NPs/DNPs moving into specialties?

djc1981 · Jun 20, 2008

Hmm..I'm not really sure about if they will be creating "residencies", but I was researching DNP programs, and many of them are already being taylored for certain areas. I think perhaps it was the U of S. Alabama? Not sure. But they are doing acute care DNPs, cardiovascular based ones, on and on, etc. So that idea would certainly not be shocking.

forpath · Jun 20, 2008

Hmm..I'm not really sure about if they will be creating "residencies", but I was researching DNP programs, and many of them are already being taylored for certain areas. I think perhaps it was the U of S. Alabama? Not sure. But they are doing acute care DNPs, cardiovascular based ones, on and on, etc. So that idea would certainly not be shocking.

The reason I did not put residencies in quotes is because many DNP programs already call their post graduate clinical training residency, or at least that is how they informally refer to it.

Thank you for replying.

Advanced Practice Columnist / Guide · Jun 23, 2008

There is a lot of supposition/presumption on SDN that APNs will eventually try to move into more specialties and create their own residencies for cardiology, endocrinology, dermatology, surgery, etc and function independently in those fields as well. Does anyone see this happening? Has this been one of the "never talk about in public" plans all along of DNPs?
It doesn't sound too unreasonable. APNs have functioned highly in midwifery (OB) and anesthesia (CRNA), so it seems "possible" to me.
If so, surely they (you) could not consider non-direct patient care oriented specialties like radiology, pathology, etc, could they (you)? How could they justify the "nursing philosophy" in those fields?
Just a serious question. No flaming, please.

Forpath, you were once an enigma to me until another post you wrote on another thread revealed what your background is. I appreciate your interest in the APN field particularly the NP role.

In my humble opinion, I doubt if there is a considerable number of NP's who would like independent practice in a specialty field. The NP was born out of a need to fill the role of primary care providers in areas where physician presence is limited. Years later, the thrust of the NP role remains the same in my opinion. Apart from the newer NP roles such as the ACNP and the NNP, all of the NP training programs or specializations are in primary care. As far as the whole APN umbrella, although the CRNA and CNM roles are quite specialized, their professions followed a separate branch in the history of nurse specialization. These APN's have actually been in existence longer than the NP.

ACNP's (myself included) fill a need for providers who can complement physician services in hospitals and in-patient settings. Many of us practice in specialty areas of medicine and surgery. However, our practice is one of collaboration with a physician and not on our own. Many times, hospital based NP's actually fill a role similar to a resident physician or a physician fellow. Our knowledge and skills related to the specialty field we work in do improve as time passes by so it does come to a point when we can guide or teach new residents who come into the specialty service we work in. As a result, some NP's are actually promoted to faculty level in some residency programs. But these expert NP's still do not work in a manner independent of the physician collaborator.

You specifically ask if the DNP movement is pushing for independent practice for NP's in specialty fields. At this point, it is difficult to actually put a finger on who wants what. Nursing is traditionally a fragmented profession. One camp may come up with a totally new idea that the other does not totally agree with. I'm sure you see that in your profession as well. New developments in the DNP field have gotten even practicing NP's surprised and caught off guard. However, we must realize that no matter what a well known nurse-academician says about their DNP program or DNP certification, the practice acts of each states still determine what a nurse practitioner can do and whether this is independent of physicians or not. As healthcare is also a business, insurance companies still control what reimbursement is given to whom and where and under what circumstances. And finally, hospitals will still enforce priviledges and credentialing to healthcare professionals and can limit what NP's are able to do.

forpath · Jun 23, 2008

pinoyNP-

Thank you for the time it took for you to respond.

I agree, it will likely be up to state legislatures and insurance companies in the end, but as you stated, nursing is fragmented, and not every nurse wants the same thing, as in medicine. But, in the case of CRNAs, were we not seeing a push for specialization in Lousiana when CRNAs were lobbying for pain medicine privileges? People speculated it was because of money, because pain medicine is more lucrative than "regular" anesthesia.

On top, there are many people, posters on here included, who feel that when an APN does the "same" thing an MD/DO does, they are practicing nursing and not medicine. If that is the over-arching philosophy of APNs, then what is to say that there will not be a push for nursing specialties? Nursing endocrinology, nursing cardiology, etc. Afterall, an APN in primary care is essentially assuming duties of specialists, as a primary care MD/DO does, when they treat depression, psoriasis, hypertension, etc, albeit in a more limited fashion.

Aren't there already APN degrees for specialties? Neonatology, psychiatry? I may be wrong.

christvs, DNP, RN, NP · Jun 23, 2008

Just wondering: is there anyone here who is currently enrolled in a DNP program (post-Master's) who likes it? If so, what are you studying/which classes are you taking? Do you feel it will better prepare you for clinical leadership? What is/will your clinicals be like? I'm considering the post-MSN/NP DNP for the future, but am still not completely sure if I want to pursue it or not.

