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¢

[AutoRotate, MSN, RN]

Yes, the course of study should be more difficult for NPs.  A minimum number of years as a RN should be required to apply to schools.  Residencies should be completed as well as a higher minimum number of clinical hours.  

But who is going to pay for residencies?  Who is going to tell the schools that they can't allow prospective students to apply and pay for graduate education ($$$) "just" because they don't know how to be nurses yet, let alone APPs?  

[Thanksforthedonuts, BSN, RN]

On 11/10/2020 at 4:59 PM, db2xs said:

What you're talking about is exactly how I felt going through NP school. It was difficult but not challenging and the books/exams were embarrassing. I used medical school textbooks during NP school. 

Do not hold your breath that the second half of your program will be better. Sorry, my friend. 

Thank you for the word of advice. I was looking to switch programs to another “brand name” university to see if it might be a better program. I’ve kinda lost hope though. I’m happy I have a 4.0 in the program.... but that really means nothing as there has been *no* challenge in the program. I know the same now as I did before I started a year ago. 

[myoglobin, ASN, BSN, MSN]

Yes, but after you graduate (or indeed even now) you can augment your education with resources such as Lecturio.com which runs from basic anatomy through a basic medical school curriculum. Part, of the reason that I can spend up to two hours on intakes with clients is because my education is cheaper and I do not need to earn as much ( and I’m 51 and owe 160k in student loans so someone who was 30 with only 50k in debt could do 2.5 hour intakes and one hour followups). Being able to spend so much time with patients goes a long way towards being effective especially in psych.

[BSN2DNPFNP]

I have to say that I agree with your concern for individuals being educated as APRN’s and not having any experience as a nurse.  At both of the graduate programs I had applied to, it was a requirement to have at least 2 years experience as a nurse.  That is concerning.  There is so much you learn as a nurse.  Even general things such as how to converse with your patients during their most vulnerable moments, building rapport with them and their family members.

In response to your concern for wishing the DNP had a higher bar for entry and offer more clinic hours.  Perhaps this depends on the school you are enrolled in.  My program requires more clinic hours for the DNP degree as well as additional courses on leadership, a more intense capstone project.  Continued encouragement for looking in to current practice and finding ways to improve. Really the focus of the DNP vs MSN degree is research, leadership, practice improvement.  It has much less to do with the amount of clinic hours or the clinic setting (although, as stated, more clinic hours are required).  What is wrong with standing next to an MD/DO and stating you are the same?  NPs provide the same assessment, diagnosis, treatment.  I would expect an experienced NP to out knowledge and new MD in certain areas, and vice versa.

[KetafolDNP, DNP, CRNA, NP]

1 hour ago, BSN2DNPFNP said:

I have to say that I agree with your concern for individuals being educated as APRN’s and not having any experience as a nurse.  At both of the graduate programs I had applied to, it was a requirement to have at least 2 years experience as a nurse.  That is concerning.  There is so much you learn as a nurse.  Even general things such as how to converse with your patients during their most vulnerable moments, building rapport with them and their family members.

In response to your concern for wishing the DNP had a higher bar for entry and offer more clinic hours.  Perhaps this depends on the school you are enrolled in.  My program requires more clinic hours for the DNP degree as well as additional courses on leadership, a more intense capstone project.  Continued encouragement for looking in to current practice and finding ways to improve. Really the focus of the DNP vs MSN degree is research, leadership, practice improvement.  It has much less to do with the amount of clinic hours or the clinic setting (although, as stated, more clinic hours are required).  What is wrong with standing next to an MD/DO and stating you are the same?  NPs provide the same assessment, diagnosis, treatment.  I would expect an experienced NP to out knowledge and new MD in certain areas, and vice versa.

I agree with what you said - I’d just add that we as a profession are only as strong as our weakest links. There are APRNs who are much more competent than their physician counterparts but that doesn’t matter if many (or perhaps most) within the profession are less competent than their physician counterparts. 

[KetafolDNP, DNP, CRNA, NP]

On 11/11/2020 at 3:25 PM, AutoRotate said:

Yes, the course of study should be more difficult for NPs.  A minimum number of years as a RN should be required to apply to schools.  Residencies should be completed as well as a higher minimum number of clinical hours.  

But who is going to pay for residencies?  Who is going to tell the schools that they can't allow prospective students to apply and pay for graduate education ($$$) "just" because they don't know how to be nurses yet, let alone APPs?  

One easy work around that has worked in the CRNA world is to simply make the certification exam more challenging. If the exams hold the the graduate to a higher caliber of knowledge the universities will have to re-tool their curriculum to provide it.

that said, for CRNAs there is only one certifying body - so you must take that exam. With many NP disciplines there is competition for certifying exams - so there is some disincentive to make the exams harder. 

[AF2BSN]

On 11/14/2020 at 2:15 PM, BSN2DNPFNP said:

What is wrong with standing next to an MD/DO and stating you are the same?  NPs provide the same assessment, diagnosis, treatment.  I would expect an experienced NP to out knowledge and new MD in certain areas, and vice versa.

