A proposal for the future of advance nursing practice

studentdrtobe · Mar 22, 2012

I think that is to be expected, again look at the DO model. It took quite a few year and establishing their own hospitals and clinics before they were accepted, even then some MDs see them as second rate doctors. Ultimately DNPs are going to have to just do it, have their own clinics and maybe even hospitals at some point. There is already a good start in some states that allow nurse ran clinics but the nursing community will need the academics to back it up if they ever want DNPs to be counted as Physicians.

DOs became equivalent to MDs because DO schools changed their curriculum to match that of MD schools. So, as a DO, you have the exact same curriculum as you do with MD schools (with the exception of OMM). MDs/DOs go through the same training during med school, learn the same things, go through the same residencies, etc. MD and DO training is 99.9999999% the same. That's why DOs are equivalent to MDs.

If midlevels changed their curriculum to reflect 4 years of med school + a minimum of 3 years of residency training involving tens of thousands of hours of clinical training (which is what MDs/DOs do before practicing independently), I'm pretty sure no one would be complaining and physicians would be fine with it. You'd have no one opposing you if that's the case. Make sense?

hoosier guy · Mar 23, 2012

Your right, it wouldn't happen overnight though. In time the DNP Program could turn into that, they could probably limit their residency requirement too. Consider that unlike physicians who have an unrelated undergraduate degree, in general, nurses learn their trade in every level of higher education. If a person was already a NP, the DNP program could be Two years adding knowledge in the MD / DO curriculum not learned in the NP programs and a shorter 2 - 3 year residency, adjusted for clinical hours accrued as a NP. In short, the DNP program could become a bridge program to becoming a physician.

studentdrtobe · Mar 23, 2012

Your right, it wouldn't happen overnight though. In time the DNP Program could turn into that, they could probably limit their residency requirement too. Consider that unlike physicians who have an unrelated undergraduate degree, in general, nurses learn their trade in every level of higher education. If a person was already a NP, the DNP program could be Two years adding knowledge in the MD / DO curriculum not learned in the NP programs and a shorter 2 - 3 year residency, adjusted for clinical hours accrued as a NP. In short, the DNP program could become a bridge program to becoming a physician.

It's not as simple as adding a year or two. It's very unlikely for there to ever be a bridge program between nurse practitioners and medicine because the content that is taught in each respective schooling system is way too different. NP/DNP programs, in their current state, emphasize a lot of theory, MPH-style courses, and business courses whereas almost the entirety of medical school emphasizes hardcore basic sciences (and their clinical application) with only one or two courses related to public health. And nothing at all regarding the business side of medicine (which explains why so many physicians have such poor business acumen). There's too much of a gap in the basic science training for there to be a bridge program, unless the NP/DNP curriculum changes. If I remember correctly, there is PA-to-DO bridge program that's one year shorter than the traditional med school length (ie. 3 yrs vs. 4 yrs) but that's because there's a lot more overlap between PA school and med school (since PAs train under the medical model).

It also doesn't make much sense to discuss undergraduate majors. The majority of students entering med school are still bio majors. Look at the AAMC data. I myself was a bio major in college. Everything I learned in 4 yrs as a bio major was covered in the first 3 months of med school, with the exception of one class (immunology...that course was in the second semester for us). And everything was covered in greater detail. So, you could make the argument that even for people who came into med school without a biology degree, they should've essentially been awarded one by the end of first semester (or first year, at the latest).

