; Smith, 2003) made an effort to identify the impact or perception of change on practice related to CE. The majority of the literature reviewed consists of quantitative, descriptive studies with data obtained by survey (Charles & Mamary, 2002; Goolsby & Wynne, 2008; Green et al., 2005; Ladd, et al., 2010; Smith, 2003), this includes unpublished work (AANP, 2008). One study included correlation (Smith, 2003). The samples in this study were obtained both by convenience sampling (Green et al., 2005; Charles & Mamary, 2002) and random selection (AANP, 2008; Goolsby & Wynne, 2008; Ladd et al., 2010; Smith, 2003). Qualitative methods were employed in addition to quantitative in one study (Green et al., 2005), with two of the articles included containing literature reviews (Ladd, 2011; Whitehead & Lacey-Haun, 2008).
Gaps in the research literature In addition to the small number of studies, the most significant gap identified is the lack of educational needs assessments with inclusion of content specific to health disparities and improvement of patient outcomes or practice change related to educational interventions. Descriptive studies to obtain data, using random samples of NPs, will provide more information in this area and identify whether NPs will seek education related to these areas if available. The addition of qualitative methods to gain further knowledge would be beneficial in exploring NPs’ understanding of, and interest in, educational content in these two important areas. A body of literature developed to explore whether MOC indicates competency is 400
J. Wynne
important. Current processes in place appear to support MOC as entry level to practice rather than increasing competency.
Pharmaceutical sponsorship and CE development The existing funding stream for CE/CME is under scrutiny for potential conflicts of interest related to the development and provision of CE to health professionals (IOM, 2009; Ladd, 2011; Saxton, 2009; Steinbrook, 2008). The Josiah Macy, Jr. Foundation sponsored a conference on CE held in 2007, which determined that CE for the health professions in the United States is inadequate. In the report of these proceedings, Steinbrook (2008) documents financial issues related to CME, noting that separate data do not exist for nursing (Appendix). However, because many programs are accredited across disciplines, it is reasonable to expect similar trends. The joint accreditation standards between the Accreditation Council for Continuing Medical Education (ACCME) and the American Nurses Credentialing Corporation (ANCC; Whitehead & Lacey-Haun, 2008) further support this premise. Outlined in this report is the escalation of profit for medical education and communication companies (MECCs) who develop and implement programs. The development of CE for health professionals is a multimillion dollar industry with commercial interests such as pharmaceutical and medical device companies historically providing greater that 50% of funding for program development and implementation (Steinbrook, 2008). All of these financial situations provide cause for concern related to conflict of interests on many levels. Enough so, that in 2003 the Office of Inspector General offered guidance to reduce the risk of fraud and abuse related to educational grants from pharmaceutical companies. The funding patterns related to the development and provision of CE/CME set up an environment of expectation on the part of the participants. As noted in the literature related to NP preferences, participants often look for decreased cost, meals, and interaction with pharmaceutical representatives in the exhibit hall when choosing educational programs to attend. The IOM, (2009) committee formed as a result of findings from Josiah Macy, Jr. Foundation conference. The committee convened stakeholders from each of the health professions, reviewing literature related to educational outcomes and identifying areas for improvement. These areas included concern for commercial funding by device and pharmaceutical companies and a focus on meeting regulatory requirements rather than identifying and minimizing important knowledge gaps. Minimal literature related to NPs and specific conflicts of interest exists, although it has been noted that NPs in
Nurse practitioner continuing education
J. Wynne
practice have a high level of contact with pharmaceutical representatives (Ladd, 2011; Ladd et al., 2010). Additionally, NPs report regular attendance at pharmaceutical supported educational programs that have the potential to increase prescribing of featured drugs (Ladd, 2011; Ladd et al., 2010). This change in prescribing habits may be related to promotion rather than identification of practice gaps or recognition of healthcare disparities requiring individualized treatment. All of the literature reviewed in this section is descriptive, with the inclusion of the proceedings from two meetings that serve as a literature review (IOM, 2009; Steinbrook, 2008). An additional literature review is included, which is in the form of a CE offering, designed to educate NPs regarding marketing versus unbiased education and the potential conflicts that exist (Ladd, 2011). Two opinion pieces are included (Saxton, 2009; Whitehead & Lacey-Haun, 2008) with only one descriptive survey that includes random sampling (Ladd et al., 2010).
Gaps in the literature There is clear evidence that the culture surrounding CE/CME is one with a potential for bias related to historical funding patterns. NP-specific data in this area are emerging. Further descriptive studies are needed specific to this discipline and the understanding of the impact on practice. It is important to gain an understanding of NPs’ recognition of potential conflicts of interest related to promotion disguised as unbiased CE.
