Nurse Education Today xxx (xxxx) xxx
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Review
Content in nurse practitioner education – A scoping review
Birgitta Ljungbeck
a,b,*, Katarina Sj¨ogren Forss
a, Hafrún Finnbogad´ottir
a, Elisabeth Carlson
a aDepartment of Care Science, Faculty of Health and Society, SE 20506 Sweden and Society, Malm¨o University, SE 20506, SwedenbMunicipal Healthcare in H¨assleholm, Management of Care and Welfare, L¨ojtnants Granlunds V¨ag 12, SE 28152, Sweden
A R T I C L E I N F O Keywords: Content Education Nurse practitioner Scoping review A B S T R A C T
Objective: Globally, the role of nurse practitioner is evolving to meet increased healthcare demands. Nevertheless,
there are factors hindering the development of this role, one of which involves differences in nurse practitioner education worldwide. Therefore, the objective of the present study is to identify what is known in the research field on the content of nurse practitioner educational programmes.
Design and data sources: The literature scoping review follows a six-stage methodological framework including: i)
formulate research questions, ii) identify relevant studies, iii) select studies, iv) chart data, v) collate, summarize and report the results, vi) consultations. Data bases searched included CINAHL, PubMed and ERIC and were followed by manual searching of reference list in the included papers. Of the 1553 papers identified, 16 met the aim of this study.
Review methods: To answer the research questions ‘what is the content of curricula in nurse practitioner
edu-cation?’ a deductive content analysis was used.
Results: Two main categories emerged. The first was related to the professional nurse practitioner role and
in-cludes research and nursing theories, leadership and collaboration, and organizational, political, economic, regulatory and legislative issues. The second is related to becoming an autonomous practitioner and includes health promotion and disease prevention, and other medically oriented content.
Conclusions: The content identified is consistent with the core competencies that nurse practitioners are expected
to have after graduation, which have been described by the International Council of Nurses and by other re-searchers. Given the lack of recent research in nurse practitioner education, the results of the present study advance knowledge in this research field. Additionally, this study may be of practical value in developing new nurse practitioner educational programmes.
1. Introduction
The role of nurse practitioner (NP) is evolving worldwide as a way to meet increased healthcare demands (Delamaire and Lafortune, 2010). Unlike registered nurses (RN), NPs have extended authority in medicine and can thus perform duties previously limited to medical doctors (Donald et al., 2013; Goldberg et al., 2014; Kutzleb et al., 2015). An NP is defined as: ‘a Nurse Practitioner is an Advanced Practice Nurse who integrates clinical skills associated with nursing and medicine in order to assess, diagnose and manage patients in primary healthcare settings and acute care populations as well as ongoing care for populations with chronic illness’ (ICN, 2020). Evaluations of the NP role have found that it contributes to increased patient safety and quality of care, as well as improved continuity and access to healthcare (Jennings et al., 2014;
McDonell et al., 2014). Nevertheless, there are factors impeding the development of the professional NP role and affecting its implementa-tion. One key issue is whether NP educational programmes provide their graduates with sufficient knowledge (Furlong and Smith, 2005; Heale and Buckley, 2015; Mundiger et al., 2000). MacKay et al. (2018) provide evidence for this concern. They investigated how well-prepared NPs (N = 159) felt during the first year after graduation. More than 50% stated that they felt they were not fully prepared for the work they were expected to handle. Also, more than 60% stated that there was a gap between the NPs’ knowledge and clinical skills in relation to their practice. The NPs felt least prepared in the area of independent decision making, time management, complex care, prescribing, billing/coding and interdisciplinary communication. The conclusion was that there is a need for further NP residency programs to support NPs in their transition * Corresponding author at: Department of Care Science, Faculty of Health and Society, SE 20506 Sweden and Society, Malm¨o University, SE 20506, Sweden.
E-mail addresses: birgitta.ljungbeck@mau.se (B. Ljungbeck), katarina.sjogren.forss@mau.se (K. Sj¨ogren Forss), hafrun.finnbogadottir@gmail.com (H. Finnbogad´ottir), elisabeth.carlson@mau.se (E. Carlson).
Contents lists available at ScienceDirect
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to advanced practice (MacKay et al., 2018).
