The "3 Ps" — pathophysiology, pharmacology, and physical assessment — are the core courses in every nurse practitioner education program. They form the foundation for competencies that are essential to advanced practice nursing, which means academic programs are responsible for determining whether NP students master 3P course content.

The challenge: Building the foundation for nurse practitioner practice

Multiple organizations, including the American Association of Colleges of Nursing (AACN) and the National Organization of Nurse Practitioner Faculties (NONPF), have published standards that emphasize the need for competency in the 3Ps. The AACN issued competency requirements in The Essentials: Core Competencies for Professional Nursing Education, and NONPF has published a draft implementation guide to assist faculty in meeting them.

“What the AACN Essentials and the NONPF competencies are telling NP programs is to make sure that their resources and their didactic program all focus on providing knowledge that enables students to build a strong foundation that assures preceptors receive better prepared students,” said Betty Vicknair, MSN, APRN, PNP, the Faculty Consultant and Integration Specialist for APEA.

In the Essentials, Domain 1.3g states that NP students must “demonstrate clinical judgment to inform and improve NP practice based on the foundational knowledge of advanced pathophysiology, advanced health assessment and advanced pharmacology.”

“These are their core behaviors,” Vicknair explained. “It means making sure that students can distinguish between normal and abnormal disease entities, analyze their interventions, and then express a good comprehension of that pathophysiology.”

This foundational knowledge enables students to make appropriate and safe decisions when they reach the clinical portion of their program.

"If they don't understand the pathophysiology of diabetes, they're not going to understand what they need to assess or what diagnostics to order when they see a patient with diabetes in clinicals," said Kathy Baldridge, DNP, FNP-BC, FAANP, the Lead Nurse Practitioner Education Specialist for APEA. “… Students can’t critically think or clinically judge in the clinical setting if they don’t have a solid foundation of knowledge.”

To build the 3P foundation — and the ability to pass a national certification exam and enter practice — faculty require effective, psychometrically sound resources. APEA develops innovative learning and assessment solutions to help meet this need.

A new way to assess 3P knowledge: Clinical Case Studies

In September 2024, APEA introduced the first and only resource that assesses an NP student’s ability to apply 3P knowledge within a patient experience. APEA Clinical Case Studies is a library of virtual case studies covering eight body systems and a variety of patient presentations. It prompts students to synthesize advanced assessment and advanced pathophysiology knowledge and apply it to develop and prioritize a differential diagnosis list and order diagnostic tests.

Clinical Case Studies provides students with exposure to clinical situations via realistic patient visits. Each case begins with the primary concern (chief complaint) and ends with the student making a diagnosis. Working through the case studies allows students to practice and apply their knowledge of pathophysiology and physical assessment.

“Clinical Case Studies addresses the first two domains of the nursing process, assessment and diagnosis,” Dr. Baldridge said. “This is the foundational knowledge they will build on to learn how to develop an appropriate plan of care and evaluate the expected course and potential complications of a disease process.”

At the start of each case presentation in Clinical Case Studies, students receive details on the patient’s:

• chief complaint
• past medical history
• surgical history
• family and social history
• review of systems
• physical findings.

The student uses this information to develop a differential diagnosis list, prioritize the list, order diagnostic testing, evaluate the results, and develop a working diagnosis. After completing each case study, the student sees a summary of their responses and learns whether the responses are correct or incorrect. They also see a rationale for each answer choice.

The initial release of Clinical Case Studies features 50 primary care cases that address the assessment and diagnosis domains; more are in development. In the future, additional case studies will address the domains of planning and implementation and evaluation. These additions will assess critical thinking in the later stages of an NP academic program.

Clinical Case Studies can be used in multiple ways to measure competency

Vicknair, who consults with nurse practitioner programs throughout the country, said Clinical Case Studies provides faculty with a resource to develop analytical and decision-making skills that increase student confidence and competency prior to precepting experiences. “It also reinforces the application of evidence-based practice and helps faculty measure student learning outcomes,” she said.

One of the most common ways to incorporate Clinical Case Studies is to assign cases that align with lecture topics. This enhances didactic presentations and provides faculty with clear feedback on the comprehension of content, Vicknair said. Additional strategies include:

• independent learning
• classroom discussion
• remediation
• preparation for precepting experiences
• exposure to diagnoses not seen in clinicals.

