Is Mandatory DNP by 2015 a Done Deal?

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RNcarlo

6 Posts

As someone who is looking into grad school and researching this topic, I am finding that most schools are pushing the DNP option because it translates as more $$$ to them. However, when researching job availabilities, I have found 0 job postings requiring a DNP. So, I think it is safe to assume that you can go with the MSN NP route for now and once this whole DNP dust settles, if it is a requirement, we'll all have to move towards this pursuit.

unplannedRN

20 Posts

It is true that nurses commonly function at a level other disciplines do only with higher degrees. In other words, a Critical Care ASN, let alone a BSN, both do work that a Bachelor's-degreed person in another field wouldn't be allowed to touch. This means that while doing their actual jobs, often they rub elbows at the higher levels of practice/education/research with other disciplines carrying higher credentials, and despite their knowledge level, therefore have lower status in a degree-besotted medical community.

What isn't acknowledged is how much of the post-graduation experiential learning takes place in nursing and other medical fields, and therefore how much is learned after the initial credential....this is just not true of dentistry, PT or other fields where the experience matters, but does not triple the knowledge level in just a few years. The only parallels are in disciplines which have similarly wide areas of clinical focus, such as medicine itself and, perhaps, a paramedic working in the city. You have to “see it all and do it all”, with a very wide scope.

The difference in doctors and nurse or PA training is that the doctors do those 10,000 hours before graduation, and the nurses and PAs do them on the job, earning about what the medical student does in his/her stipend, though the nurse gets paid by an employer. (Well, actually, the PA who is not a hospitalist will not be gaining those “see it all” hours in primary care; those you see in the acute care environment. But that’s another topic.)

Please understand, I am not comparing nursing and medicine as being the same discipline; on the contrary, I feel strongly that they are very different disciplines except in hospitalist work, where the philosophy and perspective are different, but the body of knowledge and experience demanded is quite similar. In most of AP Nursing, it is a different type of practice altogether, with only a bit more overlap than, say, a chiropractor has with medicine. Market forces cause most APNs to assume demi-doctor roles too often, and put too little emphasis on holistic care, patient educations, etc.

Anyway:

What is also often ignored is the fact that the average MSN program is considerably longer than a Master's degree in many other fields, and often requires the nurse to have 2 years of post-licensure practice before even applying to an NP program. Thus you have a BSN + 2 years of additional paid on-the-job training (4000 hours), plus 2.5 average years of post-grad education, plus the minimum 500-600 supervised hours. So the graduate has the undergrad clinical hours, plus 4000 basic RN practice hours, plus 550-700 supervised APN hours, or close to 6000 in all.

Of course, some have many more years of nursing practice in several different areas, such as dialysis, or oncology....each representing quite a residency. Even though those do not include the APN perspective, the amount of useable experience about the workings and behavior of sick bodies and minds and families under stress is huge—and irreplaceable. (In contrast, other primary-care disciplines such as medicine LEAVE that intensity after graduation, not go there for the start of, let alone the rest of, their careers. Which may be why some can honestly say, “I’ve forgotten more than you’ll ever know.” Precisely.)

Furthermore, what makes the internship/residency so valuable, whether paid or not, is that it DOES take place after the basic framework of knowledge is present upon which to build. New experiences strengthen and add to what has already been learned, and make it easier to comprehend future novel experiences. That exponential growth type of learning happens faster every year, and that is why entering a graduate program with a few years of nursing experience makes for much more learning in the same 600 hours than for the students who don't have it. (An one legitimate reason why experienced nurses rightfully scorn highly-educated nurses who don’t recognize that, or whom have never worked in acute care.)

But the bottom line is you have: BSN + 2 yrs experience, + 2.5-3 years for the MSN=8.5-9 years for the APRN, plus—what? another 2 or more years for the DNP?

What this means is that the MSN was ALREADY devoting the time and the money to be considered well-educated practitioners...but without the "scholarly" and research additional focus, and training or didactic /formal additional clinical training. This left them handicapped and disrespected....but having spent as much time, effort and funds on their “just a Masters" degrees as doctorates have in many other disciplines.

Now, how does that resemble the Associate-degreed nurse doing critical care, back in the days when "mandatory BSN" was coming? Yep—the problem is not primarily that nurses are under-educated....it’s a very sexist problem: The nurses educations are mislabeled, under-RATED, and under-RECOGNIZED.