The International Council of Nurses (ICN) influences the develop-ment of NP roles worldwide and advocates that NP programmes lead to a master’s degree (ICN, 2020). However, in many countries, this recom-mendation is not followed and there major differences in academic re-quirements. Education at lower levels, such as bachelor’s degree, associate degree, diploma or certificate is common (Delamaire and Lafortune, 2010; Heale and Buckley, 2015) and NP educational systems differ across the world. This hinders the effort to achieve a global consensus regarding the appropriate academic level for NPs (Delamaire and Lafortune, 2010). An international study with 31 participating countries, focusing on the academic level required for NP education reflects this challenge. Formal NP education existed in 22 countries (71%), but the academic levels varied. The most frequent requirements were a master’s degree (n = 10), followed by bachelor’s degree (n = 5), associate degree (n = 4) and certificate (n = 3, Pulcini et al., 2010). This lack of uniform education contributes the NP-role’s being perceived as diffuse, unclear and not always readily accepted among healthcare teams (Bryant-Lukosius and DiCenso, 2004; Heale and Buckley, 2015). Furthermore, there is insufficient research on NP education; more is needed to obtain evidence and build consensus regarding what knowl-edge NPs should have after graduation (MacKay et al., 2018; Schallmo et al., 2019). Therefore, it is important to determine the appropriate level of theoretical and practical knowledge needed for NP education. Accordingly, the aim of this scoping review is to identify what is known in research field on the content of NP education programmes.
2. Methods
The present scoping review adheres to Arksey and O’Malley’s (2007) six-stage methodological framework: i) formulate research questions, ii) identify relevant studies, iii) select studies, iv) chart data, v) collate, summarize and report the results, vi) consultations (this is an voluntary step and not used in this scoping review). It was preceded by a study protocol (Ljungbeck et al., 2019), that describes the methodological approach which followed the steps in the PRISMA Extension for Scoping Reviews (Tricco et al., 2018). Note, we continue to use “papers” when we discuss since the included papers are not only research studies but also educational standards and opinions pieces.
2.1. Stage 1: formulate research questions
To formulate the research question, the PCC-model which means population, concept and context, (Table 1) described by the Joanna Briggs Institute (2015) was used, and the following research question guided the scoping review: What is the content of curricula in nurse practitioner education?
2.2. Stage 2: identify relevant studies
A search strategy was created in collaboration with two research li-brarians with expertise in literature searches. The search strings were developed through use of subject headings (MeSH and Thesaurus) together with free-text keywords. To expand and narrow the search, Boolean operators (AND/OR) and asterisks at the end of keywords were used. To find relevant terms, an initial search was performed. The terms were tested in different combinations before a final search strategy was determined, resulting in four search strings (Table 2, - describes the PubMed search). Data-base searches took place in CINAHL, PubMed and
ERIC, between March 2019 and June 2019, and were followed by manual searching of reference lists in the included papers in August 2019. Additionally, a repeat search was conducted in January 2020 to ensure all relevant papers were included, although no additional papers were identified at that time.
2.3. Stage 3: study selection
Papers were included if they described NP education (or used the umbrella term ‘Advanced Practice Nurse’) with a focus on content, were written in English and published in peer-reviewed journals. Addition-ally, grey literature found in the manual search that addressed the content of NP education was included. Papers were excluded if they focused on the NP role in a specific clinical setting, like emergency care, or focused on NP education at doctoral level. No date limitations were set. Table 3 presents the study selection with the PRISMA flow diagram illustrating the process of papers inclusion and exclusion. Primarily, the first author (BL) screened the titles and abstracts; 1553 potential papers were identified. The web-based tool Mendeley was used to organize papers and remove duplicates, which reduced the number to 837. These abstracts were carefully read by the first author (BL) and discussed with the co-authors. A total of 792 records were excluded because they did not address the aim of the present study. This process yielded 45 papers, which were screened in full text by the first author (BL); the co-authors each read at least 6 papers chosen at random. Ultimately, 16 papers were considered to meet the study’s aim. They were assessed for methodo-logical quality with the Critical Appraisal Skills Programme (CASP, 2018). Assessing the full-text papers revealed that several papers had inadequate method descriptions or omitted them entirely. Despite this, the authors regarded these to bringing important knowledge to the field of NP education and therefore worthy of inclusion. To address the method gaps, we tailored a quality evaluation tool to this study, based on the CASP checklist (CASP, 2018; see Appendix 1). Of the included papers four were quantitative (Bednar et al., 2007; Bellack et al., 1999; Kelley and Kopac, 2001; Hinch et al., 2005), four were qualitative (Gardner et al., 2004; Hinch et al., 2005; Price et al., 1992; Woods, 1997) and three were mixed methods (Gardner et al., 2006a, 2006b; Martin-Misener et al., 2010). Finally, three of the papers were opinion pieces (Burman et al., 2009; Fenton & Thomas, 1998; Hamric and Hanson, 2003) and two were educational standards (Gioiella et al., 1996; Thomas et al., 2017).
