This is the first part of The Nurse Will See You Now, a series documenting how the increasing reliance on ill-trained nurse practitioners is imperiling US patients.

When Fred Bedell entered the emergency room on Oct. 12, 2020, he was in the throes of tremendous abdominal pain. The situation was frightening, but Bedell, a 60-year-old father of two, had little reason to doubt that he’d receive anything except excellent care at Florida Lake City Hospital, a 113-bed facility about 60 miles west of Jacksonville. For the past several years, the local chamber of commerce had named it the “Best of the Best.”

But Bedell wasn’t going to get the best care. He wasn’t even going to be cared for by a medical doctor. As happens increasingly in the US, in medical settings ranging from tranquil primary-care offices to chaotic ERs, he was seen instead by a nurse practitioner. The NP, who’d received his license four months earlier after completing a mostly online course of study, ordered a blood test. Bedell’s blood glucose was 582 milligrams per deciliter—dangerously high, an indication of severe hyperglycemia.

In a nation where nearly 1 in 9 people are diabetic, it wasn’t an exotic lab result, and the recommended treatment was straightforward. According to an administrative complaint Florida’s health department later filed against the NP, he should have admitted Bedell and administered intravenous fluids. Instead he sent the patient home.

Days later, Bedell died of diabetic ketoacidosis. An obituary describes a comics fanatic who loved his family, gardening, and Orlando’s beaches and theme parks. A settlement that included a $750,000 payment from a subsidiary of HCA Healthcare Inc., the nation’s largest hospital chain and owner of Florida Lake City Hospital, prevents his wife from discussing the events that precipitated his death. Neither the health department records nor the insurance filings indicate that a medical doctor ever weighed in on Bedell’s care.

That wasn’t unusual: Busy ERs are constantly triaging, determining where the physicians on duty are most needed. And nurse practitioners have significant responsibility and authority—perhaps more than many patients realize. In important respects, they’re now at the center of health care in the US.

To an extent, this comes down to math: There are already more than 300,000 nurse practitioners, and that figure is rising far faster than the number of doctors. In 2014 there was 1 NP for every 5 physicians and surgeons in the US, according to the Bureau of Labor Statistics. Last year the ratio was 1 to 2.75. The gap is going to shrink further still: Nurse practitioner is the fastest-growing profession in the country, and the ranks are expected to climb 45% by 2032.

After getting an advanced degree—typically a master’s or doctorate in nursing—and an additional license, nurse practitioners are allowed to treat patients in many of the same ways medical doctors do, including diagnosing ailments and prescribing medications. The shift has many benefits. For patients, more clinicians means getting care sooner. (The average wait time for an appointment with a physician is at an all-time high of 26 days.) For health-care organizations, NPs are cheaper to employ than physicians, and under some circumstances the organizations can bill insurers for their time at physician rates. The NPs themselves can get more pay, more prestige and a better work-life balance than registered nurses, which many NPs formerly were. “Millions of patients across the nation choose NPs as their health-care provider because of the exceptional care they deliver in more than 1 billion visits each year,” says Stephen Ferrara, president of the American Association of Nurse Practitioners (AANP). Nurse practitioner, he notes, is the fastest-growing provider specialty submitting claims to Medicare.

But this ongoing change also involves risks. Poorly trained NPs can pose serious dangers. In the worst cases, patients die.

Dozens of nursing students and professors who talked to Bloomberg Businessweek say the problems result from the surging number of programs, which graduate thousands of NPs a year without adequately preparing some of them to care for patients. The former director of the largest NP program in the country says she can’t recall denying acceptance to a single student. More than 600 US schools graduated students with advanced nursing degrees in 2022, according to US Department of Education data. That’s triple the number of medical schools training physicians. More than 39,000 NPs graduated in the 2022 class, according to the AANP, up 50% from 2017.

Unlike the training program for physicians, education for NPs isn’t standardized. Some candidates attend in-person classes at well-regarded teaching hospitals, but a much larger number are educated entirely online, sometimes via recorded lectures that can be years old. Interaction with professors is often limited to emails and message boards. These circumstances make the required clinical portion of an NP’s education even more important—but compared with doctors’ residencies, those stints are brief, and students say they’re of wildly variable quality.

