Doctor of Nursing Practice (DNP): My Personal Pro's and Con's

[Corey Narry]

The Doctor of Nursing Practice or DNP degree has been one of the biggest buzzwords in Advanced Practice Nursing. The mere mention of it creates a stir of emotions and strong opposing opinions perhaps of the same magnitude as the liberal versus conservative views prevalent in our current political climate. Unlike nursing buzzwords that come and go depending on what is en vogue at the moment, current Advanced Practice Nurses (APN's) who hold stronger feelings of opposition rather than agreement with the degree would be foolish to ignore the issue. There are strong indicators that support the argument that this degree is here for good.

For one, Advanced Practice Nursing while a smaller subgroup within the larger nursing milieu has shown tremendous ability to self-regulate and adapt to change. Indeed, the speed at which change have occurred in the APN environment is astonishing. The Nurse Practitioner movement, for instance, borne out of an idea in the 1960's, have now blossomed into a membership of more than 180,000 professionals (Pearson Report, 2011). In that period of time, Nurse Practitioner (NP) training completely transitioned to post-licensure nursing programs leading to a certificate to the current graduate degree offerings at the Master's and Doctoral level. The Centers for Medicare and Medicaid Services (CMS) have even kept up with this change and will only grant provider status to NP's who are trained in a graduate degree program.

One can argue that the number of DNP programs have consistently grown in numbers since the first discussion on building a practice doctorate in nursing began in 2002. The American Association of Colleges of Nursing (AACN) lists 139 institutions with DNP programs around the country, roughly 20% of the total number of member institutions totaling 670 (AACN Program List). Twenty percent may seem small but bear in mind that not all AACN member institutions are offering graduate-level programs that have a potential to be transitioned to DNP. Also, the current program list does not include online DNP programs offered by for-profit institutions that have various locations in different states of jurisdiction. My take home message from these data is that while the recommendation for making the DNP a requirement for entry to practice as an APN is farther from becoming a reality by 2015, the pace at which programs are opening up will continue and the degree is here to stay whether we like it or not.

The DNP was just an idea when I finished my training as an Acute Care Nurse Practitioner (ACNP) in 2003. At the time, academic options were clear to me: pursue a Master's degree with my preferred nurse practitioner focus; get certified in the specialty, and voila, I am all set to practice as an ACNP. The option for further academic advancement at the Doctoral level was also very clear: the next step is a PhD or a DNSc both of which have become identical in content. In fact, numerous faculty members encouraged us to consider returning to the halls of the same university (or maybe even another institution) as a PhD student at some point in our career. The idea had a glamorous appeal to it in my mind at the time and I did entertain the thought of following through. Even to this day, I still struggle with the idea and have not come to a conclusion on what the right Doctoral education path to take. What's worse, this whole DNP agenda threw a curveball in my decision-making process.

As an Acute Care Nurse Practitioner since 2004, I have matured and continue to grow professionally in my knowledge and skills as a clinician. I have stayed in the field of Critical Care as an NP since 2005 and have felt this to be my niche early in my career. In my personal quest both for academic advancement and to grow as a healthcare provider, I do not share the sentiments that the ideal MSN to DNP Bridge should be loaded with clinical content by adding so called "residencies". Don't get me wrong, I feel strongly that clinical content could undeniably be improved in the current manifestations of BSN to MSN or BSN to DNP programs for NP's. But I'm being selfish in my personal goals: since I already practice in a heavily patient care-based setting where knowledge and skills already get tested daily, my needs are different. In other words, I do not need a DNP to get a "residency" in Critical Care because I live and breathe in this specialty day in and day out.

DNP courses that deal with leadership, management, the politics of healthcare, and the financial aspect of providing healthcare can be appealing to individuals in my professional level. This is the reason why there already exist multidisciplinary degree options outside of nursing that addressed this content even before the DNP was conceived. I remember a Cardiothoracic Surgeon I knew who went to a prestigious graduate school of business for a Master's degree in Healthcare Administration. The guy had big dreams of being a division chief or a CEO. A nurse manager in one of the units pursued a Master's degree in Nursing Service Administration because she had high hopes of climbing the ladder ultimately as a Chief Nursing Officer one day. Though I consider myself a clinician foremost, a business degree is a must should I decide to pursue a role in administration. That said, I do not think a DNP is necessary if I was to pursue this direction in my career given the other degree options that already exist.