2.4. Stages 4 and 5: chart data and collate, summarize and report the results
The data were charted in two steps. First, the included papers were carefully read, and each papers’ characteristics identified: publication year, study design, country, population, content of NP education and so on. The second step consisted of charting the data deductively, using directed content analysis, as described by Hsieh and Shannon (2005). To chart the data, the NVivo 12 analysis program was used to organize the data into codes (Silver and Lewins, 2014). Initially, the data were deductively coded by the first author (BL), and all descriptions of con-tent in NP education sorted. Next, all authors read and discussed the coded text several times until agreement was reached that the coded text reflected two different main categories of content. The first category relates to the professional NP role, while the second is aligned to becoming an autonomous practitioner. Each main category contains sub-categories named according to the content they reflect (Appendix 2).
3. Results
The 16 included papers (Table 4) were undertaken between 1992 and 2017 in the United States (n = 11) or other English-speaking countries (Australia n = 3; Canada n = 1; United Kingdom n = 1). The Table 1
The population, concept and context (PCC). P (population) C (concept) C (context) Nurse
findings are presented in two main categories. The first category – the professional NP role – had three sub-categories: i) research and nursing theories, ii) leadership and collaboration, iii) organizational, political, economic, regulatory and legislative issues. The second category – becoming an autonomous practitioner – had two sub-categories: i) health promotion and disease prevention, ii) medically oriented content.
4. Content related to the professional NP role
This category involves content needed by NP students to facilitate the transition into their new professional role as NPs. The learning ob-jectives aim to develop an understanding not only of what role NPs have in the healthcare organization and what knowledge NPs are expected to bring to patients and the healthcare team but also of how NPs may contribute to further developing the role.
4.1. Research and nursing theories
To understand and enhance the NP role, NP students need advanced knowledge in research and nursing theories (Bednar et al., 2007; Bel-lack, 1999, Berlin et al., 2002; Fenton and Thomas, 1998; Gardner et al., 2004, 2006a, 2006b; Gioiella et al., 1996; Hamric and Hanson, 2003; Hinch et al., 2005; Martin-Misener et al., 2010; Price et al., 1992;
Thomas et al., 2017; Woods, 1996). The origins of nursing itself have a strong component of holistic care. It is important that NP education establish an in-depth continuation of the theories that make up general nursing education (Burman et al., 2009; Gioiella et al., 1996; Price et al., 1992). The learning objectives of research and nursing theory content aim to prepare NP students with evidence-based knowledge that will be of value for their practice (Gardner et al., 2004, 2006a, 2006b; Gioiella et al., 1996; Hamric and Hanson, 2003; Thomas et al., 2017). NPs should be able to apply research findings in their practice to provide high- quality healthcare, initiate change and improve nursing practice. Research should shape the basis for their clinical decision-making, including evaluating research, identifying problems in clinical practice settings and being aware of practice outcomes. The ability to analyse, synthesize and use knowledge and further develop strategies to integrate research into the treatment of patients is a crucial goal for NP students (Gardner et al., 2006b; Gioiella et al., 1996; Thomas et al., 2017). 4.2. Leadership and collaboration
It is important in NP education that students develop advanced abilities in leadership and collaboration (Bellack, 1999; Gardner et al., 2004, 2006a, 2006b; Gioiella et al., 1996; Hamric and Hanson, 2003; Price et al., 1992; Thomas et al., 2017; Woods, 1996). Learning Table 2
Search block PubMed.
No Search terms for block 1 No of hits
1. “Nurse Practitioners” [MeSH] 17,173
2. “Advanced Practice Nursing” [MeSH] 1489
3. Advanced Practice Nurs* 2915
4. Advanced Practice Registered Nurs* 371
5. Nurse Practitioner* 10,808
6. Advanced Nurse Practitioner* 274
7. #1OR#2OR#3OR#4OR#5OR#6 24,417
No Search terms for block 2 No of hits
8. Education [MeSH] 767,049
9. Program development [MeSH] 27,603
10 Program* 815,950
11. Course* 578,240
12. #8OR#9OR#10OR#11 1,973,230
No Search terms for block 3 No of hits
13 curriculum [MeSH] 80,079
14. curricul* 51,022
15. content of curricul* 2327
16. Syllab* 7719
17 #13OR#14OR#15OR#16 110,903
No Search terms for block 4 No of hits
18. learning objective* 3787 19. learning outcome* 3329 20. learning* 266,610 21. objective* 2,138,588 22. outcome* 1,533,724 23. Preparation* 442,996 24 #18OR#19OR#20OR#21OR#22OR#23 3,828,480
No Final search No of hits After screening of
titles/abstracts Duplicates After screening of duplicates
25. #7AND#12 8891 26. #7AND#12AND#17 1208 182 27. #7AND#12AND#17AND#24 451 122 28. #17OR24 3,898,581 29. #25AND#28 3292 30. #7AND#12AND#AND24 2535 250 Total 555 227 328
objectives focus on providing NP students with the knowledge needed to establish trust-based collaboration in the healthcare team, be an agent for change and practice innovative nursing (Gardner et al., 2004; Gioiella et al., 1996; Hamric and Hanson, 2003; Thomas et al., 2017). An NP should be able to take on a leadership role as a senior member of the healthcare team (Gardner et al., 2006a, 2006b). To develop the skills required for this role, learning objectives include critical, strategical and reflective thinking, change and management theories, effective communication strategies, conflict management, leadership styles and self-reflection of leadership, including personal leadership strengths and weaknesses, (Gioiella et al., 1996; Thomas et al., 2017).