Consider how little education a medical doctor has in research and evaluation of EB medicine. Far less than does a student of psychology, for example. Do we look down on them because they are not dually-degreed PhD/MDs? No, they learn that in practitioner-update seminars after they enter practice—but we instantly cower in shame and hurry to make amends, if we as APNs are scorned because we also lack that focus in our degree plan.

So the “old school” APN is lacking in well-roundedness when it comes to understanding EBP? The MSN programs need to dump some (not add on even more with the DNP) of the extensive repetition of 4th-year- BSN courses about public policy, health care legislation, administration, reimbursement...and make the DNP a clinical degree—albeit one with lots of ability to evaluate and add to the fund of EBP knowledge. What’s so hard about that? Are we training lobbyists, administrators, researchers-- or clinicians? Aren’t those other roles why we have the other MSNs and PhDs?

Yes, make the MSN the door to “clinical leader”, and the fork in the road t research, clinical practice, administrator, or policy activist—the doctoral roles. Grandfather the previously-educated ones not just out of necessity and fairness or even generosity, but because they learned on the job what will be spoonfed to incoming generations, as is often the case in a rapidly-developing field. (Honor pioneers, don’t scorn them as old-school! Duh: They are why the role exists!) That’s not what is happening, though.

What do we do? Instead of reworking/renaming and improving what we have, we hurry to stuff it with even more (now officially doctoral-level) “filler” courses—about 3 year’s worth, actually-- that don’t add clinical knowledge or much discernment for EBP development, but do add “education units” and money and time to the “new APN” DNP degree. Those filler courses—looking like just what they are-- also make us look foolish and lacking in self-respect, when the intent is just the opposite. They make us look stupid, in that when we feel under-educated for a role we already play, our solution is to dash out and add useless NON-clinical filler, and hit our pioneering and hopeful APRNs over the head with the new “standards” and accompanying costs.

No, nursing should long ago have made the basic APRN entry degree a DNP, but before they padded the MSN with so much time and money!

Now, in order to simply recognize the expertise the APRN has, and credential nurses accordingly, we won’t just correct the APRN educational programs to include the necessary extra foci of research, etc. Nor will the 1 or 2-year pre-grad school practice recommendation be incorporated instead as part of the formal degree plan, as it perhaps should be. Instead, a correction will mean adding even more time and money. No 8-year doctorate for nursing! It’s 9-10 years or bust for us—Never mind we’ll never be able to pay off the loans, given what APNs make in most places.

The DNP should not pile on top of the existing MSN practitioner programs; it really SHOULD replace them for clinical practice areas. The "grandfathering" that is needed is simple recognition that current APNs with MSNs already have the DNP, minus (in some but certainly not all cases) some catch-up knowledge in the areas of research, EBP evaluations, etc.

It should not add more bloat and administrative/philosophical/nursing theoretical “filler” to an already bloated Master’s program, and worst of all, offer very little increased CLINICAL expertise! No wonder other professions sometimes make fun of nursing’s scramble to attain equality; it’s too obvious, and it shows poor self-image. Ironically, this is just what the “new consensus model” is supposed to fix. We’re visibly “trying too hard” instead of demanding recognition for what we already are asked to do—and do quite competently, thank you!—as we always have at the ASN, BSN, and MSN—and yes, LPN-- levels. To be fair, we must say that many an LPN knows more on some medical and psychiatric topics than does many a practitioner of other disciplines with BS and MD degrees. I know; I’ve worked with them!

What is needed during the transition is a post-APN DNP "bridge", not a 5-year DNP for BSNs, nor a 2-3 year DNP on top of the 6-7 (including those 2 RN practice years) already demanded!

You just won't get nurses to spend 12-plus years and 140 k on educations earning 80-90k, doing whatever the AMA wants to allow them to do (i.e.; the high-volume, low-knowledge, boring but bread-and-butter essential “leftovers” in medical care), while skimming off 75% of their earnings, and complaining that NPs are shamefully under-educated MD-wannabees! We need an eight-year (top to bottom) Advanced-Practice doctoral program.... and stronger education for the public about what is medicine and what isn't.