It seems to me like the DNP marketing machine has been trying to convince NP's like me to think that we need a DNP in order to learn from courses that focus on translating research evidence into clinical practice. I find this to be untrue and insulting to currently practicing NP's trained under the Master's degree model who use evidence-based practice in providing care to their patients every day. However, a Capstone Project utilizing Translational Research is a great idea in itself and though such an activity can be accomplished outside of academia, the DNP student who conducts this endeavor is provided with structure and mentoring from experts in any field of inquiry they are interested in. This particular aspect of the DNP convinces me of the value in getting this degree.

The last argument I have been trying to contend with is the DNP's future in terms level of acceptance in academic roles in schools and colleges of nursing. There has not been a straight answer on how universities determine academic ranking for DNP-prepared faculty as this continue to vary depending on the institution. In the years I've been at the bedside as a nurse and as an Advanced Practice Nurse, I have acquired a great deal of past experiences and lessons learned that are worthy of being passed on to new generations of nurses who wish to follow the path I took. A role in the academia, though not attractive at the present given the low earning potential, is inevitable in my future. However, I seek assurance that the degree I pursue is held at the highest regard in terms of advancement in the field of nursing education. It is still tempting to forego the DNP for the much respected PhD in Nursing.

[suetje]

@traumaRus- yes I am called an educator. Fine. The 'pseudo CNS' means I do that job as well as educator because we have no CNS and it dovetals into the whole mentor educator role. I suggesated to the Director I could be called something other than CNS, su7ch as you suggest, but she also can'yt think out of the box.

[myelin]

Hey juan de la cruz, I noticed in another thread you had mentioned that UCSF was going to have another meeting about the DNP. Did you attend it? I'm wondering how that meeting went and if they're moving in the direction of starting a DNP program...

[Corey Narry, MSN, RN, NP]

I didn't go to the meeting as I was working. I don't know anyone who did but I can ask for the meeting minutes.

[OneDNP]

I have a few comments on the original thread and some of the replies.

Everyone does understand that the "should I get a DNP" question only pertains to those who are already NPs in clinical practice or NP students, right? In the next few years, this question will be moot because the MSN-NP degree is being phased out. Just as with the Bachelors of Medicine in the late 1800s to as recently as the Master's of Pharmacy in the 1990s, the profession is simply replacing one degree for another that contains a few more requirements. The DNP is also an attempt to streamline the current hodge-podge of clinical nursing doctorate titles. In most cases, this means instead of taking 2 years to get an MSN that allows you to sit for whatever board exam you are studying for, it will take 3 years plus a few hundred clinical hours and a capstone project instead. Is it degree creep? Yes. But it is a trend most other health professions have been changing over to in the past few decades and nursing, as usual, is just one of the last to join the party.

Judging by PTs, pharmacists, and psychologists I know who were grandfathered in prior to their professions making a doctorate the minimum entry to practice, it is unlikely the DNP will make a difference to reimbursement or opportunity over the next decade or so, if ever. I have APRN and CNS friends who have been practicing for a number of years with no good reason to get the DNP unless they want to double-board in another specialty. I was FNP certified and used the DNP to get my PMH certification from a school with the second oldest DNP programs in the country and one of the first to offer the soon-to-be standard BSN-DNP programs. Yes, there are poorly organized, money-grubbing programs that have been slapped together to meet the 2015 deadline, but I can name at least 3-ADN "franchise" schools that are not fully accredited yet churn out LPNs and RNs at a high profit with marginal education. You have to do your research and talk to current students and graduates of the program you are looking at, no matter what the discipline. But more importantly, you have to know what you want out of your career and lifestyle as a whole. There are a lot of things you can do with an RN besides become an APRN, and many of them are more lucrative with a lot less risk - this is why a couple of years of practice is invaluable before jumping into more school.

If you want to be a clinical practitioner, possibly teach clinical at the undergraduate level or precept at the graduate level, and think you might be interested in conducting small-scale EBP research and evaluative projects you can be directly involved with, the DNP in your area of specialty is where you should look. This is why the DNP is considered the terminal CLINICAL PRACTICE degree for nursing. If your goal is providing education at the university level or conducting larger grant-funded research projects with a lot of publications, why the heck would you want to be an advanced practice provider in the first place? Of course, interests change as life goes on, but if you already know at the RN-level that you want to be the next great theorist, basic RN practice should provide all the clinical necessary for real-world experience before moving onto the PhD or EdD. If you want to focus on nursing management and administration, well, get a law degree.