There is a lot wrong with this statement. You're not even technically practicing the same thing (medicine vs. advanced nursing). While I think NPs are *absolutely* practicing medicine, the point still stands. Just because you're using the same playbook doesn't mean you have the same understanding of the game. Primary care is one thing, but as you move further into specialization it's a completely different arena. If you go strictly by when people add NP vs. MD/DO behind their name, maybe? Situational at best. If you go by independent practice? Not even close. 

I think you're definitely suffering from Dunning-Kruger/don't know what you don't know. 

 

[myoglobin, ASN, BSN, MSN]

I personally would be offended more if an MD called themselves an NP (not that I have to worry about that).  Why:

a. In my experience they take a far less holistic perspective and are less likely to advise or emphasize interventions such as DASH diets for hypertension or CBT(I) for insomnia along with evidence based herbal alternatives such as SAM(e) for depression or even Saint John's Wort.

b. They tend to spend less time with their clients (indeed one of the primary advantages of being cheaper to educate is that NP's should be able to afford to spend more time with clients). 

c.  The three psychiatrists that I precepted under prescribed an exponentially higher number of benzo or benzo like drugs with little regard for the negative long term impact on cognition. They were also less likely to consider "anticholinergic"/cognitive burden from medications such as Seroquel.

No doubt MD's have certain advantages in their education, but that does not mean they will ever be able to meet or exceed the outcomes especially in primary care settings provided on a daily basis by outstanding NP's.  

[BSN2DNPFNP]

On 11/17/2020 at 2:07 PM, AF2BSN said:

Primary care is one thing, but as you move further into specialization it's a completely different arena. 

I know NPs that work in specialty areas and they are just as knowledgeable and capable as their MD colleagues.  Again, I believe it has so much to do with amount of experience.  And you did contradict yourself by stating "medicine vs advanced nursing" but then stating that NPs practice medicine.  NPs bring a different outlook to the game due the background as a nurse, as would a DO vs MD.  Not that there is a need for the NP to call themselves an MD, personally the title NP provides a title of a type of provider that I would prefer to be. 

[BSN2DNPFNP]

5 hours ago, myoglobin said:

No doubt MD's have certain advantages in their education, but that does not mean they will ever be able to meet or exceed the outcomes especially in primary care settings provided on a daily basis by outstanding NP's.  

I can’t agree enough with this.  There are true benefits to being and NP, and having the background as an RN that you don’t get as an MD.  There are advantages to both career paths, but both providers focus on bettering patient outcomes.  Same end goal, sometimes different approach.

[AF2BSN]

33 minutes ago, BSN2DNPFNP said:

I know NPs that work in specialty areas and they are just as knowledgeable and capable as their MD colleagues.  Again, I believe it has so much to do with amount of experience.  And you did contradict yourself by stating "medicine vs advanced nursing" but then stating that NPs practice medicine.  NPs bring a different outlook to the game due the background as a nurse, as would a DO vs MD.  Not that there is a need for the NP to call themselves an MD, personally the title NP provides a title of a type of provider that I would prefer to

*sigh* Sure, the point was missed but okay.
I also never said they couldn’t be competent or knowledgeable. I hope I am one day as an AGAC-DNP... but I’m not delusional about my training and how it stacks up. To pretend a new grad NP is the same as a new grad attending is ridiculous. Those are the two goal posts for independent practice. Ask your NP specialist friends how many gaps in their education they had and how much self study they needed to boost their knowledge base. You might be shocked.

I’m just curious— are you a boarded NP or a student? 

[myoglobin, ASN, BSN, MSN]

32 minutes ago, AF2BSN said:

*sigh* Sure, the point was missed but okay.
I also never said they couldn’t be competent or knowledgeable. I hope I am one day as an AGAC-DNP... but I’m not delusional about my training and how it stacks up. To pretend a new grad NP is the same as a new grad attending is ridiculous. Those are the two goal posts for independent practice. Ask your NP specialist friends how many gaps in their education they had and how much self study they needed to boost their knowledge base. You might be shocked.

I’m just curious— are you a boarded NP or a student? 

No doubt an MD will beat an NP on "medical jeopardy" nine times out of ten. However, "knowing more facts" does not always equate to better outcomes. Actively, bringing into practice evidence based modalities such as diet, exercise, and evidence based CAM approaches can often have profound implications on patient health. Going after the underlying insulin resistance that drives "metabolic syndrome" for example is likely to be far more effective in modifying risk factors such as stroke, heart disease and end target organ damage than is "prescribing more insulin"  or the latest greatest diabetes drug(unless it is the only way to achieve glucose regulation, and even then it should be seen as a necessary evil given that it usually increases insulin resistance in Type II diabetes thus worsening the underlying etiology). Many times even as a PMHNP I am able to reduce or eliminate cognitive dulling medications used in my clients with co-occurring seizure disorder through the use of interventions such as a low carb/ketogenic diet and or addition of MCT's. I have had many clients ask their neurologist's about these diets (in the context of seizure disorder) and they often say something to the effect of "yea they work, but they are too hard for us to patients to follow and we just don't have the time.". Well, I can often get my client to implement these approaches at least to a significant degree.  In my experience seven times out of ten the NP will do a better job in emphasizing these lifestyle modifications. Thus ,even if they lose "medical jeopardy" their patients will often win in terms of better outcomes.