4.3. Organizational, political, economic, regulatory and legislative issues Contents involving organizational, political, economic, regulatory and legislative issues appeared frequently in the included papers ( Bed-nar et al., 2007; Berlin et al., 2002; Bellack, 1999; Gardner et al., 2004; Gardner et al., 2006a; Gioiella et al., 1996; Hamric and Hanson, 2003; Price et al., 1992; Thomas et al., 2017, Woods, 1997). It is important that NPs be able to understand the relationship between these issues and how they can affect patient outcomes and healthcare delivery. The active
leadership role that NPs are expected to take on includes being able to influence local and national healthcare policy. Therefore, an under-standing of how healthcare is organized is a key learning objective in NP education. It is also important that the NP students develop the ability to understand how different political decisions can affect and constrain the NP role. Thus, issues of legislation and regulation regarding the NP role, authority, supervision, practice privileges, collaborative practice agreements and the placement of NPs positions within an organization are all included in the core content of NP education (Gardner, 2006b; Gioiella et al., 1996; Thomas et al., 2017).
Furthermore, it is crucial that NPs have a clear understanding of the business and financial complexities of healthcare and how they affect healthcare delivery. While the main purpose of this content is to develop an understanding of healthcare financing as a natural foundation for cost-effective healthcare, it also includes being able to submit proposals that can advance cost-effective healthcare. Learning objectives aim to achieve knowledge of healthcare systems’ financing, reimbursement systems, resource management, billing and coding principles, and how to develop a budget and manage resources to provide cost-effective healthcare (Gioiella et al., 1996; Gardner, 2006b; Hamric and Hanson, 2003; Thomas et al., 2017).
Table 3
The Study Selection
PRISMA 2009 Flow Diagram
Records idenfied through database searching (n = 1544) Screening Included Eligibility n oi t ac ifi t n e dI
Addional records idenfied through other sources
(n = 9)
Records aer duplicates removed (n = 837)
Records screened (n = 837)
Records excluded (n = 792)
Full-text arcles assessed for eligibility
(n = 45)
Full-text arcles excluded, with reasons (N=29) Wrong populaon (n=18) Wrong outcome (n=10) Very low-quality (n=1) Papers included in final
review (n = 16)
Papers included in final review (N = 16) Qualitave (n=4) Quantave (n = 4) Mixed method (n=3) Opinion pieces (n=3) Educaon standards (n=2)
Table 4
Compilation of the included studies. Authors, country, year of
publication and title Aim of the study Population/context Design/methods Content in NP education Bednar et al., USA. 2007.
Reconceptualizing the core of nurse practitioner education and practice
The aim was to provide an overview of the differences and similarities in educational preparation between NPs and Physician assistant (PA).
50 Nurse Practitioner programmes and 50 Physician Assistants programs.
A quantitative design with comparative descriptive statistics. Anatomy Clinical practice Health promotion Infectious disease Legislation Pathophysiology Pharmacology Physical assessment Physiology Policy Research Bellack et al., USA. 1999.
Curriculum trends in nurse practitioner programs: current and ideal
The aim was to ascertain the extent to which nurse practitioner programs addressing curriculum topics related to practice competencies needed for the next century.