I don't think a lot of people truly understand the volume of material that's learned in med school and the pace at which you learn it in. And that's understandable. It's easy to dismiss someone saying they studied 7-12 hours on an average day (every day of the week, including weekends) and even more so during exam weeks. But, honestly, that's not an exaggeration at all in med school. It's the rule, rather than the exception. It's rare to find someone who can quickly integrate and assimilate the thousands of pages of material we read in just the first two years.

hoosier guy · Mar 23, 2012

i am not by any means knowledgeable on med-school and nd/dnp curriculum. surely a curriculum transition could occur that would incorporate the majority of med-school knowledge into a 2 – 2 ½ year np program and a 2 – 3 year np to dnp “physician” program while still maintaining fidelity to the current np / dnp curriculum. at the same time there is also a sense that nurses don’t want to kowtow to what physicians say a program needs to qualify independent health practitioners and there are doctors who don’t want nurses to be considered equal regardless of their education. in my opinion that will be the biggest obstacle in dnp recognition as physicians. i mean that not to judge either side for their opinions either.

sailornurse · Mar 24, 2012

[At the same time masters level practitioners might be salvaged if they take on the physician's assistant role in this new nursing model.

Please clarify. Not sure that MSN/NPs need " salvaging". As to other glaring errors,

In many states NP's have independent practice. Your model of collaborative practice would be taking a step backward!!!

As a non-nurse I don't think you don't really understand the nurse practitioner role that has evolved, and continues to evolve.

myelin · Mar 24, 2012

Honestly, I think trying to create a "DNP physician" would be a huge step back for NPs. Seriously, one of the huge advantages that NPs have is they are not under the board of medicine and are (increasingly) independent agents. Anyone who is worried about whether or not NPs are equal to MDs (by whatever measure) is asking the wrong question.

hoosier guy · Mar 24, 2012

By salvage I mean save the masters prepared nurse practitioner if and when the DNP becomes the standard.

SHGR, MSN, RN, CNS · Mar 24, 2012

I think that is to be expected, again look at the DO model. It took quite a few year and establishing their own hospitals and clinics before they were accepted, even then some MDs see them as second rate doctors. Ultimately DNPs are going to have to just do it, have their own clinics and maybe even hospitals at some point. There is already a good start in some states that allow nurse ran clinics but the nursing community will need the academics to back it up if they ever want DNPs to be counted as Physicians.

With the Affordable Care Act there will just have to be more nurse-managed health clinics and nurse-managed health centers. I don't think this is really a choice. People need health care, APN's are able to provide this health care, and there you have it. My city has several clinics that are serving the underserved population here, which are run by APN's, and provide excellent care with a focus on preventative services and health counseling. This is a separate issue from the DNP issue of course. But the document "The Future of Nursing: Leading Change, Advancing Health" from the Institute of Medicine/Robert Wood Johnson foundation delineates this nicely. 701 pages and I'm halfway through. Excellent reading.

SHGR, MSN, RN, CNS · Mar 24, 2012

It's not as simple as adding a year or two. It's very unlikely for there to ever be a bridge program between nurse practitioners and medicine because the content that is taught in each respective schooling system is way too different. NP/DNP programs, in their current state, emphasize a lot of theory, MPH-style courses, and business courses whereas almost the entirety of medical school emphasizes hardcore basic sciences (and their clinical application) with only one or two courses related to public health. And nothing at all regarding the business side of medicine (which explains why so many physicians have such poor business acumen). There's too much of a gap in the basic science training for there to be a bridge program, unless the NP/DNP curriculum changes. If I remember correctly, there is PA-to-DO bridge program that's one year shorter than the traditional med school length (ie. 3 yrs vs. 4 yrs) but that's because there's a lot more overlap between PA school and med school (since PAs train under the medical model).
It also doesn't make much sense to discuss undergraduate majors. The majority of students entering med school are still bio majors. Look at the AAMC data. I myself was a bio major in college. Everything I learned in 4 yrs as a bio major was covered in the first 3 months of med school, with the exception of one class (immunology...that course was in the second semester for us). And everything was covered in greater detail. So, you could make the argument that even for people who came into med school without a biology degree, they should've essentially been awarded one by the end of first semester (or first year, at the latest).
I don't think a lot of people truly understand the volume of material that's learned in med school and the pace at which you learn it in. And that's understandable. It's easy to dismiss someone saying they studied 7-12 hours on an average day (every day of the week, including weekends) and even more so during exam weeks. But, honestly, that's not an exaggeration at all in med school. It's the rule, rather than the exception. It's rare to find someone who can quickly integrate and assimilate the thousands of pages of material we read in just the first two years.

studentdrtobe, I believe you have proven above exactly why APN's have such a valuable role: many, many people are still underserved by health care in the US, and we need sustainable models to train providers to provide this care. We need APN's who are willing and able to provide preventative services; to do well checks; to assess and help mitigate risk factors for heart disease, like obesity; to provide well woman care. And this is just primary care roles.