In 2022 the advanced nursing programs that awarded the most degrees were offered by institutions that deliver the classroom portion of instruction primarily over the internet, according to a Businessweek analysis of Department of Education data and information the institutions provided. The AANP says nurse practitioners “are prepared for full practice at the point of graduation and national certification,” but the students themselves appear to be less confident. A 2021 research article published in the Journal of Nursing Regulation noted that in studies of new nurse practitioners, graduates “reported uncertainty in their role, including self-doubt and feeling minimally prepared in caring for patients with complex problems.”

Medical doctors have raised alarms, for reasons that include doubts about the quality of NP education and pique because nurses with doctorate of nursing degrees can call themselves doctors in most states. The AANP has often characterized these concerns as part of a long-running professional turf war and says attempts to limit the role of NPs threaten patient access to care. But nursing students, teachers and nurse practitioners are concerned, too. Some of the NPs who talked to Businessweek say they wouldn’t entrust members of their own families to the care of some of the newly minted nurse practitioners they’ve observed.

Patients have few tools to vet their nurse practitioners. When something goes awry, public disclosure might take a long time or be incomplete, if it comes at all. The publicly available complaint against Dustin Crovo, the NP who treated Fred Bedell, was filed more than two years later, didn’t disclose Crovo’s education history and didn’t even mention that Bedell had died. Businessweek reporters had to pair the filing with insurance records to learn the outcome of the case.

A Florida Lake City Hospital spokesperson said Crovo stopped working at the facility four days after Bedell was treated; citing the settlement, she declined to comment further. Reached by text message, Crovo said that the incident “caused a lot of trauma” but that he’s “moving forward in life just fine.” In its final order on the matter, filed in June 2023, the Florida Department of Health assigned Crovo 16 hours of additional education on critical thinking and patient assessment and allowed him to keep his license.

An RN since 2015, Crovo got his advanced license after receiving a mostly online education from the University of South Alabama, which awarded the fifth-largest number of advanced nursing degrees in the country in 2022. It accepts 96% of applicants and confers more than 800 master’s and doctorates of nursing each year. A spokesperson for the university said privacy laws prevent it from commenting on specific students and didn’t answer questions about the school’s programs. Many of Crovo’s classmates had to visit campus only once, but he’d selected a doctorate of nursing practice with a focus in emergency medicine, which required him to go to campus twice over the course of two years for simulated patient encounters. (The program recently boosted the number of in-person visits to three.) On paper, if not in practice, it was the right degree to prepare him for his job at Florida Lake City Hospital.

Errors, including deadly ones, are committed by clinicians with every sort of license. But medical doctors at least have the assurance of standardized medical education and thousands of hours of training with highly experienced professionals. Those resources aren’t widely available to nurse practitioner students, which can put them at greater risk of failure. According to Florida officials, Crovo had engaged in care for which he wasn’t qualified “by training or experience.” This, even though his education was indistinguishable from that of thousands of other NPs who’ve entered the workforce in recent years.

Nurses are the most trusted professionals in the US, and that trust has largely endured even as Americans have grown wary of other classes of professionals, including teachers and police officers.

Early waves of NP students were often experienced registered nurses seeking to increase their skills and responsibilities. But as demand spiked, more schools began offering “direct entry” programs that accepted students with a bachelor’s degree in unrelated fields. Today the fastest among them can prepare students for NP licensure exams in three years of education that encompasses a bachelor’s in nursing, registered nursing licensing (all NPs have to become RNs, even if they haven’t yet worked in the field) and a master’s in nursing. In 27 states, licensed graduates are allowed to treat patients and prescribe drugs with no physician oversight, even if they have no prior nursing experience. The AANP’s Ferrara notes that, to graduate and pass the national certification board exam, NP students “must demonstrate they have integrated this prior knowledge and skill and do not progress, or graduate, simply based on hours spent in rotation.”

With a separate license from the Drug Enforcement Administration, NPs can also prescribe controlled substances. This license has made NPs particularly attractive to telemedicine companies—in 2022, Businessweek reported that Cerebral Inc., a mental health startup, employed NPs to write scripts for everything from Adderall to Xanax, and that some of them feared the company was overprescribing medications and in some cases feeding addictions. At the time, a spokesperson for the company said, “we strongly believe that we can serve almost all patients who suffer from mental health conditions.” The company later ousted its founder and stopped prescribing controlled substances after it received a grand jury subpoena from federal prosecutors.