As students work through assignments in Clinical Case Studies, faculty can consult APEA’s reporting dashboard for detailed data on usage and performance. The insights generated by this data help faculty identify the strengths and weaknesses of individual students as well as the cohort.

Using formative and summative assessments to build 3P mastery

Another core strategy to determine 3P competence is the use of formative and summative assessments to measure knowledge. Essentials Domain 1.3g recognizes these assessment types as exemplars for determining competency.

The APEA 3P Competency Exam and APEA MyQBank practice questions are tailored to measure and enhance student knowledge and competencies in the 3Ps, Vicknair said. The 3P Competency Exam is a 90-question test (75 scored items, 15 pretest) that evaluates 3P knowledge, and MyQBank practice questions build 3P knowledge by reinforcing classroom instruction through rationales that focus on concepts and content.

“The 3P Competency Exam is a comprehensive measure that can be utilized as a diagnostic tool to assess baseline knowledge or used as a progression tool to evaluate readiness for clinical settings,” Vicknair said. “MyQBank provides practice questions with detailed rationales that help students correlate didactic instruction with critical thinking and clinical judgment.”

MyQBank contains 2,400 questions focused on the 3Ps — 800 in pathophysiology, 800 in pharmacology, and 800 in physical assessment. All questions provide detailed rationales.

Vicknair recommends that faculty use MyQBank proactively by assigning students to work in the question bank associated with each course. Faculty can see whether students completed the assignments, and how they performed on them, in the APEA faculty dashboard. Another option is to use MyQBank reactively. In this approach, faculty use the question banks as a remediation tool after administering the comprehensive 3P Exam.

“Using the proactive approach, the remediation need is not going to be as great, because students will have achieved critical thinking and clinical reasoning skills,” Vicknair noted.

How a firm 3P foundation predicts certification success

Providing students a strong foundation in the 3Ps is a teaching outcome with far-reaching benefits. Beyond ensuring that students possess the knowledge necessary to enter clinicals and providing program adherence to national standards, strong 3P knowledge is directly linked to certification success.

A recent analysis by psychometricians at ATI Nursing Education (APEA is an ATI brand) determined that higher scores on the APEA 3P Exam correlate with higher scores on the APEA Predictor Exam for FNPs and AGPCNPs. Therefore, a higher score on the 3P Exam predicts success on these certification exams.

“We now know that the 3P Exam is predictive,” Dr. Baldridge said. “This means that if a student’s 3P Exam score is 68 — the benchmark — they're more likely to score 70 or better on the Predictor Exam.” Data gathered in post-testing research show that students who score 70 or higher on the Predictor Exam are likely to pass their certification exam, she said.

The psychometric analysis identified additional key information about contributors to success on the Predictor Exam and the certification exam:

• Proctoring students during the 3P Exam and/or the Predictor Exam makes a difference in scores. For example, students who weren’t proctored during the 3P Exam had artificially high scores, as borne out by their poorer performance on the Predictor Exam, Dr. Baldridge said.

• Students whose faculty assigned practice questions in MyQBank performed better on the Predictor Exam. “Have them show you that they've completed the number of questions you assigned, because that's where learning is going to occur,” Dr. Baldridge advised.

• Students who self-reported higher effort in preparing for the Predictor Exam had higher scores. Because the Predictor Exam was created using the certification exam blueprints and the NONPF Competencies as a guide, Vicknair recommends reviewing those documents. And, importantly, “Focus on studying topics that you know are weak areas. Find reliable resources that offer practice questions with rationales and concentrate on understanding these rationales to improve your knowledge, critical thinking, and clinical reasoning and judgment,” Vicknair said.

• Students who used APEA study resources, such as MyQBank study questions and Clinical Guidelines in Primary Care, had higher scores on their Predictor Exams. “Competency-based education relies on adult learning principles, which means students must constantly evaluate what they know and where they need to focus remediation,” Dr. Baldridge said. “Using MyQBank question banks in Exam mode can identify knowledge gaps in preparation for the Predictor Exam. And when they are unsure about an answer, students should fill those knowledge gaps by consulting evidence-based resources such as Clinical Guidelines in Primary Care.”

For more information on resources to help faculty develop and determine competency in the 3Ps, email Robert.Zender@ascendlearning.com or visit the Faculty Resource Center.

---