140 directors of Nurse
Practitioner programmes. A quantitative design with surveys. Accountability for cost-effectiveness and patient outcomes Communication
Disease promotion
Healthcare economic/financing Health promotion
Managed care
Patients as partners in healthcare Research
Berlin et al., USA. 2002. Master’s level Nurse Practitioner educational programs
The aim was to investigate current
status of NP educational programs. 275 university with master’s level NP programs. A quantitative design with surveys. Advanced pharmacology Advanced physical health assessment Advanced physiology/
pathophysiology
Advanced practice role preparation Diagnosis
Disease promotion Economic issues Ethics Research Health policy issues Health promotion Leadership Managed care Nursing theory Professional role issues Sociocultural diversity System theories
Treatment and management of illness
Burman et al., USA. 2009. Reconceptualizing the core of nurse practitioner education and practice
The aim was to review current master’s level NP education as well as the literature related to master’s level nurse practitioner education and practice and explain how each of these points to the need for a reconceptualization of APN practice.
Theory and research articles from nursing focused on advanced practice nursing, NPs, and doctoral education.
The method description is
inadequate. Clinical assessment Pathophysiology Pharmacology
Fenton & Thomas. USA. 1998. Advanced Practice Nursing in Texas: The interface of accreditation, regulation and certification.
The aim of the study was to deriving a model designed to ensure the education and recognition of APNs with emphasis on both
professionalism and public safety.
Studies related to advanced practice education, practice and certification.
The method description is
inadequate. Advanced assessment Clinical management of health status Clinical practice Diagnosis Pharmacotherapeutics Pathophysiology Physiology Research Role preparation Gardner et al., Australia. 2006a.
Competency and capability: imperative for nurse practitioner education
The aim was to conduct research to inform the development of standards for nurse practitioner education in Australia and New Zealand and to contribute to the international debate on nurse practitioner practice.
Fourteen NP program curricula comprising 5 from New Zealand and nine from Australian.
Twelve interviews with 12 academic convenors.
A qualitative design with
thematic analysis. Anatomy Clinical assessment and diagnosis including imaging and laboratory diagnostics
Clinical leadership Clinical practice Cultural awareness Law and ethics Pathophysiology Pharmacology Physiology Research Gardner et al., Australia. 2006b.
Nurse practitioner competency standards: findings from collaborative Australian and New Zealand research
The aim of the study was to research nurse practitioners to inform development of generic standards that could be applied for the education, authorisation and
Data were collected from relevant sources in New Zealand and the five states and territories in Australia where, at the time of the research, the
A multi-methods approach consisting of review of policies and curricula in nurse practitioner programmes and Clinical assessment Clinical decision-making Clinical leadership Collaboration Communication
Table 4 (continued) Authors, country, year of
publication and title Aim of the study Population/context Design/methods Content in NP education practice of nurse practitioners in
Australia and New Zealand. title of nurse practitioner was legally protected. Interviews with four nurse practitioners.
interviews with practising
nurse practitioners. Cultural awareness Financing Laws and policies Research
Gardner et al., 2004. Australia. Nurse Practitioner education: a research-based curriculum structure.
The aim was to investigate the educational requirements of nurse practitioners and to use the findings to inform curriculum development.
4 nurse practitioner. A qualitative design with a
deductive analysis. Clinical assessment and diagnosis Clinical decision-making Pathology
Pathophysiology Pharmacology Gioiella, E-C. American
Association of Colleges of Nursing. USA. 1996. The essentials of Master’s education for advanced practice nursing
The aim was to define the essential elements of master’s education for advanced practice roles.
Over 500 individuals, representing 44 states in Columbia including a wide range of nurse educators, clinicians, administrators and researchers.
A qualitative design with consensus-building working meetings. Advanced health/physical assessment Advanced pathophysiology Advanced pharmacology Advanced Physiology Disease promotion Ethics Health promotion
Human diversity and social issues Leadership
Organization and financing of health care
Policy
Professional role development Research
Theoretical foundations of advanced nursing practice
Hamric & Hanson. USA. 2003. Educating Advanced Practice Nurses for practice reality
The aim was to describe critical role
content needed in APN Programs The method description is inadequate. Exploration of core competencies including: - The central competency of direct clinical practice
- Expert coaching and guidance - Consultation
- Research
- Clinical and professional leadership - Collaboration
- Ethical decision making Business management considerations Developing and using APN outcome indicators Differentiation and comparison of APN roles History and definition of advanced practice nursing
Health policy realities
Inter – and intra professional issues and the importance of role clarity Introduction to trends and issues shaping advanced practice nursing Marketing considerations Organizational issues
Regulatory issues – including scope of practice, certification, prescriptive authority.
Role development
Reimbursement and billing issues Hinch et al., USA. 2005.
Preparing students for evolving Nurse Practitioner roles in healthcare
The purpose of this article is to describe the realignment of priorities in health care as they affect the experience of one university in the education of nurse practitioner (NP) students for the innovative new roles. Specifically, the curriculum and process of clinical placement will be described, along with several examples of NP roles that students have acquired after graduation.