Advanced nursing degrees can be general, preparing NPs to work in primary-care offices. Or they can be specialized, in fields including pediatrics, psychiatry, women’s health and emergency medicine, as in Crovo’s case. In these roles, they may face greater chances that they’ll encounter highly complicated or very sick patients.

In one such case, a woman named Tiffaney Dunbar died while on vacation in California in 2018. Her right fallopian tube had turned inside out, causing massive internal bleeding and, in the words of the medical examiner, “catastrophic consequences.” A jury later ruled that the tragedy was avoidable.

About two weeks before her death, Dunbar had been to the Washington Women’s Wellness Center, the busy obstetrics and gynecology clinic where her OB-GYN worked in DC. The doctor had delivered her three healthy babies, whom Dunbar dressed in matching outfits for the holidays. On this day, she was experiencing discomfort, pain and spotting, and was seen by Sarah Belna, a nurse practitioner with both a bachelor’s and a master’s degree from the University of Cincinnati nursing school. (The university advertises the master’s program she attended as “100% online.”) Dunbar learned during the appointment that she was pregnant. In the complaint and in court, a lawyer for her family argued she was not informed that she had an ectopic pregnancy.

A jury found that the center, through Belna, “failed to meet the national standard of care” in the treatment of Dunbar and issued a $17.1 million verdict to the family. The center appealed the decision, noting Dunbar was called twice to return for additional testing, which she agreed to but didn’t do. “Given the patient’s agreement to comply, Nurse Belna saw no reason to frighten Ms. Dunbar with the prospect of dying from an ectopic pregnancy,” lawyers for the health care center said in a filing. Contacted by Businessweek, a spokesperson for the center expressed condolences for the Dunbar family and said Belna provided care that was in the scope of her expertise. Belna referred questions to an attorney, who said Belna felt her education and certification adequately prepared her for her role. The matter was settled before an appeals judge could make a ruling.

Research is still being done on the performance of NPs in the most demanding roles. A working paper, originally published by the National Bureau of Economic Research in 2022 and revised earlier this year, mined more than 1 million patient records from 44 emergency rooms at hospitals in the Veterans Health Administration system. The researchers found that, “on average, NPs use more resources and achieve less favorable patient outcomes than physicians.” For the sickest patients, that includes increasing the chances of a preventable hospitalization and doubling the length of ER stays.

In a statement, the AANP said that the working paper is an “outlier” and that it’s still being peer-reviewed, which the researchers acknowledge is a multiyear process. The AANP referred to several other studies that “reliably establish the safety and excellence of NP care.” Among the studies was one by a researcher in Singapore. That review, which looked at patients across five countries including the US, determined that “the involvement of nurses in advanced practice in emergency and critical care improves the length of stay, time to consultation/treatment, mortality, patient satisfaction, and cost savings.”

In theory, students make up for the limitations of online learning with in-person training during clinical rotations. Students must obtain 500 clinical hours to graduate. That’s less than 5% of the amount required of medical doctors before they can practice medicine, and some nursing educators have called for raising the requirement to 750 hours. (Other nursing groups, including the 45,000-member National League for Nursing, have resisted calls to raise the requirement.) Even those limited hours are largely unregulated. Unlike at medical schools, which pair students with residencies at vetted institutions, most advanced nursing students must find their own clinical teachers, called “preceptors.” Most preceptors are licensed NPs, who may have as little as one year of work experience themselves. But demand is so hot that even preceptors with those credentials are hard to come by, and many demand that students pay out of pocket for their time. Schools, which aren’t required to deeply vet them, frequently do little more than confirm they have an active license with no disciplinary actions against it. In many online programs, there’s little chance a professor will ever see students working with patients in real time during their preceptorships.

With so little oversight, there’s no guarantee that students’ clinical experience will actually prepare them for the workplace. Students are sometimes given too little responsibility—say, helping work the front desk. Or too much—seeing patients on their own.

“This is an environment that is very susceptible to predatory institutions. There’s a lot of money to be made in this space,” says Amanda Choflet, dean of the school of nursing at Northeastern University in Boston, where there are eight students per clinical course and the acute-care program is taught in person. “Sometimes growing really fast in a brand-new modality isn’t the healthiest thing for a profession. And it doesn’t make for a supersafe environment out there in the real world.”

