Talk:Nurse practitioner/Archive 2

Semi-protected edit request on 9 May 2019

Please change "A nurse practitioner (NP) is an advanced practice registered nurse (APRN) classified as a mid-level practitioner. A nurse practitioner is trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose illness and disease, prescribe medication and formulate treatment plans." to "A nurse practitioner (NP) is a member of the health delivery system and practices autonomously in areas as diverse as family practice, pediatrics, internal medicine, geriatrics and women’s health care. NPs are one of four types of advanced practice registered nurses(APRN) – highly valued and an integral part of the health care system." Miraclecln (talk) 20:31, 9 May 2019 (UTC)

 Not done: "practices autonomously" turns a complete blind eye to the current lobbying for legislation for unsupervised practice going on. Even though you may dislike and want to remove the term Mid level practitioner, it is very well cited term used by WHO and NIH, as the consensus on top was developed. No amount of objection or "position statements" from professional organization is going to change that is very well accepted term. Wikipedia is not censored because a person or a group dislikes a term or a fact. So said The Great Wiki Lord. (talk) 15:24, 10 May 2019 (UTC)

The request made at Third Opinion has been removed (i.e. declined). Like all other moderated content dispute resolution venues at Wikipedia, Third Opinion requires thorough talk page discussion before seeking assistance. If an editor will not discuss, consider the recommendations which are made here. — TransporterMan (TALK) 20:47, 15 May 2019 (UTC)

I agree. NPs are allowed to practice autonomously in some places, and not in others. We can't mislead the readers by saying that they do, as if it was the same everywhere. WhatamIdoing (talk) 17:47, 22 May 2019 (UTC)

Can we get a consensus on this? A nurse practitioner (NP) is a member of the health delivery system who is educated and clinically prepared to practice autonomously in areas as diverse as family practice, pediatrics, internal medicine, geriatrics and women’s health care. NP practice regulations vary by state. NPs are one of four types of advanced practice registered nurses (APRN) – highly valued and an integral part of the health care system. [5] Miraclecln (talk) 16:54, 20 May 2019 (UTC)

Oppose: (1) There is no independent source cited to support the contention that NPs are "educated and clinically prepared to practice autonomously". (2) NP regulations vary by country, not just by state. This article is Nurse practitioner, not Nurse practitioners in the USA. This is the English Wikipedia, not the US Wikipedia. (3) Telling the audience that NPs are a type of advanced practice nurse will lead them to believe that all NPs have post-graduate education in nursing. I'm afraid that may be true in much of the USA, but dubious in may third-world countries. It needs a comprehensive, independent source to make those kinds of claims. (4) Although it is undoubtedly true that NPs, like all health providers, are valued by the communities they serve, that is not part of the definition of a NP, no matter how much their professional body would wish it to be. --RexxS (talk) 17:41, 23 May 2019 (UTC)

References

 Not done: per User:WhatamIdoing and User:RexxS. So said The Great Wiki Lord. (talk) 18:08, 23 May 2019 (UTC)

Semi-protected edit request on 18 May 2019

Delete the following sentences, since they now appear in the new "Controversy" section: "The opponents of independent practice have argued that nurse practitioner education is "flimsy," because it can consist of online coursework with few hours of actual patient contact.[7] The number of patient contact hours in nurse practitioner training is less than or equal to 3% of physician training.[1] Increased utilization of nurse practitioners is leading to increased cost of care through increased use of resources and unnecessary referrals.[8][9][10]" NPTruth (talk) 14:52, 18 May 2019 (UTC) — NPTruth (talk • contribs) has made few or no other edits outside this topic.

 Not done: please establish a consensus for this alteration before using the {{edit semi-protected}} template. The summary of findings belongs in the lead. Controversy section will be expanded further. So said The Great Wiki Lord. (talk) 22:09, 18 May 2019 (UTC)

I agree with NPTruth and the request to make this change. With all the voices on this page requesting this change, we seem to have a consensus that this is not neutral language and is out of place on Wikipedia. Miraclecln (talk) 16:45, 20 May 2019 (UTC)

 Not done: A parade of brand new single purpose accounts does not demonstrate a consensus. You're going to have to work with your opposition to find some compromise, not attempt to bludgeon them with repeated edit requests. - MrOllie (talk) 16:52, 20 May 2019 (UTC)

This is not a new account MrOllie, and it is clear that the NP page is not written from a neutral perspective as per the Wikipedia pillar of neutrality. Miraclecln (talk) 17:07, 20 May 2019 (UTC)

I've attempted to tease out a little more of what the source https://www.managedcaremag.com/archives/2018/9/nurse-practitioners-docs-lawmakers-give-us-our-independence says. It seems to present a reasonably balanced overview of the opposing positions, although it does not contain the word "flimsy", which I've consequently removed. If anyone is unhappy with my expansion, or has other reliable sources that belong in that section, please let me know and I'll do my best to try to find some common ground here. --RexxS (talk) 20:12, 22 May 2019 (UTC)

Thanks for making that change, RexxS (talk). Since the word flimsy is also included in the first paragraph, it would be helpful to continue the revision there to improve the article's accuracy. Thanks again. Miraclecln (talk) 17:07, 23 May 2019 (UTC)

@Miraclecln: My apologies for not noticing that in the lead. I've amended it to reflect the current content in the body of the article. Please let me know if you find that edit problematical. --RexxS (talk) 17:50, 23 May 2019 (UTC)

RexxS "Opponents of independent practice also say many nurse practitioners are being flimsily educated through online coursework with few hours of actual patient contact." is from the article. That's where I had gotten that term. So said The Great Wiki Lord. (talk) 20:34, 23 May 2019 (UTC)

@TheGreatWikiLord: Two points to consider: (1) There is a subtle, but important distinction between describing the manner of education as being done "flimsily" (which is a criticism of the training mechanism), and describing the education itself as "flimsy" (which would be a criticism of the resulting education). I don't think you can make the leap from one to the other that simply. (2) The criticism is quoted second-hand from opponents of independent practice. We have to be careful when summarising a source that discusses two sides of a dispute not to report just what one side says when the other side is quoted as well. Our article didn't counterbalance the accusation by (unnamed) opponents with the response from Maureen Cahill from the National Council of State Boards of Nursing, who pointed out that NP courses contain the same mix of online and in-person training as medical schools use. We should aim to describe disputes, not to engage in them.