Advanced Practice Columnist / Guide · Jun 23, 2008

Aren't there already APN degrees for specialties? Neonatology, psychiatry? I may be wrong.

Somebody can correct me if I am wrong but I thought Neonatal NP's practice in a very similar manner as critical care NP's - under collaboration with a physician specifically a neonatologist. Psyhciatric and Mental Health NP's, I guess, can practice independently depending on the state practice act.

Nursing continues to be at the top in terms of public perception of being the most ethical and honest profession. I think it is important that we safeguard this image by protecting the public and making sure that whatever endavor we get into, we have the safety of our patients in mind. It is quite unsafe in my opinion to enter into independent practice for NP's in specializations where there is no established standards as far as training and certification. Currently, FNP, ANP, ACNP, WHNP, NNP, PNP, PNP-AC, PMHNP (I may have omitted one or two, so pardon me) are the only NP certifications with established standards for training and certification.

Even though specialization is not uncommon in nursing and there is an abundance of RN-specific specialty certifications for nurses (CCRN, CEN, CRRN, OCN, etc.), there isn't much in the way of actual subspecialty certification for NP's in fields such as cardiology, endocrinology, and such. There may be NP programs specifically directed to these subspecialty fields but there is no established uniformity in the curricula between programs.

I also know of advanced practice certification in oncology (AOCN) and diabetes management (BC-ADM) but these are not specifically offered to NP's alone. Until we come up with established standards for subspecialty practice, I think NP's should continue to practice the way we are doing at the current time.

SteveNNP, MSN, NP · Jun 23, 2008

Somebody can correct me if I am wrong but I thought Neonatal NP's practice in a very similar manner as critical care NP's - under collaboration with a physician specifically a neonatologist. Psyhciatric and Mental Health NP's, I guess, can practice independently depending on the state practice act.

NNPs are basically ACNPs trained specifically to neonates. (chest tubes, lines, intubations, etc...)

NNPs can practice independent from physicians like the rest of APNs.... the problem is that our scope of practice is age 0-2. It makes for a VERY narrow target population, which restricts private, outpatient practice.

The only NNPs working out of the hospital that I know of would be at a high-risk followup clinic, or independent flight transport team, but both those would definitely have a MD involved anyway...

Advanced Practice Columnist / Guide · Jun 23, 2008

NNPs are basically ACNPs trained specifically to neonates. (chest tubes, lines, intubations, etc...)
NNPs can practice independent from physicians like the rest of APNs.... the problem is that our scope of practice is age 0-2. It makes for a VERY narrow target population, which restricts private, outpatient practice.
The only NNPs working out of the hospital that I know of would be at a high-risk followup clinic, or independent flight transport team, but both those would definitely have a MD involved anyway...

Right...I guess that's what I was trying to say in my first post. NP's of all kinds have provisions for independent practice (meaning no physician involvement) in twenty or so states but the entire mechanism to allow for independent practice in specialty fields are not present, specifically, full insurance reimbursement across the board and priviledging in hospitals across the board. It is loosely reported that less than 1% of NP's run an independent practice on their own. This is possible in primary care settings where hospital priviledge is not necessary and insurance reimbursement is less complex than in acute care settings.

djc1981 · Jun 24, 2008

NPs seem to have cornered the market on neonatology. I've read that most NICUs prefer them because of their very specialized, concentrated training in the field, thus its a market you'll rarely see PAs in. According to the Advance survey, they are well compensated for this as well, being the second highest paid NPs after emergency NPs.

core0 · Jun 24, 2008

NPs seem to have cornered the market on neonatology. I've read that most NICUs prefer them because of their very specialized, concentrated training in the field, thus its a market you'll rarely see PAs in. According to the Advance survey, they are well compensated for this as well, being the second highest paid NPs after emergency NPs.

This tends to be very local. Even in one city there can be differences in practice. By advance data there are about the same percentage of NPs as PAs in practice. By numbers I am guessing that there are quite a few more NPs but its really hard to tell.

David Carpenter, PA-C

SteveNNP, MSN, NP · Jun 26, 2008

NPs seem to have cornered the market on neonatology. I've read that most NICUs prefer them because of their very specialized, concentrated training in the field, thus its a market you'll rarely see PAs in. According to the Advance survey, they are well compensated for this as well, being the second highest paid NPs after emergency NPs.

It's really just that there's a huge need for midlevels in neonatology period. We have one PA in our NICU. She was absolutely terrified at first, but is now getting the hang of it, which is completely understandable for someone who has not "grown up" in a NICU, like an NNP.

The need is created by there not being a huge number of pediatric residents to begin with these days, (which spend only 90 days in NICU) and even less neonatal fellows who have a 3-year program before becoming attendings (we have 3 start each year)

Couple that with an exploding fertility business, increasing numbers of multiples and premature births, and there you have it. An unlimited need for midlevels.