Nobody makes more money educating nurse practitioners than Adtalem Global Education Inc. The publicly traded company, based in Chicago, owns Walden University and Chamberlain University, which together granted more than 8,600 advanced nursing degrees in 2022, or 1 out of 7 awarded that year. Adtalem has expanded this business line quickly: Its advanced nursing programs are now larger than those of the 13 biggest nonprofit programs combined. Adtalem’s revenue, thanks in large part to nursing degrees that can cost $44,370 or more, came to about $1.5 billion in 2023, financed partly by taxpayer-funded federal student loans.

Adtalem isn’t a household name, but its previous moniker, DeVry University, was, thanks to its ubiquitous advertising. DeVry listed on the New York Stock Exchange in 1991, and by 2010 it was a for-profit education juggernaut offering business and technology degrees on campuses in 26 states. But it was plagued by class-action lawsuits and investigations and eventually drew rebukes from government agencies. In 2016 the Federal Trade Commission settled a $100 million suit alleging DeVry’s ads were deceptive, and the Department of Veterans Affairs suspended the school from one of its education programs. Amid the crisis, the company changed its name to Adtalem in 2017 and the next year sold DeVry University, whose enrollment had cratered, for zero dollars.

Adtalem held on to a lesser-known asset, Chamberlain University, which trained thousands of nurses a year. And to fill its DeVry-size hole, Adtalem turned to Walden University, a campus-free online university based in Minneapolis. In announcing the 2021 completion of its $1.5 billion acquisition of Walden, Adtalem touted the school’s ability to address “rapidly growing and unmet demand for healthcare professionals in the U.S.”

Adtalem is run by Stephen Beard, whose strategy emphasizes dominating nursing education in the US. “We fully intend to both defend our leading position in nursing and to grow it,” Beard told attendees at the Morgan Stanley Technology, Media and Telecom Conference in March. “That is very, very important to us.”

Walden and Chamberlain’s programs, with so-called asynchronous courses—students can go at their own pace with a trove of taped lectures and flexible paths to graduation—are especially appealing to students who are already in the workforce and need to balance their education with a job. Educators describe this as the “didactic” portion of a nurse’s instruction. The practical portion of the program—the clinical hours spent shadowing a preceptor—is the final piece.

At the Morgan Stanley conference, Beard told attendees that Adtalem’s size is an asset for clinical training, because “we don’t run into some of the challenges that smaller nursing schools have around preceptors for the last mile of that educational journey. We’ve got an expansive network of opportunities for our students to do their clinical rotations before they move into practice.”

Some of his students disagree.

“That’s absolutely a false statement,” says Raea Thompson, a current Walden student in Tomball, Texas, who served in the US Air Force before becoming an in-flight nurse in helicopter ambulances. “The only thing Walden does is give you an Excel spreadsheet” with precepting locations that other students have used, she says. “They’re not placing you anywhere. They’ll do coaching calls and talk to you about how to approach a potential preceptor. I’m sorry, I’m a grown adult. I know how to talk to them. I need a job.”

In 2019 one student’s complaint about the school’s placement practices reached the email inbox of Linda Steele, then the head of Walden’s nurse practitioner programs. Discussing the student’s concerns on a thread with colleagues, Steele was frank about the potential consequences if the program’s accrediting body, the Commission on Collegiate Nursing Education, found out about Walden’s practices. Walden had to be “very careful because we are responsible for the placement of clinical students even though we do not directly do it,” she wrote. “If word got out of this to CCNE that students are responsible for finding and booking everything we would be in great trouble.”

That email was discovered by two hedge funds that unsuccessfully sought in 2021 to prevent Adtalem from acquiring Walden, which they deemed a bad investment. The funds, Engine Capital LP and Hawk Ridge Capital Management LP, flagged the correspondence to Adtalem, the Education Department and the CCNE. No public actions were taken.

Steele, who ran Walden’s nurse practitioner programs for eight years, says she developed concerns as it grew. Before she left in 2020, the school had more than 15,000 NP students and fewer than 20 full-time faculty, she says, and made up the difference with hundreds of part-time teachers who weren’t always qualified: “Most of the people we hired had never taught before.” She says she was fired after raising concerns about Walden’s failure to mentor and train its part-time teachers.