As a matter of opinion, I also find the use of the word "flimsy" to be contradicted by the figures quoted in the source. It seems to me that the view is very much a minority one, not to mention very specific to the dispute in the USA. I wouldn't have thought it WP:DUE for us to make use of it in the article without also very fully reporting the refutation that the other side of the dispute provides. It would be extraordinary for the training of so many medical providers to be found to be "flimsy", and extraordinary claims require extraordinarily strong sources. This isn't one. --RexxS (talk) 01:37, 24 May 2019 (UTC)

Inappropriate sources

As of the current revision, the article cites quite a few unreliable and/or misrepreseted sources. In particular:

• Reference 1 is basically a press release by an advocacy organization. That's clearly not a reliable source. It also doesn't support the statemet it's cited for in the lead, "The number of patient contact hours in nurse practitioner training is less than or equal to 3% of physician training." - assuming that's referring to clinical hours, then the numbers given by the source are 500-1500 vs. 15,000-16,000, which amounts to 3.1%-10%, definitely not "less than or equal to 3%".
• Reference 8 groups NPs with physician assistants and, as far as I can tell, makes no statement about only NPs, and it also doesn't seem to say anything about cost.
• Reference 9 also groups NPs with PAs, with no meaningful statement about only NPs.
• Reference 10, conversely, compares NPs and PAs. It does not say anything about the cost impact of an increased role of NPs.
• Reference 13 is an opinion piece, not a reliable source for statements of fact. It's pseudonymous, too, and comes with an explicit disclaimer.
• Reference 14 is misrepresented. I assume it's meant to support the statement that "Many schools have 100% acceptance rates" - except it shows that only eight schools out of 228 had a 100% acceptance rate, and it further qualifies the result by noting that those are generally schools with small applicant pools. I don't think 8/228 is "many", and the source certainly doesn't say so.
• Reference 16 is used misleadingly; the quote refers to nurses in general, not nurse practitioners. "Younger nurses and those with higher levels of education [presumably including NPs] reported higher EBP competency (p < .001)."
• "NPs are also more likely to order unnecessary tests and procedures such as skin biopsies and imaging studies." - reference 9 (already mentioned above) explicitly does not comment on whether the additional images ordered by NPs (and PAs) are unnecessary or whether the physicians they're compared with order too few images.
• Reference 19 is an editorial, not a peer-reviewed study.

I don't know whether the above list is exhaustive (at some point I grew tired of checking sources), but it's big, and it's systematic. It needs fixing, and that likely means getting rid of much of the "controversy" section when there are no reliable secondary sources for the content. Huon (talk) 03:04, 21 May 2019 (UTC)

Thank you for pointing these out Huon. Others and myself have mad similar suggestions in the past with rationale as well. Looking forward to having these substantive edits made to clean up this entry with acceptable standards. NPTruth (talk) 15:17, 22 May 2019 (UTC)

Yes, Huon, thank you. And thanks to the many others who have provided sources to contradict the current NP article description/references and who have voiced requests to change the page. Raraavis31 (talk) 14:10, 25 May 2019 (UTC)

The Great Wiki Lord., What is the status of addressing these unreliable and misrepresented sources. Why isn't this being addressed? Thank you, NPTruth (talk) 21:45, 31 May 2019 (UTC)

I took a look at some of the sources criticised above.

Reference 1 defines itself as "The Primary Care Coalition is a partnership comprised of the Texas Academy of Family Physicians, the Texas Pediatric Society, and the Texas Chapter of the American College of Physicians. These seem quite eminent bodies, and although they are clearly writing from the physician's point of view, that doesn't make them an unreliable source. According to WP:NPOV, we must represent "fairly, proportionately, and, as far as possible, without editorial bias, all of the significant views that have been published by reliable sources on a topic." This would certainly appear to me to be one of them. If the conclusions they draw are challenged by an equally reliable source, let's say the AANP, then we should describe the dispute, but not engage in it. I did my best to accurately summarise the source, but it was removed by Huon. @Huon, I disagree that all of the content you removed was inappropriately sourced; would you care to comment before I start reverting you?

Reference 8 found the following: "Referrals from physicians were scored higher (percentage of agree/strongly agree responses) than were referrals from NPs and PAs for each of the following items: referral question clearly articulated, clinical information provided, documented understanding of the patient's pathophysiology, appropriate evaluation performed locally, appropriate management performed locally, and confidence returning patient to referring health care professional. Referrals from physicians were also less likely to be evaluated as having been unnecessary." Now that does indicate that the study found statistically significant differences between referrals from physicians and referrals from NPs and PAs combined. That information is relevant to a comparison between physicians and other referrers, including NPs, so it is on-topic for this article. However, if it is used, we should make clear it is a single study and does not directly compare physicians with NPs.

I agree that reference 13 is an opinion piece, and doesn't contain anything useful that can't be better sourced (like the number of states in the USA that allow independent NP practice), so I'd have no objection to dropping it.

Nevertheless, I think you're trying too hard to remove perfectly reliable sources such as TAPF and the Mayo Clinic. These certainly have limitations and need to be used carefully and transparently, but I don't believe that they fall below the threshold of reliability in describing some of the controversy surrounding independent practice for NPs in the USA. As far as I can see, a controversy exists, and we should be describing it impartially. That means adding sources and attempting to present all sides, not removing sources just because we don't agree with their conclusions. --RexxS (talk) 22:37, 31 May 2019 (UTC)

Regarding reference 1, those "eminent bodies" are currently involved in a political dispute about whether NPs may practice without supervision by physicians (for which the nurses apparently have to pay the physicians, and even if they didn't have to do that, they'd still be unwelcome competition). The Managed Care Magazine article states that physicians (likely via their advocacy organizations) are not above making false allegations against NPs ("Doctors have alleged that nurse practitioners don’t carry malpractice insurance (they do)."). I don't think we can take such "eminent bodies" at their word when their clientele's financial interests are at stake without a reliable independent source backing them up. Will we, in the spirit of NPOV, also present as fact, in Wikipedia's voice, what "eminent bodies" such as the NPs' advocacy organizations have to say on this topic? I hope not.

Regarding those sources that group NPs with PAs, they firstly don't meet WP:MEDRS and secondly provide no information specifically about NPs. They also were used in a misleading way that made NPs look bad, and given that this happened to many of those sources, I doubt it's an innocent accident. Example: "NPs are also more likely to order unnecessary tests and procedures such as skin biopsies and imaging studies." - the source explicitly doesn't say that the additional images ordered by NPs (and PAs) are unnecessary but notes that it may well be that physicians order too few images. The Mayo Clinic source also was cited for a statement about costs - does it actually say that?