I say that only slightly in jest.

On the matter of MD training hours: Medical school applicants are not required to have a single hour of clinical practice before entering their program and generally do not touch a living patient until their second year of schooling when they are around age 24. The person with a BSN degree of the same age who applies to an NP program would have already had 4000 hours (assuming a 36-40 hour work week) of independent, basic nursing practice in addition to the undergraduate clinical training with patients that they started around age 19. True, the RN-level practice is not as independent as those providers with advanced degrees, but the core skills of assessment, organization, interpersonal dynamics, experiential knowledge base, and holistic care management are developed and refined. This "basic practice" is the foundation for advanced practice, and to ignore these hours when comparing training programs is neglectful and manipulative from those who try to belittle our profession. I would further argue, and the satisfaction and outcome research bears this out, that when it comes to primary care, the cost of medical training and drain on medicare to fund primary care residencies is neither cost-effective or efficient. The problem is not that NPs have fewer hours of training than MDs, the problem is perpetuating the belief that one actually needs 10000 hours of school to deliver quality primary care. This is an oversimplification, but I liken it to taking beginning Spanish over and over when you are already fluent in 2 dialects. How much education do you really need to deliver quality primary care? There is a capstone project for you!

On PA doctorates and such: It is my understanding that the PAs were created as the MDs' answer to NPs, though certainly the role has changed over time. I think PAs have a huge semantic hurdle to overcome given that it contains "physician" and "assistant" in the title. I suppose the discussed replacement of "physician associate" is a little better, but that still sounds far more handmaiden-like than nurse practitioner. Then again, when I tell people I am a nurse practitioner, I still get some folks asking me if I plan to get my RN. I have enough trouble in my own profession without taking on their concerns, but one thing I will speak out on is the occasionally proposed (by MDs, usually) merging of PAs and NPs into a single MLP or physician-extender title. No thanks.

On the DNP experience: I graduated in May and kept a blog of my journey to the "Dr. Nurse." One of the running jokes I heard when I talked about pursuing a doctorate in nursing was the old "there can't be that may ways to change a bandage," however I was enriched in ways I did not expect and it translates to how I care for patients.

[Corey Narry, MSN, RN, NP]

OneDNP said:

Everyone does understand that the "should I get a DNP" question only pertains to those who are already NPs in clinical practice or NP students, right? In the next few years, this question will be moot because the MSN-NP degree is being phased out. Just as with the Bachelors of Medicine in the late 1800s to as recently as the Master's of Pharmacy in the 1990s, the profession is simply replacing one degree for another that contains a few more requirements. The DNP is also an attempt to streamline the current hodge-podge of clinical nursing doctorate titles. In most cases, this means instead of taking 2 years to get an MSN that allows you to sit for whatever board exam you are studying for, it will take 3 years plus a few hundred clinical hours and a capstone project instead. Is it degree creep? Yes. But it is a trend most other health professions have been changing over to in the past few decades and nursing, as usual, is just one of the last to join the party.

The DNP does not only pertain to those who are already NP's and NP students. There are DNP programs offered to those with a nursing administration or nursing education focus not to mention the fact that other APN groups have DNP programs too (CRNA, CNS, CNM). The MSN is not being phased out. Many schools are adopting a BSN to DNP format but that decision is voluntary on the school's part. There is no mandatory requirement to transition to all DNP by 2015. For that to happen, four things must be in place: 1. all schools have to offer a DNP, 2. NCSBN participating boards of nursing must require a DNP, 3. national certification boards (ANCC, AANP, AACN, PNCB, NCC) must require a DNP, and 4. CMS must require a DNP to obtain an NPI number. AACN and NONPF are recommending the 2015 deadline, both these entities have nothing to do with NP regulation.

OneDNP said:

If you want to be a clinical practitioner, possibly teach clinical at the undergraduate level or precept at the graduate level, and think you might be interested in conducting small-scale EBP research and evaluative projects you can be directly involved with, the DNP in your area of specialty is where you should look. This is why the DNP is considered the terminal CLINICAL PRACTICE degree for nursing. If your goal is providing education at the university level or conducting larger grant-funded research projects with a lot of publications, why the heck would you want to be an advanced practice provider in the first place? Of course, interests change as life goes on, but if you already know at the RN-level that you want to be the next great theorist, basic RN practice should provide all the clinical necessary for real-world experience before moving onto the PhD or EdD. If you want to focus on nursing management and administration, well, get a law degree.

