By Caleb Melby

The stakes are high. For many students, it’s the only time they’ll work with real patients as an NP before entering the workforce. And if they can’t get the hours, their graduation will be delayed. So students beg on Facebook for placements, drop off cookies at front desks for potential preceptors—and, when they find someone who’s willing, often pay the person themselves.

For the public, the ramifications are greater. Even some hospital leaders acknowledge there’s so little quality control that patients can’t be sure their NP is properly trained to treat them. Struggling to ensure they’re prepared to handle the duties assigned them, students have few places to find help.

Many have turned to Dino Soriano.

A decade ago, Soriano founded a company called Clinical Match Me to help patch this broken system. For a flat $1,995 fee (paid by the students, financing options available), Clinical Match Me will do the work that their universities often refuse to: finding, scrutinizing and paying clinical instructors. The company advertises a roster of more than 220,000 potential preceptors across all 50 states, and it’s placed students from more than 280 advanced nursing programs. It’s one of the biggest players in the NP matchmaking business.

Soriano’s experience has given him a deeper look into the fractured education infrastructure that nursing students face. Increasingly, NPs are taking on roles previously filled by physicians, but their regimen hasn’t kept pace with those growing responsibilities. Soriano, like many within the health-care industry, has concluded that more needs to be done. The clinical hour requirements, for instance, are simply “insufficient to properly train them and prepare them to be safe,” he says.

For Soriano these problems are personal. When he couldn’t find a preceptor, his own graduation from Walden University, the for-profit online school that graduates the most advanced nurses, was delayed.

As a problem-solver, though, he cuts a somewhat awkward figure. In 2020 he pleaded guilty to one count of conspiracy to commit Medicare fraud after federal prosecutors accused him of receiving compensation for prescribing orthotic equipment for which he falsified testing and examination records. In the charges, prosecutors made clear that Soriano was unaware of the overarching fraud scheme, even as he profited from it. Nevertheless, he pleaded guilty, and multiple states revoked his NP license. He then transferred Clinical Match Me to a new entity with a new owner, for whom he serves in a consulting role. (The chief executive officer says Soriano has “never been a principal in the current company, so his conviction should be irrelevant.”)

Clinical Match Me isn’t flawless; some of its clients complain about their placements. But its very existence underscores the extent of the problem posed by NPs’ ever-growing role in US health care. It also points the way toward potential solutions for lawmakers, hospitals, accreditors and the regulators that have failed to properly police the training of the nation’s newest NPs.

To hear it from one lobby for NPs, such providers are “equipped to provide safe, high-quality, cost-effective, patient-centered care upon graduation.”

Many students disagree. Debra Anderson, an NP student in Sacramento, became concerned about her schooling after she met a university official who “literally told me not to worry about the quality of my clinical training, that I would learn everything I need to know after graduation.” Frustrated and disillusioned, Anderson signed up for NPHub LLC, a Clinical Match Me competitor that’s helped 8,000 students find clinical rotations.

Students and even investors in a for-profit company that offers NP degrees have told the US Department of Education they’re concerned about the lack of enforcement around rules concerning clinical placements. Despite that, the department last year issued a clean bill of health to the autonomous agency that accredits most of those schools, the Commission on Collegiate Nursing Education (CCNE).

A spokesman for the Education Department said federal law bars the department from setting standards for accreditors, and that its oversight of them is limited to determining whether they meet the standards they set for themselves.

Even with those constraints, the department now has reason to act, students and educators say. Schools are “responsible for ensuring adequate physical resources and clinical sites” according to CCNE rules. But widespread failure to pair students with preceptors shows the accreditor is refusing to meaningfully enforce that standard, they say.

And now the organization's former director of accreditation is raising concerns too—the first time a CCNE insider has acknowledged students’ longstanding complaints. For consumers “it is difficult to know whether the professional who is providing your care is qualified to do so,” says Lori Schroeder, who held her post from 2012 to 2019. “Graduation from an accredited program is not sufficient assurance.”

At the same time, the largest group for people who educate NPs is pleading with accreditors to adopt more stringent rules. In an Education Department hearing in March, Mary Beth Bigley, CEO of the National Organization of Nurse Practitioner Faculties, appealed to the government to review standards set out by CCNE.

In 2022, Bigley’s organization, with the help of 18 other groups, updated a standardized program for educating NPs. Since then, Bigley testified, accreditors “have self-selected only a few of these industry standards” and were therefore running afoul of federal rules mandating that such oversight be “sufficiently rigorous.” A continued failure by the Education Department to act would result in substandard programs that “may impact patient safety and worsen patient outcomes,” Bigley said.

After a Bstory earlier this year revealed systemic problems at some of the biggest online programs run by for-profit companies, Bigley’s organization issued a press release again excoriating the accreditors for failing to adopt the standards it recommended. Those measures, the group stated, would “safeguard the profession against external interests that do not align with its integrity.” (Bigley declined in an email to say what interests she was referring to.)

Benjamin Murray, deputy executive director for CCNE, said many groups submitted input during the standards revision process and that those groups “may disagree with the final result.” The rules that are ultimately adopted are “a matter of CCNE Board judgment, informed by the totality of the public input.” Regarding Schroeder’s concerns, Murray said the agency’s policies have changed since she left the organization and that it has “appropriate and publicly available procedures and standards.”