What we should do in the controversy section is add a subsection entitled "independent practice" (since that's really what the controversy is about) and document the valid criticisms (and who made them, not just "experts" as if the physicians had no own interest here), the NPs' own arguments, and the false allegations, all as supported by independent sources. Putting studies such as the Mayo Clinic's in the "controversy" section is WP:SYN at best (since the source doesn't mention any controversy), a smear job at worst. Huon (talk) 23:34, 31 May 2019 (UTC)

@Huon: (1) You seem to have a fundamental misunderstanding about what NPOV requires. It doesn't matter that the eminent bodies are involved in a dispute. If they have a significant view on that dispute, then we must report it, not suppress it. We don't take disputed views "at their word", "in Wikipedia's voice", but we attribute each of them and describe the dispute. "X says this; and Y says the opposite." That's NPOV 101 and I'm surprised you don't know that.

(2) You also seem to have a misunderstanding of MEDRS. We require biomedical claims to be sourced to secondary sources, of course, but are you seriously suggesting that something like "Nurse practitioners are also more likely to make unnecessary referrals" is a biomedical claim? It simply isn't. It should of course read more like "A study by the Mayo Clinic indicated that nurse practitioners and physician assistants are more likely to make unnecessary referrals". Secondly, it doesn't matter that the study grouped together NPs and PAs; the results are relevant but need to be presented properly. I'm happy to see appropriate wording, but you can't just remove relevant, reliable sources, because you mistakenly think they have to be secondary or that they have to only make the comparisons you want to see.

The sentence "Increased utilization of nurse practitioners is leading to increased cost of care through increased use of resources and unnecessary referrals." is cited to three sources, not just the Mayo Clinic, so it is disingenuous to criticise the Mayo Clinic source for not mentioning costs, when it's clearly there to support the "unnecessary referrals" phrase. It's nonsense to suggest that using the Mayo Clinic as a source is SYN, since the source's conclusions are completely pertinent to the controversy. On the other hand, that sentence is drawing a conclusion in Wikipedia's voice, whereas at best it should be doing no more than attributing the results of some studies. Where I do agree with you is in your view that much of the selection and summation of sources provides a misleading picture, as we're only seeing part of it, very much from the perspective of the physician. I'd like to see the AANP's view examined and reported far more, as it is in the Managed Care magazine, which seems to discuss both sides.

Why did you remove "While NP training includes 500 to 1,500 hours of patient contact, family physician training includes on average 15,000 to 16,000 patient contact hours." Is that not a statement of fact, sourced to TAPF, and one of the key elements in the controversy?

Why did you remove "To become an NP requires 1.5 to 3 years of post-baccalaureate training, compared to physicians who are required to complete a minimum of 7 years of post-baccalaureate training. A new nurse practitioner has between 500 and 1,500 hours of clinical training, compared with a family physician who would have more than 15,000 hours of clinical training by the time of certification." Are those not statements of fact, reliably sourced and completely relevant to the topic "Limitations of education".

We most certainly don't need any more subsections of Controversy in the United States; it's UNDUEly long as it is. If you've identified the nub of the issue (and I think you have), then source it and write about it in the main section – as you say, that's really what it's all about.

So, are you prepared to restore the factual narrative that you removed, or do I have to revert your bold edits, and then we debate each of the dozen sourced sentences that you removed? --RexxS (talk) 01:56, 1 June 2019 (UTC)

RexxS, I removed the statements you ask about because they were presented in Wikipedia's voice as statements of fact, not something attributed to the advocacy organization that makes the claims, and putting such advocacy (it says so right in the source's URL!) in the lead is a grossly WP:UNDUE weight. NP organizations dispute those claims (which is not mentioned), and even if they didn't, this is not the "how NPs are worse than physicians" article.

I have pointed out a reliable third-party source stating that this political dispute involves outright falsehoods presented by the involved parties - and that likely includes the likes of the "eminent bodies" behind reference 1. Such position papers are not reliable sources subject to editorial oversight, and apparently they don't care much about facts either.

I see that you already reverted my edits. If you want to go all wikilawyer on me, I should point out that it was me reverting The Great Wiki Lord's additions... and the WP:ONUS to establish a consensus is on the editor who wants content included. Much worse, however, is that there's now (again) a statement in the lead that's not supported by the cited sources and likely not even true. Are you prepared to remove the contra-factual narrative you restored, or do I have to revert your edits? Huon (talk) 11:59, 1 June 2019 (UTC)

Sorry, I just saw that it was Spyder212, not RexxS, who reverted my edits and re-introduced statements that are unsourced and likely untrue. Huon (talk) 12:31, 1 June 2019 (UTC)

My reversion is continued on my talk page. Spyder212 (talk) 13:45, 1 June 2019 (UTC)

Spyder212, you re-added this statement to the lead: "Increased utilization of mid-level practitioners, such as NPs and physician assistants, is leading to increased cost of care through increased use of resources and unnecessary referrals." It cites three sources, but I don't see that any of the three sources confirms that costs of care increase if more mid-level practicioners are utilized. The one source that I found discussing costs, reference 9, says that the increased use of resources "may [...] offset at least some savings" of reduced labor costs, but it certainly doesn't say that it is leading to an increased cost of care. Can you please point out which source confirms that claim? Huon (talk) 22:09, 1 June 2019 (UTC)

Please note the sentence structure. All three sources provide evidence that mid-level practitioners such as NPs and PAs lead to unnecessary increased utilization of resources, increased poor-quality referrals to specialists, increased referrals to ER, and increased questionable imaging studies, amongst many others. What do these unnecessary increases lead to? They clearly won't diminish costs. Use more resources unnecessarily = increase spending on those resources unnecessarily. Increase referrals to specialists = increase billing for these specialists visits, some of which could have been avoided by primary care physicians. Increase referrals to ER = increase billing for these visits as well, many of which could have been avoided by primary care physicians. Increase ordering of imaging = increase billing for unnecessary imaging. In the end, lack of competence leads to increased costs. In a private system, the user pays for it. In the public systems, it's the government that sees its budgets get sucked up way too quickly. If you actually took the time to read the sources, they all talk about increased costs... just as an example, "While increased use of imaging appears modest for individual patients, this increase may have ramifications on care and overall costs at the population level." Spyder212 (talk) 04:08, 2 June 2019 (UTC)

