DNP: Mirroring the Path of DO?

[AF2BSN]

I realize there are many people who find no value in a DNP. I have to say that I’m a little disappointed in my BSN-DNP program, especially in the era of the pandemic. One of the things that shocked me was sitting in an advanced assessment course and overhearing cheering from some students. What were they celebrating? 

Passing their NCLEX. 

How are you sitting in an NP Program learning to practice medicine (yes, I said it) and not even a licensed nurse? When I have conversations with new grad nurses it just astounds me. To further my dismay, the rigor just doesn’t seem there. For those doing online programs, especially new grads, how do people expect online tests/a few papers/500hrs of clinicals to produce an independent practitioner? I’m in-seat at a prestigious public school and it still seems like a total mind-bending affair.

The more I think about it, the more I wish the DNP would have a higher bar for entry, deeper dive into sciences, offer more clinical rotation hours, offer Step 1/2, and offer more residency/fellowship training. I realize there are many of you who would scoff at this, but hear me out. If the DNP is going to be the terminal degree pushed on nursing, where is the value? Are people honestly okay with standing next to a residency trained MD/DO and saying they’re equivalent? If you’re being honest, you can’t say that. So, then what?

A recent survey by MDs and DOs showed virtually no difference in their practice and perception of care— despite osteopathic medicine touting holistic medicine and inclusion of manipulative therapy. Why can’t nursing step in to fill the care shortage, provide this type of care, and show our colleagues we deserve to practice medicine next to them? There are many who were trained in the 70s, 80s, and 90s who feel they were well prepared. That’s not the world we live in today, however. Online programs have diluted rigor, over saturated the market, and reduced pay. 

It’s time for a change and it’s time to say enough is enough. Not everybody deserves to be an NP. Everybody does deserve the best care possible, however. If nursing is truly about taking care of patients they should support this. Help the DNP evolve like the DO did, but keep your roots. 

0.02¢

[meanmaryjean, DNP, RN]

You do realize DNP is a degree and not a role, correct? I have a DNP and am not an advanced practice nurse. 

[AF2BSN]

I do. You do realize we’re in the NP forum and it’s assumed we’re discussing clinical practice, no? I know it’s not a “role”, but it continues to be pushed as the terminal pathway for NPs for entry into practice. 

[Corey Narry, MSN, RN, NP]

I think @meanmaryjean did touch on the complexities of your questions. Yes, the DNP was initially conceived with the advanced practice role in mind.  I have just started practicing as an NP when the conversation about transitioning to a "clinical doctorate" for NP education was starting to simmer.  I have to say that it was quite promising at first when there was talk of longer clinical "residencies" and adding more classroom hours to the existing clinically-focused courses in the initial discussions at the time. 

Unfortunately, nursing being the way it likes to cast a wide net got in the way and the DNP became more diluted as more stakeholders got involved.  The final product did not become a "clinical doctorate", rather another nursing degree that leads to many different paths for nurses in leadership roles.  I also think the word "terminal degree" should never be used for NP education.  It misleads people that we are to learn everything in the program.  We don't just learn from obtaining our degrees as there is always continuous learning in the field of healthcare.  However, I agree that NP programs (DNP or not) need some serious rethinking and restructuring.  We have to do that regardless of DNP being a thing.  

[Corey Narry, MSN, RN, NP]

OP, I'm intrigued by the title of your post.  When you say "mirroring the path of DO", it does open a deeper discussion on what Advanced Practice Nursing is as opposed to what Physicians are.  DO's are physicians, let's get that straight for the purpose of my post.  I agree that our role as NP's blur the lines of medical practice.  As we strive for independent practice, we are asking for legitimacy as equals with physicians.  As it stands currently, the concept seems to work well in the primary care arena. 

The issues get more complex in the specialties and in the acute care setting where we can be standing side by side with physicians who spent years of fellowship training and multiple board certifications.  DO's did start separately from MD's at first and established their own schools, GME programs, and even their own hospitals.  Is that something the NP field can accomplish? theoretically yes, but is it something our leaders are striving for? I'm afraid not.

[AF2BSN]

@juan de la cruz I appreciate the feedback on my post. While I can appreciate DNPs in executive leadership, nurse analytics, etc. I think you hit the nail on the head re: dilution. 

I think there is a lot to learn about how the DO materialized, remained separate for so long, and (maybe a cautionary tale) how chirality to the MD came to be. At this point sole AOA accredited residencies are going the way of the dodo as they all must be ACGME certified or die. What does that tell me? A path outside of MD exists that evolved to parity. Nursing can do the same.