The issue I raised with academia is the fact that some schools do not grant tenure to DNP trained faculty. Sure, if all you want is to teach undergrad and NP labs in a university setting and go contract to contract each academic year that's good for you. I prefer the same level of respect as other Associate/Assistant/Full Professor with PhD's. If that's not going to happen I am not sure I want this degree. NP preceptors are volunteer faculty - they receive no salary from the schools. Why would you need a law degree for nursing management and administration?

OneDNP said:

On the matter of MD training hours: Medical school applicants are not required to have a single hour of clinical practice before entering their program and generally do not touch a living patient until their second year of schooling when they are around age 24. The person with a BSN degree of the same age who applies to an NP Program would have already had 4000 hours (assuming a 36-40 hour work week) of independent, basic nursing practice in addition to the undergraduate clinical training with patients that they started around age 19. True, the RN-level practice is not as independent as those providers with advanced degrees, but the core skills of assessment, organization, interpersonal dynamics, experiential knowledge base, and holistic care management are developed and refined. This "basic practice" is the foundation for advanced practice, and to ignore these hours when comparing training programs is neglectful and manipulative from those who try to belittle our profession. I would further argue, and the satisfaction and outcome research bears this out, that when it comes to primary care, the cost of medical training and drain on medicare to fund primary care residencies is neither cost-effective or efficient. The problem is not that NPs have fewer hours of training than MDs, the problem is perpetuating the belief that one actually needs 10000 hours of school to deliver quality primary care. This is an oversimplification, but I liken it to taking beginning Spanish over and over when you are already fluent in 2 dialects. How much education do you really need to deliver quality primary care? There is a capstone project for you!

I am not going to touch those statements.

OneDNP said:

On PA doctorates and such: It is my understanding that the PAs were created as the MDs' answer to NPs, though certainly the role has changed over time. I think PAs have a huge semantic hurdle to overcome given that it contains "physician" and "assistant" in the title. I suppose the discussed replacement of "physician associate" is a little better, but that still sounds far more handmaiden-like than nurse practitioner. Then again, when I tell people I am a nurse practitioner, I still get some folks asking me if I plan to get my RN. I have enough trouble in my own profession without taking on their concerns, but one thing I will speak out on is the occasionally proposed (by MDs, usually) merging of PAs and NPs into a single MLP or physician-extender title. No thanks.

Never heard of a proposal to merge the NP and PA professions and again I'm not going to touch those other statements too

[myelin]

NPs and PAs will never merge. Unless the PAs want to become nurses, lol. BON and BOM are two entirely separate entities, and honestly, the fact that NPs are overseen by the BON (and not the BOM) is what confers them a huge advantage.

[SycamoreGuy]

"I prefer the same level of respect as other Associate/Assistant/Full Professor with PhD's. If that's not going to happen I am not sure I want this degree."

That really depends on the school, I know of a state school that has a DNP (without a PhD) as the program director of graduate nursing.

[Corey Narry, MSN, RN, NP]

SycamoreStudent said:

"I prefer the same level of respect as other Associate/Assistant/Full Professor with PhD's. If that's not going to happen I am not sure I want this degree."

That really depends on the school, I know of a state school that has a DNP (without a PhD) as the program director of graduate nursing.

Being program director does not guarantee tenure...the schools I've looked at (and are interested in teaching at if I ever do it), have two separate faculty rankings: clinical track and research, only research faculty gets tenure.

I know that's how academia work. I am an NP in a medical center where our attendings are Professors in the School of Medicine. About half of their activities involve research/publishing and the other half is clinical practice. They all have MD degrees, not all have MD, PhD.

[zoidberg, BSN, RN]

juan de la cruz said:

I am not going to touch those statements.

Good for you, I admire your restraint.

No one wants to merge PA's and NP's. Maybe streamline how they both operate, and bring their scope up to full in areas where one is noticeably more free to practice fully, but its not exactly possible to make them the same thing.

[mmrb]

Excellent summary of the pros and cons of the DNP degree, I agree on your astute observations. As a former clinical faculty member of a prestigious School of Nursing, I was told that the DNP degree would not be considered a "tenure" degree. So, if my purposes of pursuing an advanced degree were for teaching, why would I pursue a DNP vs. a PhD for academic advancement? Not only that, but I believe the nursing profession needs more PhD prepared nurses for the future.