The minimum undergraduate grade-point average for incoming students was 2.5—not high enough, in Steele’s view, to guarantee all applicants were of high quality. The school became “all about the money,” she says. “I don’t think we ever refused anybody.” Steele worries about the impact Walden’s graduates will have on America’s patients. “People’s lives are in our hands,” she says. “There are more opportunities for error when you have so many students and you don’t have very high requirements.” The school has bestowed more than 30,000 advanced nursing degrees in the past decade, or about 1 out of every 13 awarded, federal data show.

A spokesperson for Adtalem Education, the parent company of Walden University, didn’t directly dispute Steele’s assertions about enrollment and staffing head count. The company “is committed to ensuring students graduate prepared to pass required licensure and certification exams and enter the healthcare workforce,” the spokesperson said in an email.

In an interview, Beard described Steele’s allegations as “old and cold.”

“She’s made these assertions before. They have been examined, they’ve been looked into, and they’ve been determined to not have merit,” Beard said, adding that experiences shared with Businessweek by Adtalem’s students aren’t “representative of what’s happening across the broad range of students that attend our institutions.” Adtalem’s spokesperson said that the accreditation of its advanced nursing programs was renewed after Steele’s email about the CCNE, and that a dedicated team vets preceptors’ licenses, educational backgrounds and professional experience. In an email, CCNE Deputy Executive Director Benjamin Murray declined to answer questions about students’ concerns and Walden’s practices, and he didn’t identify any schools that have been penalized for running afoul of his commission’s preceptor rules. The CCNE expects schools to “support students who are not successful in identifying appropriate clinical sites,” Murray said.

The federal government briefly funded preceptorship programs as part of the Affordable Care Act. From 2012 to 2018, the Centers for Medicare and Medicaid Services spent $176 million to provide “qualified clinical education” for nurse practitioner students, with an emphasis on rural medicine and in-demand specialties such as obstetrics and gynecology. Preceptors were compensated by the program, nursing schools were given resources to recruit clinical placement staff, and hospitals hired additional administrative support teams. These practices mirrored the system that exists for both physician assistants and M.D.s.

An evaluation report of the program deemed it successful and found it increased the likelihood NP graduates would take on jobs in rural and other medically underserved communities. But startup costs drove the price per student to $47,000, and the federal government hasn’t renewed the experiment. Only one of the 19 schools of nursing that participated in the program have continued paying preceptors on behalf of students since the funding dried up.

For students, difficulty finding preceptors often means delayed graduation and a slower path to a higher income to repay their student debt. For the US health-care system, the problem is bigger than that. As students grow desperate to graduate, they end up settling for clinical training that fails to prepare them to successfully treat patients, while often paying for the privilege. “I think those students are being scalped, honestly,” says Ann Kriebel-Gasparro, a Walden faculty member and president of the Gerontological Advanced Practice Nurses Association.

Most students who spoke to Businessweek said their schools could address a significant concern if the institutions shouldered the burden of finding, vetting and paying preceptors. That would be particularly meaningful for direct-entry NP students, who likely never treated patients prior to entering their program and don’t necessarily know what a quality preceptor should look like.

In 2018, Shea Sawyer, a 2016 Walden graduate, initiated a campaign to force schools to place students with preceptors. He briefly thought he’d succeeded. In August of that year, the CCNE changed its rules to say that schools are “responsible for ensuring adequate physical resources and clinical sites.”

The victory turned out to be fleeting, thanks to a gaping loophole. The CCNE told Sawyer that schools can still ask students to find their own preceptors before offering one. In practice, that means students have to prove they’ve attempted dozens or hundreds of cold calls, and asked friends and acquaintances, before the school steps in. In the event they do get offered one, there’s no guarantee it will be in the same state. For students working full time, that’s functionally the same as not being offered one at all.