Rush University College of Nursing in Chicago with focus on educations of nurse practitioners.
The method description is
inadequate. Advanced pharmacology Business Cultural diversity Disease prevention Economics
Ethical decision making Health assessment Health policy Health promotion Integrated health systems Managed care Nursing theory Pathophysiology Reimbursement
Regulatory and marketing principles Research and outcome evaluation Role theory
Kelley et al., 2001. USA. Advanced Health Assessment in Nurse Practitioner Programs
The purpose of the study was to examine the content, teaching methodologies, depth and placement of advanced health
140 schools of nursing Quantitative design with
surveys Health assessment including obtaining history and interviewing, physical assessment, ethnic and cultural considerations,
5. Content related to becoming an autonomous practitioner
This category involves two kinds of knowledge that NPs need to independently manage patients. Consequently, it focuses on developing in-depth knowledge of health promotion and disease prevention and other medical information. However, the challenge for NP students seems to be to learn medical topics while maintaining a holistic approach that includes providing patient-centered care, which is the very foundation of nursing and thus needs to be the basis of the learning process in medical topics. Also, the results demonstrate that NP students need to understand how their role differs from the physicians; they not are expected to replace physicians but to complement them.
5.1. Health promotion and disease prevention
Several researchers highlight health promotion and disease preven-tion content as central to NP educapreven-tion (Bednar et al., 2007; Bellack et al., 1999; Burman et al., 2009; Gioiella et al., 1996; Gardner et al., 2006a; Hamric and Hanson, 2003; Hinch et al., 2005; Kelley and Kopac, 2001). Bellack et al. (1999) found that health promotion and disease prevention is the most important content in NP education. To achieve advanced abilities in this area, the NP students need to grasp a wide range of influences and be prepared with knowledge of how cultural, racial ethnic, age and gender differences can affect patients lifestyle choice and their decisions in treating and managing illness (Gardner Table 4 (continued)
Authors, country, year of
publication and title Aim of the study Population/context Design/methods Content in NP education assessment courses within nurse
practitioner programs. developmental assessment and functional assessment. Martin-Misener et al., USA. 2010.
Education of Advanced Practice Nurses in Canada
The aim of this paper is to provide a critical analysis of current advanced practice nursing education in Canada with a view toward what will be needed in the future.
The scoping review includes 322 papers consisted of both published and grey literature. 62 interviews and 4 focus groups.
A mixed methods design with a scoping review, focus groups and individual interviews.
Health assessment
Management of health and disease, including prescribing
Pathophysiology The National Organization of
Nurse Practitioner Faculties. (NONPF). USA. 2017. Nurse Practitioner core competencies content
Grey literature – the paper includes the NP Core Competencies and a list of suggested curriculum content.
Barriers to NP practice Business development
Clinical decision making based on evidence and patient/provider partnership
Communications
Critical thinking development Cultural issues
Diagnostics Disease prevention Ethical issues
Financial issues, cost benefit analysis Health policy and health care reform Health promotion
Interprofessional/team competencies Laws and rules to enhance quality Leadership, change, and management theories
Legislative and regulatory processes Organizational practices Patient management Pharmacology Physiology Pathophysiology
Political processes, political decision making processes, and health care advocacy
Problem solving
Provider-patient relationship Safety and quality
Theories/conceptual frameworks/ principles for practice
Price et al., USA. 1992. Developing National guidelines for Nurse Practitioner education: An overview of the product and the process
The aim was to offer updated guidelines that could be used by a broad contingency of NP faculties for the purpose of NP curriculum development or revision.
The National organization of Nurse Practitioner appointed an ad hoc education committees to review existing NP education curricula and to formulate national guidelines.
The method description is
inadequate. Content divided into five areas: Helping role Management of client health/illness status
Monitoring and ensuring the quality of healthcare
Organizational and work role competencies
Teaching-coaching function Woods. England.1996.
Conceptualizing advanced nursing practice: curriculum issues to consider in the educational preparation of advanced practice nurses in the UK.
The aim was to describe educational preparation of advanced practice nurses, and the author considers a number of issues facing curriculum designers in the development of advanced practice nurse programmes in the UK.
A Florence Nightingale scholarship to the USA and Canada, investigating the educational preparation of advanced practice nurses.
The method description is
inadequate. Advanced health assessment Advanced pharmacology Advanced physiology Clinical decision-making Collaboration Ethics Health promotion Research Nursing theory Policy-making Prescriptions
et al., 2006a; Gioiella et al., 1996; Hamric and Hanson, 2003; Thomas et al., 2017). Moreover, NPs need to be able to establish trust-based relationships to encourage health promotion and disease prevention (Gioiella et al., 1996; Thomas et al., 2017).