Thank you for confirming that you're engaging in original synthesis. "May have ramifications" is not the same as "is leading to increased cost", particularly since you're ignoring the labor costs which the source says are well documented to be lower for NPs. I'll also note that the imaging source explicitly says that they have no opinion on whether the NPs' additional images are unnecessary or whether the physicians order too few images. Huon (talk) 11:30, 2 June 2019 (UTC)

Spyder212, the "increased cost" logic isn't sound. It's possible that it would lead to increased costs... but it's possible that there would be net savings. Let's assume the numbers are correct, and there's about almost a 3% chance of unnecessary referral to a physician. But if you save money on every routine visit, then you are still likely to come out ahead. You'd have to make about 30 trips to your Nurse Practitioner (a savings on the order of US $3,000 in my market) to get that extra referral (a list price on the order of $500). You still saved $2,500 overall. WhatamIdoing (talk) 15:21, 3 June 2019 (UTC)

This of course is also OR, but it captures the gist of what the one source discussing a possible increase of cost through increased use of resources says: "may [...] offset at least some savings". Huon (talk) 16:24, 3 June 2019 (UTC)

I have (again):

• Removed the WP:SYN about lower costs from the lead. Not what the sources say, not a summary of what the body of the article says. Clearly inappropriate. It's not for us to draw our own conclusions from sources that say something else.
• Rewritten the summary of the VA source. "Claimed" is a weasel word meant to discredit results we find inconvenient. And "these studies were shown to have a high potential for bias" is flat-out false. Bias is mentioned in connection with exactly two of the studies, and for one of them the VA says there was a "medium risk of bias" (for the other study where a potential for bias is mentined, it's not ranked "medium" or "high"). Spyder212 apparently didn't like that result and, while adding weasel words, also made the medium potential of bias vanish. I can understand that this is a politically charged topic on which editors may have strong opinions, but I draw the line at deliberate misrepresentations of the sources. That's not acceptable, and unless Spyder212 can give a very good explanation for that edit, I'll likely propose a topic ban from a topic where they have shown that their opinions are stronger than their adherence to core Wikipedia policies (such as "don't lie about what the sources say").
• Removed a sentence about a "tremendous need to enhance nurses' skills" that was sourced but not about NPs but about nurses in general.

It appears we do have to discuss every single inappropriate sentence one by one, though I'm not sure how useful that is if, while we do that, a couple additional weasel words and falsehoods get added. Huon (talk) 13:57, 2 June 2019 (UTC)

Huon, et al, I'd like to propose expanding one of those sentences for better clarification: “In the U.S., NPs have been lobbying for full practice authority.” To be more accurate, the line should include mention that 22 states and the District of Columbia have already granted full practice authority to nurse practitioners. The sentence as currently stated is incomplete. Thank you for your consideration! Raraavis31 (talk) 08:10, 13 June 2019 (UTC)

That seems overly detailed for the lead of an article on the profession in general. Such details of relevance to parts of a single country should probably be put in the body. Huon (talk) 23:51, 15 June 2019 (UTC)

Being careful with primary sources

We try very hard to avoid primary sources when we're talking about efficacy and other scientific subjects, and to defer to independent secondary sources. In particular, I found a quite surprising pattern in the ===Quality of care=== subsection: The two recent secondary sources give a neutral-to-positive impression, but every single primary source (one was more than a decade old!) was strictly disparaging information. Another "strange" thing is that the review articles was at the end, so the reader first has to get a laundry list of negative information before finally being told the bottom line.

This makes me concerned that there may have been some (perhaps unintentional) cherry-picking of sources here, in addition to a case of burying the lead (which the MOS discourages). It is especially important that we don't use primary sources to de-bunk the conclusions of secondary sources. This is explicitly prohibited by WP:MEDRS and is a violation of WP:NPOV.

I have removed the primary sources. I would like to see this section build entirely from secondary sources, since that is the best practice for Wikipedia articles, especially when facts are in dispute. If you want to look for more review articles, then go to https://www.ncbi.nlm.nih.gov/pubmed/?term=%22Nurse+Practitioners%22%5BMAJR%5D On the left-hand side of your screen, look for a filter section called "Articles". Click "Reviews" in that list. Try to focus on articles published in the last few years (there's a date filter that will let you see only articles in the last five years).

If you need help determining whether a source is a secondary source, you can always start a new section at WT:MED to ask. People there are very helpful at helping editors figure out whether a journal article is a review article, meta-analysis, or other form of high-quality source. WhatamIdoing (talk) 18:10, 22 June 2019 (UTC)

Semi-protected edit request on 14 July 2019

This reference contains derogatory statements towards NPs. Mid level provider assumes NPs are less than physical providers . NPs have been shown to have comparable patient outcomes as physicians and in some cases better outcomes. Additionally who are the low level providers would this be the RN. You neglect to include the hours of Basic RN education that is also part of the NP preparation. NP hold two licenses on RN the other NP you cannot practice as without RN experience.The physician focus langague should be removed Wvitale5 (talk) 03:35, 14 July 2019 (UTC)

 Not done. It's not clear what change(s) you want to make. Edit requests require precise requests so that an editor that's not familiar with the article can easily understand the exact change you want. It's also not clear which reference(s) you're referring to, or exactly what part of the article you have a problem with. –Deacon Vorbis (carbon • videos) 14:08, 14 July 2019 (UTC)

References

All major organizations EXCEPT physicians have come out saying the term mid level is derogatory. I don't come to Wiki to be insulted. NP care is not judged medically or legally different from physicians. We practice according to the same standards. I've included the official paper from the AANP. Please change it and stop with the insulting terminology.

https://www.aanp.org/advocacy/advocacy-resource/position-statements/use-of-terms-such-as-mid-level-provider-and-physician-extender "Use of Terms Such as Mid-level Provider and Physician Extender The use of terms such as “mid-level provider” and “physician extender” in reference to nurse practitioners (NPs) individually or to an aggregate inclusive of NPs is inaccurate and misleading. The American Association of Nurse Practitioners® (AANP) opposes the use of these terms and calls on employers, policymakers, health care professionals and other parties to refer to NPs by their title. In 2010, the Institute of Medicine (IOM) developed a blueprint for the future of nursing. A key recommendation of this report is that NPs should be full partners with physicians and other health care professionals.i Achieving this recommendation requires the use of clear and accurate nomenclature of the nursing profession.