Lydia Lopez knows a thing or two about nursing education. An RN since the 1990s, she teaches classes on nursing at the University of Mount Saint Vincent in the Bronx borough of New York. When she decided to return to school to become a family nurse practitioner, she was shocked by the lack of support for her clinical hours at Chamberlain. Early last year, after being delayed several semesters because the school didn’t place her with a preceptor and she couldn’t find one herself, she eventually paid $1,995 to a third-party matchmaking service—an increasingly common option—to place her at Mujtaba NP Walk-In Clinic in Clifton, New Jersey.

In many ways, the Mujtaba enterprise illustrates one potential future for a health-care system increasingly reliant on NPs. There are no US-licensed medical doctors, but three Mujtaba family members referred to themselves as “Dr.” on their website until Businessweek inquired about the titles and they were removed. Prior to that inquiry, if consumers were curious what, exactly, the Mujtabas are doctors of, they’d need to know what “DNP” stands for—the words “nurse” and “nursing” appeared nowhere on the site. In addition to treating common ailments such as influenza, rashes and pain, the Mujtabas also offer aesthetic treatments: Botox, “vampire facials” (which involve taking a patient’s blood, separating out the plasma and injecting the plasma back into the patient’s face) and dermal fillers.

Lopez’s preceptor, Assad Mujtaba, graduated from medical school in the Caribbean but isn’t licensed as a physician in the US. He got a business degree, then his NP degree. Lopez says that after showing up early on her first day in January 2023, she was handed a patient chart by a medical assistant. She expected to see patients only with her preceptor present, but she says Mujtaba was nowhere in sight. “What do I do, say no?” she asked herself. She examined the patient. When her preceptor came to the office, Lopez presented her findings from the appointment. Mujtaba’s primary response, she says, was that she needed to spend less time—no more than 15 minutes—with a patient. That made her uncomfortable; she was a student and knew it would take her longer to do a proper assessment.

Asked about Lopez’s experience, Mujtaba said in an email that Lopez, as a nursing leader and educator, “should have been more responsible.” In a subsequent interview he said, “I was telling her ‘I cannot put a patient in there for an hour with a student. They’re going to get pissed off.’”

A medical emergency prevented Lopez from completing her hours that winter. After she recovered, she again signed up with the matchmaker, which again paired her with Mujtaba. With few options available, she accepted the posting. That’s proof, Mujtaba says, that her experience couldn’t have been as bad as described, but Lopez says she was just desperate to graduate. It didn’t matter. Mujtaba didn’t have space for Lopez, so the matchmaker paired her with a Clifton-based physician instead. Lopez googled the doctor. The second hit was a $50,000 settlement for alleged Medicaid fraud. She didn’t take the placement. She still hasn’t done her clinical hours or graduated from an NP program.

If Lopez and Mujtaba don’t see eye to eye about her experience at the New Jersey clinic, they at least agree this system isn’t ideal. Mujtaba, who graduated from Molloy University in New York, says that his classes were in person and that the school paired him with his preceptors. “I still feel like brick-and-mortar is the way to go,” he says.

He could be describing the competitive and highly regarded program at Emory University in Atlanta. The admission rate is 54%, and many students attend classes on campus, with a faculty member for every seven of them. Preceptor placement is rarely a problem: Students get priority on postings at the university hospital. If a student wants to attend remotely and have clinical training near home, 18 full-time staff work on that. The university’s hospital has been pioneering an NP residency program to bolster the skills of early-career NPs, not unlike residencies offered for physicians. And having a campus comes in handy for other reasons, notably a learning facility where students simulate examining patients, delivering babies and other procedures. This comes at a price. Tuition for a master’s in nursing practice runs $77,958—that’s 75% more expensive than Walden. Federal data show that Emory awarded a comparatively small 193 advanced nursing degrees in 2022.

Nurse practitioners who spoke to Businessweek often said they were motivated to talk because their own loved ones had received substandard care from a fellow NP. Korey Houska, an NP in Minnesota, says he became alarmed when an NP in North Dakota made sudden changes to the medicines administered to his mother, who suffers from multiple sclerosis and pulmonary hypertension.