I’m currently enrolled in an AGAC-DNP program and let’s be honest, while critical care nursing experience helps, it’s not the same thing as practicing critical care medicine. I’ll graduate and need 3-4 years of APP work before being comfortable/competent in a given specialty. How can NPs complain about supervision prior to FPA in this case? Better yet, how do NPs decide to work in FPA states immediately after graduation? These NPs who may have struggled to find quality preceptorship and forced to precept with somebody who took their boards 6 months ago. It seems like a lot of Dunning-Kruger/blind leading the blind. Meanwhile, NPs act indignant about collaborative agreements and don’t understand why an individual with 4 years of medical school and 3-7 years of graduate medical education (not to mention a fellowship to boot in some cases) would balk at NPs.

Overall, I think there is a real pathway to improve NP education by way of the well-tread DO pathway as a guide. Whether nurse accrediting bodies will own up to the mess they’ve created with online degrees/relaxed standards and forge a new path is unlikely. It’s disappointing. 

[WestCoastSunRN, MSN, CNS]

Great discussion!  I agree, collaborative agreements don't bother me and I do not want to be out "on my own" in a provider role - even as a niche/specialty CNS provider. I do, however, want my salary to reflect the additional years of schooling - AND - I really think it should reflect the years of experience I have in nursing - bc I am an advanced practice nurse.  

One of the problems with APRNs is that the salary discourages nurses who have put in real time at the bedside to return to school.  And yet, most nurses (I think) really value the idea of a somewhat seasoned RN in the APRN role.  

As for the DNP - yes, it is diluted.  I am also attending a very reputable state school for my DNP, and I am determined to get my money's worth.  So I am doing a clinical residency outside of my own specialty (and actually clinical hours are a requirement for my program, tho I guess these are different for non-APRN students).  My capstone is no joke, either.  In fact, the idea for my capstone was the impetus for me pursuing the DNP.  

But it shouldn't be a "it is what you make it" thing.  As a profession, we can do better.  Thanks for the topic!

[AF2BSN]

@WestCoastSunRN thanks for the reply and insight!

The topic of APRN salary has a lot of moving parts and you’re right, many seasoned RNs have a hard time taking on the additional responsibilities with the same/less pay. FNPs are taking $65K a year to land a job— it hurts to see that and it’s criminal! I suspect that an RCA would reveal a multifactorial issue but, online programs “accredited” and taking in financial aid is a large problem. They keep pumping out these APRNs to “meet a demand”, without realizing the consequences of supply-demand. The downward pressure on salaries with people scrambling to land a new grad position is astounding. I think the biggest thing is that many have never negotiated a contract and have no idea what goes into that. Base salary, RVU production bonus, malpractice insurance, CME dollars, PTO, etc. are all things an RN would likely never consider. They just sign the first contract and keep their mouth closed because they need to start paying that loan off. 
 

You are so right about the “it’s what you make of it”. If I hear that one more time I’m going to scream. The impetus is on the school to provide a thorough, rigorous, thoughtful, and enriching experience. We’re paying for it— give it to us! We deserve it and our patients deserve it! 

[DrCOVID, DNP]

It's actually kind of funny as I had this thought to myself a while ago. One could liken the DNP to the DO, as nursing is supposed to be more holistic. I see the word "medical" thrown around here, but we aren't supposed to be "practicing medicine". Nursing wasn't meant to be focused on medicine. Unfortunately, our healthcare system is the way it is... but I digress.

The DNP could be much better than what it is. There are just lots of problems that have already been talked about frequently; too many online schools, low entry requirements, masters entry, but mostly lack of clinical time and rigor in the curriculum. Forget MD/DO, most other clinical doctorates have more stringent requirements.

[RiverRat788]

On 10/14/2020 at 4:15 PM, AF2BSN said:

he more I think about it, the more I wish the DNP would have a higher bar for entry, deeper dive into sciences, offer more clinical rotation hours, offer Step 1/2, and offer more residency/fellowship training. I realize there are many of you who would scoff at this, but hear me out. If the DNP is going to be the terminal degree pushed on nursing, where is the value? Are people honestly okay with standing next to a residency trained MD/DO and saying they’re equivalent? If you’re being honest, you can’t say that. So, then what?

If you want all that, there is a career path for you.  It's called Medical School.

And I know about what I speak.  Both of my daughters are fellowship trained MDs.

[DrCOVID, DNP]

23 minutes ago, RiverRat788 said:

If you want all that, there is a career path for you.  It's called Medical School.

And I know about what I speak.  Both of my daughters are fellowship trained MDs.

You are right, there shouldn't be another comparable, respectable option under nursing. Because you say so!

[AF2BSN]

@adammRN while I appreciate that nursing is a separate discipline than medicine, It’s definitely medicine at the graduate acute care/critical care level. “Advanced nursing assessment” is kabuki to keep ourselves from being forced into supervision under physicians. Otherwise, I completely agree with your posts. 
 

@RiverRat788 if I could go back in time I definitely would. I’m here now looking across the DNP landscape and hoping to make a positive change in the next decade. I would love to reach out to MD/DO academic colleagues to form a beefier NP curriculum. Hell, an NP to MD/DO bridge should be an option for those who would like it.