5.2. Medically oriented content
A major part of NP education focuses on medically oriented content like anatomy, advanced physiology, pathophysiology, pharmacology, physical and mental health assessments, and differential diagnostics (Bednar et al., 2007; Berlin, 2002; Burman et al., 2009; Fenton and Thomas, 1998; Gardner et al., 2004, 2006a, 2006b; Gioiella et al., 1996; Hinch et al., 2005; Kelley & Kopac, 2001; Martin-Misener et al., 2010; Thomas et al., 2017; Woods, 1997). With in-depth knowledge in these areas, the main learning objectives should be to gain autonomy in clinical decision-making and independently manage patients’ health-care needs (Gardner et al., 2004). Woods (1997) highlights advanced pharmacology as a key module in NP education to supply the knowledge needed to prescribe appropriate medications for different conditions. Advanced pharmacology content is intended to provide NP students with knowledge concerning the side effects and interactions of medi-cations and how to prescribe them based on efficacy, safety and cost awareness (Thomas et al., 2017).
Kelley and Kopac (2001) investigated health assessment courses in NP programs, where the learning objectives are to enable NPs to conduct a full health examination of patients, including obtaining history and interviewing, physical assessment, considering ethnic and cultural ele-ments, and mental and functional assessments. Price et al. (1992) point out that an NP should be able to observe, conceptualize, diagnose and analyse complex clinical or nonclinical problems related to health. The educational process must include a strong clinical component to develop health assessment and judgement abilities and thus enable the NP graduate to become an autonomous practitioner (Hinch et al., 2005; Price et al., 1992; Thomas et al., 2017). Therefore, clinical practical courses are essential content in NP education and should be taught iteratively. Each student’s existing skills and needs are the starting point for achieving the learning objectives, and a tailored plan for each stu-dent’s progress should be designed (Hinch et al., 2005). Gardner et al. (2006a) offer a similar description and hold that learning objectives in practical courses should incorporate flexibility to accommodate self- identified learning needs.
6. Discussion
The result indicates that NP education should be built upon two main content areas namely, the professional NP role and becoming an autonomous practitioner. More specifically, this implies that core sub-jects in NP programmes need to prepare NPs for their leadership including collaborative skills and the increased medical responsibility that this extended nursing role entails. We base this statement on how the content of leadership in NP education was frequently mentioned in the included papers, (Bellack, 1999; Gardner et al., 2004, 2006a, 2006b; Gioiella et al., 1996; Hamric and Hanson, 2003; Price et al., 1992; Thomas et al., 2017; Woods, 1996). The results demonstrated that leadership content aims to prepare NP students for multiple functions, which we interpret as preparation for two kinds of leadership: clinical leadership and the more prominent role of influence political decision- making at both national and local levels. The importance of NP stu-dents’ being prepared for both leadership roles has major support in other research. For instance, Anderson (2018), Carryer et al. (2007) and Ryder et al. (2019) all emphasize that the NP role includes two kinds of leadership that are consistent with those we have identified. First, they cite the clinical leadership role, which includes being an innovative and rethinking leader in collaboration with healthcare team and patients. Second, they note the professional leadership role, which includes strategic leadership and in which NPs are expected to be involved in and
influence healthcare policies and practices at the local, national and international levels (Anderson, 2018; Carryer et al., 2007; Ryder et al., 2019). Thus, it seems reasonable that the sub-category emerging in the present study focusing on organizational, political, economic, regulatory and legislative issues is necessary for NP students to acquire the knowledge needed to wield influence. To further support the importance of leadership content in NP education, also Callaghan (2008) and Nie-minen et al. (2011) studies show that NPs play a major role in leading the healthcare team. In line with the present study, Callaghan (2008) points to how NP leaders need to have the competence to support, engage and motivate team members in the dynamic, rethinking and ever-changing environment of contemporary healthcare.
The issue of becoming an autonomous practitioner demonstrates how medically oriented content should have a major place in NP edu-cation allowing for independent management of patients. This content was mentioned in most of the included papers (Bednar et al., 2007; Berlin, 2002; Burman et al., 2009; Fenton and Thomas, 1998; Gardner et al., 2004, 2006a, 2006b; Gioiella et al., 1996; Hinch et al., 2005; Kelley, 2001; Martin-Misener et al., 2010; Thomas et al., 2017; Woods, 1997). Furthermore, the results show that an essential part of NP edu-cation is to achieve competence in physical, mental and functional as-sessments, which require in-depth knowledge of physiology, pharmacology and pathophysiology. This view has support in other studies. For example, Parker and Hill (2017) argue that the core of the NP curriculum consist of the three main areas: physiology, pharma-cology and pathophysiology. Together with advanced knowledge in critical thinking, clinical decision-making and comprehensive assess-ment, these areas constitute the NP’s autonomous role (ibid). Also, Nieminen et al. (2011) describe the NPs’ clinical competence from several perspectives, noting especially the value of advanced skills in physical assessment. This can be exemplified by checking patients’ vital parameters, in contrast to the registered nurse, NPs are expected to perform more comprehensive examinations of patients, including auscultation of the lungs and heart and the palpation of various organs (ibid).