“You could have killed my mom,” he remembers thinking. “Thank God she has me to rely on, but not everybody has that.” Houska says he’d never take on a patient as complicated as his mother. He encouraged her to seek care instead from a medical doctor 40 miles away. His own degree is from Purdue Global, started by Purdue University after it acquired for-profit Kaplan University for $1 in 2018. Houska says that it wasn’t as rigorous as he’d hoped and that he worries about NPs now entering the system. “I personally know of two people who graduated Chamberlain’s online family NP program, who I worked with as bedside nurses, that I wouldn’t have trusted to start an IV on me, let alone be my provider,” Houska says. (“Purdue Global leadership and its School of Nursing leadership feel its nurse practitioner graduates are adequately prepared for advanced practice,” the school’s dean and vice president, Melissa Burdi, said in a written statement.)

John Canion has a similar story. A nurse practitioner based in Texas for almost two decades, he was disturbed when his 74-year-old father fell and went to an urgent-care clinic. The NP who treated him determined that he’d broken several ribs and sent him home. Canion insisted his father go to the emergency room, which he did, only to be seen by another NP, who also sent him home. Three days later his father began feeling worse and returned to the ER, where it was discovered that he’d ruptured his spleen. He then had to be taken by helicopter to a trauma center.

“One day these people are gonna take care of me, and they’ve taken care of my family and not done a good job,” Canion says. “I do see a nurse practitioner myself, but it’s one I know very well. I know their education, I know their training, and I know that they’re very good at what they do.”

In 2018, Canion and a group of like-minded NPs attempted to create a new professional association, which they wanted to call the American College of Clinical Nurse Practitioners. The idea was to focus in part on standardizing and improving NP education. But the AANP threatened the group with a copyright infringement lawsuit, hobbling its momentum, Canion says.

Afterward the AANP formed an education committee and invited him to join it. He did briefly: “I wanted to see if we could change from the inside,” Canion says. That didn’t work either. He stepped down and has since gone on industry podcasts in an attempt to reach an audience.

Some NPs say they fear professional reprisals for voicing their concerns. They often cite Rayne Thoman, a registered nurse who left the nurse practitioner program she was taking part in at D’Youville University in Buffalo and went public with her doubts about it. In 2020 she granted an interview to Physicians for Patient Protection, a group of doctors who’d been raising concerns about NP training. Afterward she was booted from an NP Facebook group. A group administrator described her as someone who “cavorts with our enemies” and exhibits “frightening behavior.”

“I was so naive when I filed those complaints,” Thoman says. “I thought something was going to happen.” She opted not to pursue her NP license; she still works as an RN.

For now, patients have to trust that schools, licensure exams and nursing boards are keeping them safe, even if many nurses doubt they do. “If I was a patient and I knew that my nurse practitioner didn’t have prior experience in nursing, I would ask for a different provider,” says Tracy Sibley, a registered nurse getting her advanced degree from Walden University. “I mean the foundation of a nurse practitioner is nursing, but if you don’t have that foundation, it’s scary to think you can prescribe medications to people just because you got an ‘A’ on a test.” —With Rosa Laura Gerónimo and Anna Kaiser

Methodology

To examine the training of the surging number of nurse practitioners in the US, Bloomberg Businessweek compiled data from the Department of Education’s Integrated Postsecondary Education Data System (IPEDS) on graduate degree completions from 2013 to 2022, the last year of available figures. Such degrees are a prerequisite for applying for an advanced practice registered nursing license, though not all graduates will do so. The analysis focused on 20 nursing instructional program types, including Family Practice Nursing and Adult Health Nursing, to capture the range of coursework that could lead someone to work as a nurse practitioner, nurse anesthetist or nurse midwife. The review omitted master’s and doctorate degrees in nursing administration, nursing education and forensic nursing, because such degrees are less likely to be correlated with people becoming NPs. Uncategorized nursing degrees were also excluded. The IPEDS classification was used to specify whether each institution that awarded these degrees was for-profit, private nonprofit or public. Businessweek then surveyed the 50 institutions that awarded the most advanced nursing degrees in 2022 to determine whether they provided instruction for their advanced nursing degrees primarily online or in person. Businessweek relied on its own research when schools didn’t respond.

Businessweek calculated the ratio of doctors to nurse practitioners in every state and nationally using estimates from the US Bureau of Labor Statistics’ Occupational Employment and Wage Statistics program. Such comparison over time can be challenging, given the government’s changing definitions for professions. Businessweek’s analysis focused on two categories that have been generally stable. The number of doctors corresponds to the broad categories of physicians and surgeons, and the number of nurse practitioners to a single occupation code.