NPs are licensed, independent practitioners. NPs work throughout the entirety of health care, from health promotion and disease prevention to diagnosis that prevents and limits disability.ii These inaccurate terms originated decades ago in bureaucracies and/or organized medicine; they are not interchangeable with use of the NP title. The terms fail to recognize the established national scope of practice for the NP role and authority of NPs to practice according to the full extent of their education. Further, these terms confuse health care consumers and the general public due to their vague nature and are not a true reflection of the role of the NP.

The term “mid-level provider” implies an inaccurate hierarchy within clinical practice. NPs practice at the highest level of professional nursing practice. It is well established that patient outcomes for NPs are comparable or better than that of physicians.iii NPs provide high-quality and cost-effective care."

The article should be titled NP vs MD since the author insists on comparing NPs to MDs in every paragraph. Is it about NPs or NPs conpared to MDs? All references to physicians should be removed.2601:C5:180:2850:C1B5:5630:FEDF:B2A8 (talk) 04:01, 1 September 2019 (UTC)

"

Semi-protected edit request on 27 February 2020

please remove the following (politically inflammatory) words from the article:

"and a type of mid-level practitioner. NPs are "

", but does not provide the depth of expertise needed to recognize more complex conditions" 99.249.234.32 (talk) 13:50, 27 February 2020 (UTC)

 Not done. I fail to see anything political in these statements. Moreover, the second one of those is well-sourced. They seem to help identify the subject of the article. –Deacon Vorbis (carbon • videos) 16:23, 27 February 2020 (UTC)

Semi-protected edit request on 29 February 2020

EDIT FIRST FEW SENTENCES....

“in some states are mid level providers and in other states they are independent practitioners” 2601:154:C100:E1E0:91CD:CA3B:BC32:8EEA (talk) 23:47, 29 February 2020 (UTC)

 Not done. This article is about more than just the United States (based on your IP address). Moreover, right at the end of the lead, it says: "In some places, NPs are required to work under the supervision of a physician, and in other places they can practice independently." That seems to get the same point across that you want pretty clearly. –Deacon Vorbis (carbon • videos) 00:26, 1 March 2020 (UTC)

Semi-protected edit request on 5 March 2020

Nurse practitioners are NOT midlevel practitioners. We are autonomous nurses who diagnose, prescribe, and educate. Our scope of practice is determined by state laws, education, and clinical experience. I would ask you to please remove the end of this sentence: NP training covers basic disease prevention, coordination of care, and health promotion, [[[[but does not provide the depth of expertise needed to recognize more complex conditions]]. This is not an evidenced-based statement in any way. Research shows that NPs can take care of 80% of the patients who they evaluate without referral, the same as a family physician (also 80% according to the AAFP). You can visit this page: https://www.aanp.org/about/all-about-nps/whats-a-nurse-practitioner to get a better understanding and MORE CONCISE (less negative) definition of a NP.

2601:602:CA00:4210:7D32:C1E3:63CC:C2CA (talk) 04:51, 5 March 2020 (UTC)

 Not done. Statement has a source attached; please establish a consensus to remove this material before making this edit request. –Deacon Vorbis (carbon • videos) 15:32, 5 March 2020 (UTC)

Semi-protected edit request on 22 May 2020

Add the following under United States - Quality of Care:

A large cross-sectional study comparing opioid prescribing patterns of primary care physicians (MDs), nurse practitioners (NPs), and physician assistants (PAs)found that NPs in states allowing independent prescription authority were >20 times more likely to overprescribe opioids than in prescription-restricted states. "Most NPs/PAs prescribed opioids in a pattern similar to MDs, but NPs/PAs had more outliers who prescribed high-frequency, high-dose opioids than did MDs." Popcorn science (talk) 23:07, 22 May 2020 (UTC)

 Not done: please provide reliable sources that support the change you want to be made. Please wait a bit; this appears to be a preprint ["ahead of print"] (which are unreviewed and not considered reliable sources, see Talk:Coronavirus_disease_2019#Discretionary_sanctions_on_the_use_of_preprints, which equally applies on any medical subject). RandomCanadian (talk / contribs) 23:50, 22 May 2020 (UTC)

Completely agree that preprints should not be published. However, this is an online publication ahead of the physical print copy in the Journal of General Internal Medicine meaning it has undergone the peer review process. Popcorn science (talk) 22:46, 24 May 2020 (UTC)

References

Midelevel term consensus

Three other contributors have also called for the removal of this term, multiple solid sources have been given. It is my understanding consensus is built like this in talk pages. If this does not qualify as consensus, how can I help us move towards it? — Preceding unsigned comment added by Concernedcitizenforaccuracy (talk • contribs) 09:57, 7 June 2020 (UTC)

There are also quite a few people who have expressed the opposite view in the talk page archives. If you want to change it at this point someone would probably need to stage a WP:RFC to demonstrate consensus to change the lead. This can be kind of a tricky process, I would not recommend starting here as a new editor. - MrOllie (talk) 11:17, 7 June 2020 (UTC)

Semi-protected edit request on 4 January 2021

"A nurse practitioner (NP) is an advanced practice registered nurse and a type of 'Advanced Practice Provider (APP), NOT 'mid-level practitioner. There is no mid-level as NPs practice equivalent as MDs and DOs. 2600:1700:5441:8230:288D:E963:DB31:CC9F (talk) 22:02, 4 January 2021 (UTC)

 Not done. This is a controversial proposal that has been discussed extensively before (see the talk page archives for the arguments for and against). - MrOllie (talk) 22:04, 4 January 2021 (UTC)

Semi-protected edit request on 7 September 2020

Please change "A review of studies comparing outcomes of care by NPs and by physicians in primary care, urgent care, and anesthesia conducted by the Department of Veteran Affairs found that outcomes in the assessed studies were generally comparable" to "A review of studies comparing outcomes of care by NPs and by physicians in primary care, urgent care, and anesthesia conducted by the Department of Veteran Affairs found that outcomes in the assessed studies were generally comparable, however the strength of evidence of this study ranged from insuffienct to low."

The article itself states " there was no difference in health status, quality or life, mortality, or hospitalizations favoring either APRN or physician care, although the strength of evidence was generally low," yet the wikipedia page has deliberately left out the second part of this sentence. The article citation should either be edited or removed. Wolf 1623 (talk) 23:03, 7 September 2020 (UTC)

@Wolf 1623: Not done for now: please provide reliable sources that support the change you want to be made. If it is already mentioned in the existing sources please point it out.