As for the DNP being the entry level for the nurse practitioner, this is the point of contention that has caused so much negative backlash against the DNP, in my opinion. I think it's fine to have the DNP as an educational option for nurses. There is absolutely no way that the individual states are going to require this for NP licensing. There is NO evidence to support that a DNP changes anything about the ability for the NP to perform at the highest level to practice within the current prescribed role. Hospitals will also not alter their pay structures for a "degree. Instead, they will alter their pay structure for a defined job. So, if you have a DNP and may be possibly better prepared to take on the job of say, an Advanced Practice Director, then it may well be beneficial. But if you're up for an NP position and someone has a master's degree and 10 more years experience than you, I don't think it will get you anywhere.

Furthermore, until our profession can agree on the BSN as the ENTRY level for practice, we should stay away from meaningless mandates that were meant to increase enrollment in universities who could not attract enough PhD candidates, and therefore wanted the DNP to be the required level of entry for NPs!!!

[priorities2]

mmrb said:

As for the DNP being the entry level for the nurse practitioner, this is the point of contention that has caused so much negative backlash against the DNP, in my opinion. I think it's fine to have the DNP as an educational option for nurses. There is absolutely no way that the individual states are going to require this for NP licensing. There is NO evidence to support that a DNP changes anything about the ability for the NP to perform at the highest level to practice within the current prescribed role. Hospitals will also not alter their pay structures for a "degree. Instead, they will alter their pay structure for a defined job. So, if you have a DNP and may be possibly better prepared to take on the job of say, an Advanced Practice Director, then it may well be beneficial. But if you're up for an NP position and someone has a master's degree and 10 more years experience than you, I don't think it will get you anywhere.

Mmrb, I really like your point! I've heard too that nurse practitioners have been more than adequately prepared at the masters level. But it makes me wonder: How did other health professions end up starting as bachelor's or associate's-prepared field and move up the line to doctorates - like physical therapy and others? Were there other circumstances in those instances of degree inflation that aren't present in the case of the DNP?

[Will352nd]

OneDNP said:

I have a few comments on the original thread and some of the replies.

On PA doctorates and such: It is my understanding that the PAs were created as the MDs' answer to NPs, though certainly the role has changed over time. I think PAs have a huge semantic hurdle to overcome given that it contains "physician" and "assistant" in the title. I suppose the discussed replacement of "physician associate" is a little better, but that still sounds far more handmaiden-like than nurse practitioner. Then again, when I tell people I am a nurse practitioner, I still get some folks asking me if I plan to get my RN. I have enough trouble in my own profession without taking on their concerns, but one thing I will speak out on is the occasionally proposed (by MDs, usually) merging of PAs and NPs into a single MLP or physician-extender title. No thanks.

Not quite right. PA's were one of the answers to primary care shortage in 60's. It had nothing to do with "the MD's answer to NP's". The PA model was never to indended to just be an "assistent" to the physician. The role was, and is, to extend healthcare while working with the supervision of a physician. Supervision is defined as "available for consult/advise"....not "under the thumb" as frequently suggested/implied on this site. Most States have done away with the archaic chart co-signature rules and the Physician doesn't have to be in the same building...just available. Sounds a lot like collaboration doesn't it? The "assistant" title has been the bane of the PA since it's onset...it is what it is.

The first NP Program (what we recognize as an NP today) was developed in 1965 at the University of Colorado. Dr. Eugene Stead tried to implement his PA model using nurses in 1964, but he was disillusioned by the by the push-back he was getting from the organized nursing organizations at the time. He went with military medics with his first PA class in 1965 instead. The value of nursing was recognized, but it was the decision of the NURSING organizations not to go with Steads model as opposed to Stead answering to the NP model tit for tat. Sources: Physician Assistant History Society and AANP - Historical Timeline

NP's have it pretty good in regards to practice laws...and good on them. But it has little to do with being "better" or being more "competent", and everything to do with having a better lobby that is independent of the BOM. I know you didn't imply this and it is not an accusation, but it is "implied" quite a bit throughout the NP community.

IMO, there will never be a merging of PA and NP. Most PA's were not nurses so it would make it difficult for them to practice "advanced nursing". NP's were not trained in the medical model and would have to build a stronger base in the core sciences to meet the curriculum of a PA program. Different approaches for the same goal...treat the patient.

Just some thoughts from a guy who considered NP and PA and went with the PA model.