(You younger nurses may not know that in the 1950's only doctors drew blood, started IVs, inserted tubes in any orifice, etc. Now, of course, LPNs do those things, and technicians, too. Likewise, its a ridiculous red herring to refer to primary care by APRNs as medicine-only territory, or to claim that RNs who do advanced nursing, AND can provide those very basic services along with the more important work of education etc, (i.e. nursing!) are trying to be demi-doctors. )

It's an insult to the intelligence of the public and the practitioner. Adding the DNP on as just extra money and hours or "term papers due" (whether as a 2nd post-grad degree, or a straight-shot from the BSN) instead of reworking the current programs to a more reasonable time frame and cost, is a mistake. Instead of boosting the APRN up to a higher level of prestige and recognition more in line with what he/she actually does, it's reaching down from the Ivory Tower to yank her up by the collar, "Get your act together! Can't you see that little old MSN is demeaning us real nursing scholars?!"

unplannedRN

20 Posts

I should clarify (re primary care) by "education" I meant patient (not nursing student) education, a much more important function of "real nursing" than dispensing antibiotics for a sore throat, although that is important, too. It's just that it is no more invasion of "exclusively medical doctor territory" to provide basic medical diagnostics and treatment that it was for the first nurses who inserted an NG tube back in the 60s.

Much of what made such care primary care activities as diagnosing anemia or strep throat or diabetes "medicine" is now done by other departments and software anyway. (How do you know you have anemia? The automated blood cell counter says so!)

Ironically, the hands-on provider such as a the APN who can't prescribe tests as quickly and easily gains diagnostic skill and intuition by having to examine, listen, and think more deeply before automatically ordering a bunch of tests, and so may be a better and more cost-effective diagnostician than someone who has been trained to run the gamut, mainly for liability reasons. But nurses who will do these basic formerly-medical services can still be more nurses than doctors, equally qualified, but in a different field, that just overlaps enough to allow them to do so conveniently as part of a larger, more holistic service. (How did that kind of anemia happen, and what can you do about it? "Let me explain...")

Much of primary care nursing is medical holistic health assessment, education and coaching for patients and their families. In the meantime, much PCP care is becoming, for workload and liability reasons, triage to specialists' care, or to their own "mid-level practitioner's" care--and my PCP, for one, is very frustrated by this!

Doctors already have "junior MDs"--partners with the equivalent of a medical school degree (with first-year internship) behind them, but who are unable ever to advance through their own residencies to independence. They're called PAs, and having chosen to stop at that level in medicine, they are the ones to rightfully maintain the role of "doctor's right hand", with all the privileges and limitations thereof.

Grneyzrn

108 Posts

Specializes in Pediatrics, Med-Surg, Infectious Disease.

I'm a BSN about to start MSN and when I checked with Tn BON they told me that as of now NPs only need to have a masters degree to get certified. So for Tn right now DNP isn't required

Specializes in Consultation Liaison Psychiatry.

The DNP as it currently exist is not a clinical degree. I doubt very much that insurers will reimburse an NP with a DNP focusing on nursing education at a higher rate than an MSN prepared NP. Are insurers going to start asking for our transcripts to ascertain the focus of doctoral work? I can see that they might reimburse for significantly more formal clinical education but that is not what the DNP is about.

Specializes in Consultation Liaison Psychiatry.

PA's are not junior MDs. Their education is most definitely not the, "equivalent of a medical school degree (with first year internship) behind them." PA's have a two year program of study.

I remember the days when the discussion was around how much more rigorous the MSN/NP program was than other masters programs. In fact, nursing leaders described the education as closer to other doctoral programs. It's hard for me to understand why, if our programs are already rigorous, we should be required to add more years of theory and capstone work to earn the DNP. If I want doctoral education for clinicians, I want to see additional clinical education (as opposed to capstone/practice hours). Why should one post-MSN DNP program require 27 semester credit hours while another requires 45+?

Look at the variation in curricula of different programs.

There is an assumption by our colleagues in other health professions (and even among nurses) that DNPs are all NPs. What about all the CNOs and educators that haven't been in clinical practice for years? How can someone tell that those DNPs are different than DNP prepared NPs? MDs/DOs are all physicians with the same educational preparation.

Medical school curricula are all pretty much the same. RN program curricula vary from program to program. Some students have one day/week for a few weeks in a clinical setting and others have 2 days/week for 6 weeks in that setting. Maybe we should standardize basic nursing clinical education before trying to change graduate education.

Vidablue

1 Post

The difference in doctors and nurse or PA training is that the doctors do those 10,000 hours before graduation, and the nurses and PAs do them on the job, earning about what the medical student does in his/her stipend, though the nurse gets paid by an employer. (Well, actually, the PA who is not a hospitalist will not be gaining those “see it all” hours in primary care; those you see in the acute care environment. But that’s another topic.)