As for citations please mention specifically which and why they need to be edited or removed. Please ping me here or text me at my talk page if you think I made a mistake. Thank you. -ink&fables «talk» 11:24, 19 October 2020 (UTC)

@-ink&fables: Apologies for the late response. The citation in question is the 15th reference mentioned in the Wikipedia article, titled "Evidence Brief: The Quality of Care Provided by Advanced Practice Nurses." Under the executive summary, the journal article in question states "In primary and urgent care settings, there was no difference in health status, quality or life, mortality, or hospitalizations favoring either APRN or physician care, although the strength of evidence was generally low," however the Wikipedia page seems to have deliberately left out the later part of the statement. The absence of the statement skews the perceived strength of the study and thus should be either removed or edited for completeness.

Reviewed reference. Agreed. Honestly not even surprised this type of information is manipulated...  Done. Spyder212 (talk) 02:11, 14 March 2021 (UTC)

"Controversies and criticisms"

2 students complaining about their classes is not "controversies and criticisms". "Controversies and criticisms" would be something like "many doctors have argued that NPs are more likely to kill patients" or "PETA reports that animal sacrifices are a regular part of NP training and should be banned". --142.163.195.253 (talk) 18:35, 12 November 2021 (UTC)

I agree. There definitely is some level of criticism, particularly from 'doctor' associations (like the Australian Medical Association). I guess the question is how do we differentiate criticism like that, seemingly coming from a fear that NPs will 'replace' or de-throne GPs etc despite NPs having better patient outcomes, from valid criticism? I'm primarily concerned that it's going to be a lot of he-said-she-said sort of thing, between doctor associations and nursing associations. — ItsPugle Talk 02:15, 13 November 2021 (UTC)

Concerns about "mid-level" terminology

The term "mid-level" provider is a problematic and condescending term that is used to politically bully nurse practitioners from achieving full practice authority. The term "mid-level provider" is defining APRNs by how physicians perceive nurse practitioners' relationship to physicians (i.e. inferior, less than, not as competent etc.). On the other hand, terms like "advanced practice provider" are describing nurse practitioners by their elevated standing in their own field. The term "mid-level provider" is marginalizing and indicates a glaring ignorance about the scope of practice, education, and training of APRNs. As soon as I graduate with my DNP degree and FNP certification in May 2022, I will never allow anybody to call me an "mid-level provider" without letting them know to never call me that ever again. Wikipedia needs to do better and remove this slur immediately. — Preceding unsigned comment added by Dseverson17 (talk • contribs) 19:50, 16 June 2021 (UTC)

@Dseverson17: I'm a Guild of Copy Editors volunteer coming late to the game to address tags - this has been discussed in the archives and there appears to be no consensus to change the terminology, based on sourcing. TimTempleton ^{(talk) (cont)} 01:59, 4 February 2022 (UTC)

Multiple Errors

The general tone of the article appears biased and political, most of the major points are un-cited or incorrectly cited. If someone can tell me how to call for higher level dispute/article resolution, please do.

"A nurse practitioner (NP) is an advanced practice registered nurse and a type of mid-level practitioner." -The term mid-level practitioner is opposed by a wide variety of NP and non-NP organizations. The term is noticeably absent in the PA, pharmacist, and dentist articles and should not be included here either.

NP or DNP and PA are all mid-level providers. Obtaining a DNP does not make a nurse practitioner a physician. Physicians across the world, are individuals who practice medicine and always hold a DO or MD (or equivalent degree). NP, DNP, and PA are mid-level practitioners because of the level of education and training required (much less than MD or DO physicians). To draw an equavalency conclusion, NP, DNP, PA education must meet the same standards of medical education as physicians: 1. medical school, 2. passage of 4 board examinations spread across medical school, residency and at end of residency. NP & DNP education lack standardized medical education and training.

"NP training covers basic disease prevention, coordination of care, and health promotion, (but does not provide the depth of expertise needed to recognize more complex conditions.)" -()Statement is inaccurate and improperly cited, Citation 1: PCP-TAFP is an anti-NP lobby, the article cited is inaccurate and heavily politically biased. Citation 2 is about NPs providing expertise for the opioid and indirectly refutes the very sentence it is cited in, very off-topic.

"To become an NP requires between 1.5 and 3 years of post-baccalaureate training, in addition to prior training and experience as an RN, though there are alternate routes to training." -As linked "post-baccalaureate training" is currently not legal for NPs, they were phased out a long time ago. All NPs complete, at minimum a Masters. This is GRADUATE education.

"There are also Psychiatric, Adult Geriatric Acute Care, Adult Geriatric Primary Care, Pediatric, and Neonatal nurse practitioner programs." -Womens health NP is missing from this list.

"Many of these programs have their pre-clinical or didactic courses taught online with proctored examinations. (Once the students start their clinical courses they have online material, but are required to perform clinical hours at an approved facility under the guidance of an NP or Physician.)" -ENTIRELY UN-CITED, ()Statement not qualified to the previous sentence, thus inaccurate, also un-cited.

"A new nurse practitioner may have between 500 and 1,000 hours of clinical training." -Inaccurate, many NP programs require over 1,000 clinical hours, see UTHSC programs, PCP-TAFP again only citation, bad source.

"The quality of education (and of applicants) for NP schools has been cited as a reason to not allow NPs to practice medicine autonomously." -This is an UN-CITED argument that says it is cited.()Entirely inaccurate, even TAFP/PCP does not discuss applicant quality

"Some graduate nursing schools have 100% acceptance rates." -accurate source for "graduate nursing" which is frequently not NP programs, CITED ARTICLE(14) NOT ABOUT NP PROGRAMS. Statement is inaccurate/improperly cited.