Not every person needs the care of an MD or DO that spent the resources to get trained as such. Some people do need that care, but not every time. That's great that we have physicians with years of training and residencies, but we- societally- also need APN's.

coast2coast · Mar 24, 2012

Reading over all of your comments ... your vision for advanced practice nursing appears to be making us into doctors. That's not very helpful - most APNs could/would go to medical school if they so desired. There's a reason we chose not to. It's hardly worth slogging through a decades-long fight to revise the (already suspect) DNP curriculum to get it accepted by the AMA. Just go to medical school if that's where your heart lies.

Also - by what reasoning would you give DNPs (as they currently exist, since turning them into doctors would then put them under physician scope of practice) increased scope of practice over master's prepared NP's? There is no research to support a difference in clinical outcomes.

As a non-NP, I don't think you realize that the reputation of the DNP degree is still somewhat up in the air in the nursing community. Remember that there are also PhD-prepared nurses in this mix. Many nurses and NPs, myself included, don't really think the DNP curriculum in its current form significantly adds to clinical practice. It seems to be focused on practice management and other organizational activities. It's a great degree if that's the type of role you want to have, but it doesn't seem to have any bearing on day-to-day clinical functions of nurse practitioners. Master's programs are still the basis for that type of education.

You have inspired a good discussion here OP. I just think you need a liiiiitttle more information and familiarity about how NPs are currently functioning before you charge head trying to reorganize our profession :)

FNPdude74 · Mar 25, 2012

BCgradnurse,

We WILL get that recognition. Well... That's my future vision anyway. :) BTW, I get uncomfortable now when new (not even done with residency yet) physicians at work described us as midlevels and "subordinates to physicians". So I said: "alright dude, lets have a nice talk shall we". hehe

Psychcns · Mar 25, 2012

MY DEA license says "mid level practitioner" I am ok with this. (I am a psych CNS working as a psych NP).

I like physician collaboration--they have had thousands of hours more clinical than me and know the hard sciences better than I do. I can practice with very little or no collaboration because I am very experienced. There are many physicians who, for varying reasons (perceived liability, turf, etc) do not like to collaborate/supervise. The ones that i can to talk to about cases make my job easier and I think the patients get better care.

When I work as an psych NP I do the same work as a physician. One time when I was transitioning a case to a physician because I was leaving a facility, I sat in on his initial evaluation. It was very good and exactly the same interview I would have done.

I am very glad for non-nurses to be interested in advanced practice nursing and the barriers to practice we face. A non-nurse is closer to being a consumer/client than I am, and I think APRN's need to join more with consumers to establish consumers ability to see NP's instead of physicians if they choose. I can prescribe in 36 states--why not all 50? Politics, including the history of CNS education, how the Psych NP role evolved from the CNS curriculum, Boards of Nursing with restrictive ideas, and Boards of Medicine who want to keep their turf. I am a good prescriber and a good clinician--patients like me. Yet in 16 states and more because of BON hurdles, they cannot see me.

I suggest the OP check out the National state board of Nursing site, and the national CNS site.--each APRN category likely has a site. This is the time to establish the four categories in advanced practice in all states.

I think a hard science DNP is good. I think bridges from RN to APRN to MD are good. But it becomes political.

OP, thanks for your efforts.

A proposal for the future of advance nursing practice

Should the scope of practice for NP's be expanded?