The present dilemma of NPs has echoes of a century ago, when physicians themselves looked at a landscape of snake-oil schools and a hodgepodge of standards and decided to create a standardized education based on the medical school at Johns Hopkins University. Many NPs and other health-care providers say a standardized curriculum would help NPs as well. So would in-person requirements for classes, stricter accreditation, better vetting of clinical placements and more formalized, robust residencies.

Little of that is likely to happen without better funding. And money from the federal government has been difficult to come by. The Centers for Medicare and Medicaid Services (CMS) funds physicians’ residencies, for instance, but not NP training. Beginning in 2012, CMS conducted a trial for funding NP training that the agency later deemed a success. Since the initial $176 million was spent, though, it hasn’t been repeated.

As a new administration takes power in Washington next month, it’s unclear what momentum, if any, there will be for greater funding or fixes. But lawmakers from both parties agree more should be done to protect consumers.

Senator Ed Markey, a Massachusetts Democrat who serves on the Committee on Health, Education, Labor and Pensions, said in an emailed statement that while NPs serve a vital role in the health-care system, for-profit companies “exploit nurse practitioners by cutting other essential roles to reduce spending and raise revenues.”

Representative Mariannette Miller-Meeks, an Iowa Republican on the Subcommittee on Health in the lower chamber, says she’s concerned that deploying NPs to meet health-care demand “often leads to worse patient outcomes.” A physician, Miller-Meeks says that she supports NPs but that “rigorous educational modifications and certifications” must be imposed before states further increase their responsibilities.

In the absence of legal or regulatory changes, some educators are taking steps to improve NP education on their own. Allyson Neal, assistant dean of graduate nursing programs at the University of Tennessee at Knoxville, says her school phased out its master’s of nursing degree because it didn’t prepare students for the intensity of work they’d face. UT Knoxville now offers only a doctor of nursing practice degree, or DNP.

Many in nursing, Neal says, have “recognized that because patients are sicker and health care is more complex,” a doctoral degree is necessary. UT Knoxville’s DNP degree runs three years rather than two and requires 200 more clinical hours (840 total) than the most popular online master’s programs offered by the two biggest providers, Walden University and Chamberlain University, both owned by the for-profit company Adtalem Global Education Inc. A spokeswoman for Adtalem declined to comment for this story.

Cutting the master’s program wasn’t an easy decision; it meant forgoing hundreds of tuition-paying students. But “that’s what we feel like it takes to provide the type of care that patients truly need,” Neal says.

Like-minded educators believe the move to doctoral-level degrees should be universal. If it were up to Bigley’s group, it would be. But without accreditor buy-in, her organization’s standards are mostly unenforceable suggestions. And they’ve been ignored by the largest online schools, many of which are run by for-profit companies that could lose a fortune if they adhered to the proposed rules.

The Largest Graduate Nursing Programs Teach Online

Walden University and Chamberlain University—online-only schools owned by Adtalem—dominate advanced nursing education in the US; below, master’s and doctorate degrees awarded at the 25 biggest schools

Without standardized requirements, the current system incentivizes schools to race to the bottom. Because many NP students are already registered nurses and have to balance the demands of work and training, the biggest advanced programs compete for enrollment with promises not of the most rigorous educational experiences but of the most frictionless ones. Increasingly that means go-at-your-own-pace classes, no requirements to visit campuses and no guarantees students will interact with professors outside of email and messages.

When it comes time for their clinical rotations, though, they’re often met with a rude awakening: The job of finding placements is their responsibility.

Anderson, the Sacramento student, says she came to realize her school was happy to “accept a poor preceptor willing to sign the student’s paperwork rather than risk losing the preceptor and exposing the real problem, a poor training model.” Switching to NPHub meant paying for preceptors, but she thinks that’s a fair trade for the rigorous training she’s received, not to mention the time saved that she’d previously spent hunting for them on her own. She’s since become an unpaid evangelist for the company.

In addition to working with students to help them find preceptors, Krish Chopra, founder of NPHub, has begun joining with schools to place some of their students on behalf of the institutions. “If NPs are really the future of health care, then universities need to professionalize their clinical experience,” Chopra says. “This space just needs an accrediting body that can enforce what should be practiced. It’s not rocket science, man.”

Another improvement would be to dramatically increase the number of NP residencies, but those are few and their appeal is limited. Like physician residents, NP residents get paid a fraction of what they’d earn on the open market, making nonrequired residencies a hard sell. For now they mostly attract the profession’s best and brightest, who are looking to practice at a high level.

That could change if employers started to see the value of residencies. Recently, Soriano has been selling health-care leaders on a 2,400-hour NP residency program that can be deployed in their own facilities. Faced with a seismic shift in how hospitals are staffed, executives are listening.

“Over the years, you’ve got more and more people going into these specialties, and the training hasn’t kept up with the scope of work,” Soriano says. “Instead of hiring somebody on a résumé, a prayer and an interview—gambling a six-figure salary—you are now getting to cherry-pick health-care providers out of your residency program.”

What does Clinical Match Me get out of it? Soriano calculates the company could gross tens of thousands of dollars per resident, and he estimates that about 35,000 new NPs graduate each year.

“I don’t know if you did that math in your head,” he says. “That’s a lot of zeroes. A lot of zeroes.”