Yet another cornerstone, not as prominent but highlighted as necessary, is to include nursing theories and research methodologies to support development of professional and clinical competencies as NP. This is corroborated by a majority of the included papers (Bednar, 2007; Bellack, 1999, Berlin et al., 2002; Fenton and Thomas, 1998; Gardner et al., 2004, 2006a, 2006b; Gioiella et al., 1996; Hamric and Hanson, 2003; Hinch et al., 2005; Martin-Misener et al., 2010; Price et al., 1992; Thomas et al., 2017; Woods, 1996). The underlying assumptions are that extended competence in research methodology and nursing theories aim to prepare NP graduates to exercise appropriate clinical decision-making as autonomous practitioners. Secondly, competence in these fields is necessary when evaluating practice outcomes, and in enhancing the NP role. Additionally, we believe that research methodology and nursing theories are necessary content to maintain the nursing focus, even if the NP role requires more medical skills. Two decades ago, Mundiger et al. (2000) revealed a crucial point highlighting the critique against NP programs as being too similar to medical doctor education. If nursing theories are not incorporated in NP education, there is a risk that NP programs will be perceived as merely pale imitations of medical doctor education (ibid). From our point of view a critical issue in successfully developing new NP programs is that the nursing focus – rather than the medical focus – must be central when developing NP frameworks on the national level and in designing local NP programs.
Finally, the content that has emerged in present study is clearly aligned to the competence framework that the ICN emphasizes as necessary for the NP role (ICN, 2020). In line with the present study, ICN defines the NP role as an advanced autonomous leadership role in clinical practice. Thus, it is possible to summarize present study results in accordance with previous research and position papers concerning NPs’ areas of expected competence, as well as ICN’s recommendations for educational preparation.
6.1. Strengths and limitations
The strength of the study, despite the limited access to recent papers, is the correlation to the competencies that ICN as well as previous studies and papers highlight as necessary for NPs. This may increase the credibility of current results, although some of the included papers are more than two decades old. Nevertheless, it is possible to conclude that no major changes have occurred regarding the core content of NP edu-cation. However, a limitation might be that several of the included pa-pers are not research studies but opinion pieces or educational standards, nevertheless there is a value in including these papers to get a more comprehensive result. According to the scoping methodology used, it is possible to include a wide range of papers including grey literature, even if the papers are of varying quality, thus we consider inclusion of grey literature a strength. However, it needs to be noted that some of the included papers have inadequate or non-existent method-ological descriptions, although we tailored a CASP-based (2018) quality evaluation tool to help overcome this limitation. In addition, all included papers originate from a limited number of Western, English- speaking countries, but there has been no focus in the present study to discover differences between countries. It is also worth noting that the included papers from Gardner et al. (2004, 2006a, 2006b) all focused on developing the NP role in Australia and New Zealand. Nevertheless, we decided to include all of the three papers since each paper had a slightly different focus. Additionally, it may be important to mention that we did not limit the search to master’s level NP education, though we excluded doctoral level since it does not appear to be a commonly recommended level.
7. Conclusion
Conclusively, the current scoping review identified two main areas, professional role and autonomous practice, that educators need to focus when developing NP education. Thereby, learning objectives need to reinforce subjects that support professional development and thus pre-pare NP students to become autonomous healthcare leaders. Specif-ically, we want to emphasize the importance of designing new NP programs from a nursing focus rather than a medical focus. We think it is essential to emphasize that the NP role requires highly qualified nurses who are experts in nursing care with extended medical knowledge without losing its unique nursing character.
Supplementary data to this article can be found online at https://doi. org/10.1016/j.nedt.2020.104650.
Authors’ contribution
All authors (BL, KSF, HF and EC) contributed to conception, design and data analysis. BL was primarily responsible for acquisition of data and drafting the article. KSF, HF and EC revised the article critically for important intellectual content. BL, KSF, HF and EC approved the final version to be submitted.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Ethical approval
None declared/not applicable.
Declaration of competing interest
None.
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