Recommendation for future research and clinical practice The inclusion of options for education including outcomes of programs, performance improvement, and healthcare disparities on educational needs assessments is fundamental. A clear understanding of the choices NPs make regarding mandatory CE programs can provide guidance to those planning NP CE related to healthcare disparities. Practicing NPs, outside academia, may have little exposure to emerging data surrounding outcomes, individual performance improvement, and health disparities. It is important to cultivate a clear picture to develop appropriate educational content. Specific research on NP understanding of the factors that impact CE program availability will further identify areas for educational interventions. NP-specific research related to conflict of interest surrounding commercial support of CE is important. A clear understanding of NPs’ recognition of promotion versus unbiased CE should be developed. The existing funding stream
minimizes CE program choices and NPs may not recognize this influence. Exploration of all these factors has the potential to the development of a CE planning model to be used to assist planners and providers of NP CE, incorporating content that addresses patient outcomes, healthcare provider performance improvement, and healthcare disparities. Additionally, outlining NP-specific recognition of healthcare disparities and practice gaps has the potential to influence regulatory reform relevant to mandatory CE and MOC. Currently, regulatory bodies provide little guidance regarding content of CE choices. MOC requirements, as they exist today, do little to document increasing clinical competence, but appear to support an entry level of competency. Future research has the ability to provide support for increased regulatory input in this area.
Conclusions The nursing literature supports no connection between CE requirements, which meet regulatory standards, and improvement in patient care. The literature on the historical funding patterns for CE/CME indicate a bias toward biomedical and pharmacological interventions, missing other extremely significant gaps in practice such as health disparities. No evidence was found that supports NP choice of specific educational programs related to health disparities, patient outcomes, or performance improvement. Educational needs assessment surveys designed to guide program planning for NPs, typically do not include these topics. At this time it may be concluded that NPs are impacted by the historical culture surrounding the funding, development, and provision of CE. These factors correlate with the historical return on investment that pharmaceutical companies, MECCs, and professional societies have come to expect when providing education to healthcare providers of all disciplines. This convergence of factors results in a lack of CE programs designed to measurably improve patient health across culture, age, and disease state.
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American Nurses Credentialing Center. (2012). Renewal requirements. Retrieved from http://www.nursecredentialing.org/RenewalRequirements. aspx APRN Joint Dialogue Group Report (2008). APRN Consensus Work Group, & National Council of State Boards of Nursing APRN Advisory Committee. Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved from http://www.aacn.nche.edu/education-resources/APRNReport.pdf Charles, P. A., & Mamary, E. M. (2002). New choices for continuing education: A statewide survey of the practices and preferences of nurse practitioners. Journal of Continuing Education in Nursing, 33(1), 88– 91. Goolsby, M. J., & Wynne, J. E. (2008). Interprofessional education: Educational needs of U.S. nurse practitioners. Abstracts from CME Congress 2008, Vancouver, British Columbia. Journal of Continuing Education in the Health Professions, 28(S1), 33–46. doi: 10.1002/chp Government Accountability Office. (2008). Testimony before the Committee on Health, Education, Labor, and Pensions, U.S. Senate. Primary care professionals: Recent supply trends, projections, and valuation of services. GAO-08–472T. Retrieved from http://www.gao.gov/new.items/d08472t.pdf Green, R., Gorzka, P., & Kodish, S. (2005). Achieving excellence in practice: A model for continuing education for nurse practitioners. Journal of the American Academy of Nurse Practitioners, 17(11), 452– 459. Institute of Medicine (IOM). (2009). Redesigning continuing education in the health professions. Retrieved from http://www.iom.edu/Reports/2009/ Redesigning-Continuing-Education-in-the-Health-Professions. aspx
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Appendix: ACCME funding charts
Table A1 Income and expenses for continuing medical education in the United States, 1998–2006
Year
ACCME accredited organizations
Total income
Commercial support
Ad and exhibit income
Registration fees and other income
Total expenses
Profit margin
1998
632 655
2000
680
2001
674
2002
686
2003
697
2004
716
2005
716
2006
729
$302 million $388 million $467 million $569 million $746 million $971 million $1.07 billion $1.12 billion $1.2 billion
$125.9 million $148.2 million $168.9 million $160.0 million $187.3 million $183.3 million $197.0 million $235.7 million $244.9 million
$457.7 million $574.6 million $635.4 million $665.2 million $662.9 million $620.1 million $784.5 million $899.2 million $940.3 million
$842.1 million $920.9 million $1.05 billion $1.18 billion $1.33 billion $1.54 billion $1.61 billion $1.72 billion $1.82 billion
5.5%
1999
$888.5 million $1.11 billion $1.27 billion $1.39 billion $1.60 billion $1.77 billion $2.05 billion $2.25 billion $2.38 billion
20.5% 20.6% 18.1% 20.3% 15.2% 27.4% 31.0% 31.0%
Data are from the 2006 annual report of the ACCME. Of the 729 ACCME accredited providers, 718 reported data on total income, 601 on commercial income, 446 on advertising and exhibits, 650 on registration fees and other income, and 721 on total expense. Data on providers that are accredited by state medical societies are not included. Adapted from Steinbrook (2008, p. 105).
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