You are extremely misguided on many aspects in regards to not only a PA education, but also a NP education. First of all, a NP program can take only a total of 5 years from freshman in college to NP to graduate. There are 1 year FNP programs FYI. I.E. - get your ADN, do an online BSN while acquiring the clinical experience, then 1 year of Masters. Not to mention, you can even obtain the FNP degree ONLINE. And a lot of these programs are pushing out highly unqualified NPs, because they only have to go to class 1 day a week and do 2-3 days of clinical a week. Most NPs have no clue what they are doing, and it is no wonder why I see hundreds of them lose their licenses because of unsafe and unethical practice every year. I would be more concerned with the fact that you can get an ADN , BSN, and MSN all online. How in the world does that signify competency? The Nurse Practitioner was originally created to aid in the shortage of doctors in rural areas, and quite frankly, should have remained that way. A NP's education is no where even comparable to a PA's. And no, PA's have a more substantial amount of clinical rotation hours required during their program, and take many of the same classes the first year that med students do their first and second. MD/DO graduates have residencies for a reason, and that is because they are no where near prepared yet, even after 4 years of insane post graduate study and clinic to be considered competent. That is way PA's are already having to go into residency programs after graduation, because the bottom line is, it is THAT important. NPs lack education and clinical hours in school and do not have enough supervised clinical hours after graduation, plan and simple. This is a harsh post, but you have to understand that practicing medicine is serious business and it should REQUIRE an MD or DO ONLY. NPs and PAs both just do not have the knowledge and expertise to be considered anything above a mid-level provider.*Furthermore, being a PCP is not about "seeing it all, know how to treat all". You sound incredibly ignorant. NPs have preceptors that must sign off on EvERYTHING they do just a little FYI, also. They are and never will have absolute autonomy. Not to mention, a PA can also own and operate his/her own clinic just as a NP can. There honestly is no difference, it is just the wording within the guidelines and laws that give you that misconception. And no, I am not a PA.

Specializes in Consultation Liaison Psychiatry.

You are mistaken about the need for NPs to have preceptors who, "must sign off on EVERYTHING they do." That is entirely dependent on state laws. NPs are autonomous in a number of states. Ideally, NPs maintain collaborative relationships with physicians but that is not mandated in independent practice states.

You are also misinformed about online education. Online NP programs may have didactic work online, both synchronous and asynchronous learning; however, all clinical work is done in real clinical sites with real preceptors. Any FNP program that can be completed in one year requires that the student have already completed the pre-clinical advanced A&P, pharmacology and physical assessment courses. The one year programs are generally designed for those who are already prepared as NPs or Clinical Specialists in another specialty.

Online ADN to BSN programs require online coursework but real clinical experience. The actual difference between ADN and BSN education is limited to a nursing research course, community health, and whatever general education credits are required to gain a baccalaureate degree. The only people who can complete an ADN to BSN program in one year are those who already had many credits beyond their ADN preparation.

I agree with you that neither NP nor PA education compares to MD/DO education and residency. Medical students and residents live medicine for 7-8 years. Those that compare a DNP to MD/DO have no understanding of the rigor of clinical education required of physicians.

Specializes in FNP, ONP.

Almost every single aspect of Vidablue's post is dead wrong. S/he has not idea what they are talking about, in addition to some obvious (misinformed) bias. Take it with a grain of salt.

Vida, I am a DNP in independent practice and have been from the day I graduated. No one signs off on anything I do, no one reads it, no one checks up on me. I have complete autonomy, and I am an excellent clinician. You are the one appearing ignorant here. Please become more informed before coming to a nursing forum and trying to tell us our business, lol.

Sincerely, Dr. Devil

Specializes in ER / Critical Care.

Vida is a pre-nursing student.... I wonder where she got all this information from??? I read through her post and thought "whaaaaaat?" Then looked at her profile and was like "oh, ok" :)

I'm by no means an expert, I'm still in nursing school myself- but her post is full of misinformation.

Kuriin, BSN, RN

967 Posts

Specializes in Emergency.

Erm, Viva...you're wrong. PAs need to have their charts signed off by physicians whereas NPs do not. NPs can own a practice but need a MD for on-call. If anything, NPs are more autonomous compared to PAs.

Specializes in Consultation Liaison Psychiatry.

NPs in Maine don't even need an on call physician although I think it's wise to have collaborative relationships with multiple providers.

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