"The highest average starting salary reached $197,000 in 2016." - Citation 29 refers to a BLS report that lumped CRNAs with NPs, starting salaries are not that high for NPs, but for CRNAs

See Also- Barefoot doctors should be removed, it is entirely unrelated, implies incompetence, and its not mentioned in the midlevel practioners or physician pages. Concernedcitizenforaccuracy (talk) 10:33, 7 June 2020 (UTC)

— Preceding unsigned comment added by 2605:A601:51FC:264:51DA:5925:2E8C:6BA6 (talk) 09:38, 7 June 2020 (UTC) 

Can I just add that having visited this page for the first time today, my immediate impression is that this article seems very heavily North American focussed. Here in the UK we have Practice Nurses (ref). I assume this to be the same thing, or is this article written by and aimed at a purely US/Canadian audience, focusing on one very specific job title? If it isn't, it needs to take a global focus on the topic/role. Nick Moyes (talk) 11:02, 7 June 2020 (UTC)

The equivalent UK title is the 'advanced practice nurse' or 'advanced nurse practitioner'. - MrOllie (talk) 11:24, 7 June 2020 (UTC)

@MrOllie: - I'm a Guild of Copy Editors volunteer and I came here to clean up the tags. I saw your comment. Is there any reason why this wouldn't be a merge candidate with Advanced practice nurse? TimTempleton ^{(talk) (cont)} 02:08, 4 February 2022 (UTC)

Problematic. Also, no source

"NP training covers basic disease prevention, coordination of care, and health promotion, but does not provide the depth of expertise needed to recognize more complex conditions"

This entire statement is problematic. NP training varies. There are NPs in many roles and specialties that diagnose and manage complex conditions. Chloemwspaulding (talk) 20:53, 17 March 2022 (UTC)

The lead section is a short summary of the article. More details (and sources) can be found in the article body. MrOllie (talk) 21:13, 17 March 2022 (UTC)

Semi-protected edit request on 30 January 2022

NP are not mid level providers, research shows care is equivalent to that provided by physicians. Some NP have doctorate degrees and can practice independently in some states. 70.58.138.45 (talk) 23:21, 30 January 2022 (UTC)

This has been debated extensively on this talk page (see the archive links). You must show that consensus has changed before making such a request. - MrOllie (talk) 23:24, 30 January 2022 (UTC)

(but there was no "consensus" to begin with when such a term was used originally) — Preceding unsigned comment added by 24.102.93.30 (talk) 02:17, 24 March 2022 (UTC)

Summarization of edits

Hello, I am a student editor and I chose to evaluate and edit this article for an assignment. To begin I began by expanding the lead section. I added content that provided more detail to the summarization of the article. I also modified the neutrality of the article. The article contains pieces of disputable/political information. In the introductory sentence, the writer refers to NPs as a type of “mid-level practitioner.” This statement is very controversial and was disputed heavily on the talk page. After utilizing my sources and researching, this statement can be deferred by other dependable sources and therefore should not be incorporated. I removed this terminology and defined what a nurse practitioner is in a different way. Additionally, I created a section regarding the duties and responsibilities of a NP.Although the duties of a nurse practitioner vary, I summarized the main roles in bullet points. I also updated/expanded the information concerning the education requirements of a NP. I recapped the steps on how to become a nurse and then a NP and added it to the article. I also created a qualities section which includes important characteristics a nurse practitioner should attain in order to excel in their field. Moreover, I constructed a section describing the settings NPs work in, and this material is significant to understand the wide variety of practice settings they are can be employed in. Lastly, I incorporated a new section regarding the importance of NP's during the Covid-19 pandemic. NPs continue to play a critical part in the demand for clinicians globally due to the crisis.Caramc456 (talk) 23:44, 28 March 2022 (UTC) 28 March 2022

Yes, a series of single purpose editors have disputed the term 'mid-level practitioner', but outside of a few advocacy organizations (whose opinions we should not accept uncritically), the sources are pretty clear that NPs are in fact mid-level practitioners and identify them as such. On Wikipedia we follow the sources and do not omit things just because a vocal minority doesn't like them. You also added some material that was unduly focused on US regulations - Wikipedia is a global encyclopedia and should cover things from a global perspective, and US regulations do not determine how the profession works in the rest of the world. MrOllie (talk) 00:41, 29 March 2022 (UTC)

Semiprotected edit request June 9, 2022

Please remove the first reference on this page. This link no longer works: https://www.who.int/workforcealliance/knowledge/resources/Final_MLP_web_2.pdf. There continues to be frequent vandalism on this page. Broken and outdates links are just two of many quality and accuracy issues with this page. Thank you Miraclecln (talk) 01:15, 10 June 2022 (UTC)

Thanks for noting the broken link. I fixed it by adding an archive URL rather than deleting it. I agree that there has been frequent vandalism on the page - the constant deletion of well founded criticism is really inappropriate. MrOllie (talk) 01:24, 10 June 2022 (UTC)

The constant reversal of edits that improve the accuracy of this page are also inappropriate and reinforce existing bias. Thank you for making that edit. Miraclecln (talk) 14:07, 10 June 2022 (UTC)

I would have no issue with simple factual updates if they were not accompanied by POV pushing and constant removal of criticism. MrOllie (talk) 14:17, 10 June 2022 (UTC)

Agreed, but why are we linking to resources that were published in 2010 and 2013? Those are way out of date. There seems to be some POV pushing related to a reliance on resources that are no longer relevant. Miraclecln (talk) 14:29, 10 June 2022 (UTC)

I see no indication that they are out of date. MrOllie (talk) 14:51, 10 June 2022 (UTC)

Semi-protected edit request on 30 June 2022

Change:

but does not provide the depth of expertise needed to recognize more complex conditions.

To:

but does not provied the depth of expertise needed to recognize and treat more complex conditions.

While NPs may be able to recognize complex conditions through personal (just as many non-medical personnel may be able to) or professional experiences of the condition, treatment of these complex conditions requires considerably more expertise. I had taken into consideration the difference between "recognize and treat" and "recognize or treat" into account when considering the sokution to this issue. The argument that POV editors are making is valid here, however changing it to "recognize and treat" will strength the validity of the statement. HippocratesLlama (talk) 21:57, 30 June 2022 (UTC)

 Not done: According to the page's protection level you should be able to edit the page yourself. If you seem to be unable to, please reopen the request with further details.Fbifriday (talk) 02:37, 10 July 2022 (UTC)

Consistent Biased Edits/Revisions

The term "mid-level provider" is inappropriate, as in most states NPs have full practice authority, whereas "mid-level providers" must work under physician supervision. It also implies the existence of "low-level providers" which is an unfair and misinformed way to refer to nurses, techs, or medical assistants.Hungrychoir (talk) 21:20, 11 January 2023 (UTC)

Any time that edits are made to address the already biased point of view, there is an an editor who reverts the content back. This has to stop. There are consistent justifications and references for the edits and they are ignored or refuted with weak arguments and opinions. There is clearly something wrong here when one looks at this page and revision history. This is not about a narrative pushed by any organization. With over 355,000 Nurse Practitioners practicing in the U.S., why can't there be an unbiased and factual description of the profession? Seriously. — Preceding unsigned comment added by NPTruth (talk • contribs) 03:37, 6 June 2022 (UTC)

Yes, I do revert attempts to slant this article by removing criticism of and information about the limitations of this profession. Such blatant POV pushing is what has to stop. MrOllie (talk) 10:45, 6 June 2022 (UTC)

Are you actually reading this article or are you on some quest to maintain disinformation on the profession? I am providing factual information about the profession with references only to have them removed. You are acting in bad faith and are completely pushing your biases here. Again, I respectfully ask you to re-read the edits rather than maintain your quest to reject edits based on your biased POV. — Preceding unsigned comment added by NPTruth (talk • contribs) 11:49, 6 June 2022 (UTC)

Semi-protected edit request on 6 October 2023

I would suggest a change to the last line of the first paragraph which currently states "NP training covers basic disease prevention, coordination of care, and health promotion, but does not provide the depth of expertise needed to recognize more complex conditions.[3]".

I read the article listed as the source and it does not come to the conclusion that NP education does not provide depth of expertise needed to recognize more complex conditions.

Based on this source the sentence would be more accurate if it were broken into two sentences to read as:

"NP training covers basic disease prevention, coordination of care, and health promotion. One study found that although reasons for referrals to specialists are similar for both physicians and NPs, the quality of documentation in the referrals may be lower for NPs (3)."

The source remains the same as in the original writing but I have pasted it below.

Lohr, Robert H.; West, Colin P.; Beliveau, Margaret; Daniels, Paul R.; Nyman, Mark A.; Mundell, William C.; Schwenk, Nina M.; Mandrekar, Jayawant N.; Naessens, James M.; Beckman, Thomas J. (9 Oct 2013). "Comparison of the Quality of Patient Referrals From Physicians, Physician Assistants, and Nurse Practitioners". Mayo Clinic Proceedings. 88 (11): 1266–1271. doi:10.1016/j.mayocp.2013.08.013. PMID 24119364. 2001:569:7BAF:8100:5157:128E:8D4:ED10 (talk) 19:49, 6 October 2023 (UTC)

 Done Pinchme123 (talk) 17:43, 9 October 2023 (UTC)

Removal of non-factual information

This talk article is being created to settle a dispute between two editors. On November 19, 2023 I deleted the following information from the page as it is not factually correct. The following is the information I provided as to my edits. The edits were shortly reversed by an another editor for not being neutral however the information was not removed for being critical but because it is not supported by the reference, draws a conclusion that does not exist, and simply presents incorrect information.

“Although nurse practitioners are required to be licensed as registered nurses prior to obtaining their advanced practice registered nurse certification, there are several programs that combine a nursing undergraduate degree with nurse practitioner training.” This statement does not a have a reference and the information is not factually correct. There is no such thing as an undergraduate NP program. There are also no MSN entry to nursing practice degrees that are NP training programs. MSN entry to nursing degrees are for non nurses who already have an unrelated bachelors degree. The MSN entry to nursing degree allows someone to get an MSN with their initial RN licensure instead of duplicating a BSN. That MSN however does not have an NP specialization and the graduate would have to either attend a DNP NP program, MSN NP program, or a graduate certificate NP program.

The second part of the statement is also factually incorrect and draws a conclusion the article does not support as it states “Other nurse practitioner programs have 100% acceptance rates.” which is not what the referenced article states. The article is titled “Nursing Master's Programs With 100% Admit Rates” and never does it specifically say the programs are nurse practitioner training programs. MSNs are offered in a variety of specialties including informatics, leadership, and education, none of which are nurse practitioner training programs.

Hue16459 (talk) 02:47, 20 November 2023 (UTC)

I replaced the citation with one that specifically indicates the type of nursing master's program, so this is 'factually correct' after all. I trust that resolves the issue. MrOllie (talk) 02:57, 20 November 2023 (UTC)

The first part of the paragraph remains inaccurate and should still be removed as you have presented no further information to support its accuracy. The updated reference provided for the second part is a website that offers paid advertisements and the information relates to initial nurse licensure and undergraduate programs. “Many nursing programs are highly competitive and have significantly more applications than they could reasonably accept. But if you have your heart set on becoming a nurse, don't lose faith! We've compiled a list of nursing programs with a strong track record of producing excellent nurses - these programs also have very high acceptance rates!“ Additionally the school requirements listed under each of the ten school refer specifically to undergraduate nursing licensure not advanced practice. The updated reference again is inadequate to draw the conclusion stated. Hue16459 (talk) 03:19, 20 November 2023 (UTC)

All relevant facts now have citations attached, and the presence of advertising does not rule out a source. On Wikipedia the sources are followed - your personal belief about what is 'inaccurate' is immaterial here. MrOllie (talk) 03:30, 20 November 2023 (UTC)

I suggest the following edit to the first section as the program listed grants students both a BSN and MSN as a single admission process but still as separate degrees. Per the nursing school accreditation process you must have a BSN and an active RN license to be an MSN NP student. Additionally if a student is unable to pass the NCLEX and receive their RN license they cannot continue on into the MSN portion of the program.

Although nurse practitioners are required to be licensed as registered nurses prior to obtaining their advanced practice registered nurse certification; there are several accelerated nursing programs that offer an undergraduate nursing degree and eligibility for registered nurse licensure followed immediately by a nursing graduate degree and eligibilty for advanced practice registered nurse licensure without any prerequisite work experience as a registered nurse. Hue16459 (talk) 03:55, 20 November 2023 (UTC)

Although nurse practitioners are required to be licensed as registered nurses prior to obtaining their advanced practice registered nurse certification; there are several accelerated nursing programs that offer an undergraduate nursing degree and eligibility for registered nurse licensure followed immediately by a graduate nursing degree and eligibility for advanced practice registered nurse licensure without any prerequisite work experience as a registered nurse. Hue16459 (talk) 03:56, 20 November 2023 (UTC)

As for the other issue “Other nurse practitioner programs have 100% acceptance rates.” this information is not a direct quote supported by literature and is instead a conclusion drawn by an individual therefore I have every right to challenge its accuracy. The initial reference now the secondary reference do no state this information nor do they support the conclusion as both articles are specifically related to undergraduate nursing education. Hue16459 (talk) 04:16, 20 November 2023 (UTC)

You can challenge whatever you like, but it is properly sourced, so there are no grounds to delete it. MrOllie (talk) 04:25, 20 November 2023 (UTC)