Why are NP's with terminal degrees (MSN for now DNP by 2015) with advanced NP certification considered midlevels? Does the affirmation and utility of this title suggest NP's lay somewhere in the spectrum between basic RN (within the discipline of nursing) and physician (not within the discipline of nursing)?
In reviewing ANCC and AANP NP certifications it appears that the ARNP and NP certification appears to be the highest certification for NP's. So if NP's are midlevel, and the ANCC/AANP NP certification process is considered at the highest-level certification for NP's, what exactly would be the next step to advance out of the "mid-level" tier in the nursing discipline in the context of NP practice?
I understand PA's are considered midlevel providers because PA's practice medicine under the supervision and direction of the physician. There is no doubt or contest as to PA's following medical-based models for both training and care of patients. Do you think because PA functions (medicine) overlap with NP functions (nursing practice) that by association NP's and PA's are lumped together as "midlevels?" If so, since many basic functions of unlicensed assistive personnel (UAP's) overlap the practice of nursing, would it be appropriate to categorize UAP's and RN's both as "nurses"?
For those NP's that work in states where no physician supervision is required for NP practice including independent prescribing (AK, AZ, DC, IA, ME, MT, NH, NM, OR, UT, WA, WI, WY) do you consider yourself a "midlevel" practitioner?
Lastly, if NP's are truly "midlevels" wouldn't a better title be "Midlevel Practice Nurse" instead of "Nurse Practitioner?"
CORE0, it must frustrate you that DNP's, NP's and PA's will not by law be called Doctor in the clinical setting, if you want that there is Medical School.
In keeping with your pattern, you are again misinformed. As far as the title "Doctor" for DNP's, out of all 50 states and DC there are only 7 non-enlightened states (relax, Georgia is one of them) by which have restrictions for NP's using the title doctor.
Core0 You fullfill my expectations of a PA, LOL Insults are very mature......
IM is now 4 years in many progrems, there are a Few that are 3 Years, , I was speaking in general but when Nurses and PA's start to argue, emotions are used as facts. This is one reason why I'm becoming a Doctor verses staying an RN, just tired of the BS in the profession.
Yea right as much as we are to believe you are a PA-C,
I will not prove my resume on the forum. But what has been posted here about Medical training is wrong, I'm in my 4th year of Medical School.
2 years of Basic science and 2 years of clinicals, then you are a MD but with a training License,
US grads can get a full License in many states after 1 yr Residency
FMG grads can get a Full License in 3 yrs Residency
Licensing is state by state not universal.
people tend to insult others on these forums when they are frustrated when faced with the facts posted.
MD's and DO's have years more training then a PA/NP/DNP in Medicine, it is a fact that undisputatble.
I do not consider my 20 years as an RN medical training and neither do the Medical Schools.
I understand from reading your SDN posts that you dislike PAs. Sadly I agree with you on many issues. I work in a profession where the physician is the captain of the ship as it were. I believe that as the only holder of an unrestricted license to practice medicine or surgery thats the way that it should be. I also agree that its inappropriate for non-physicians to use the term Doctor in a clinical medical setting.
Having studied health care education extensively I also agree that physicians have more clinical and didactic training than any other medical professional.
The best study of medical school education is probably the one here:
There are a lot of problems with the actual paper, but the analysis of medical education is pretty solid. The caveats are its only three schools and it was done in 1995 before PBL was the rage.
The important part is here:
" The medical school curriculum in many ways follows a similar format (Table 8). In the first year the basic sciences comprised 79% (706 hours) of the program, whereas the clinical sciences comprised 21% (184 hours), However, in year 2, the basic sciences decreased to 64% (590 hours) and the clinical sci- increased to 36% (335 hours). In years 3 and 4, the students are in a series of clinical clerkships.
Year One. The following program is included in the first year microscopic anatomy (129 hours), biological chemistry (144 hours), gross anatomy (178 hours), physiology (136 hours), basic neurology (95 hours), biomathematics (24 hours), clinical sciences doctoring (129 hours), clinical sciences interactive teaching
(32 hours), clinical application (2-3 hours), and assignments (100 hours). The total contact hours in year I are 890 (184 in clinical sciences, 706 in basic sciences) with an additional 100 hours in assignment& The scheduled hours per week are 30 (for 33 weeks).
Year Two. In the second year, the curriculum includes the following- microbiology and immunology (151 hours), patholo- (140 hours), pharmacology (83 hours), pathophysiology of diseases (246 hours), psychopathology (41 hours), doctoring/clinical fundamentals (212 hours), genetics (35 ), and clinical pharmacology (17 hours). The total contact hours in year 2 are 925 (590 in bask sciences, 335 in clinical sciences). An additional 100 hours are spent in assignments, and the scheduled hours per week are 30.
Year Three. The third year of the medical program involves 52 weeks of core clinical clerkships for a total of 1878 hours. The average number of hours scheduled per week is approximately 36.
Year Four. The fourth year is also dedicated to clinical activities and composed of required student selected electives (selectives) for 26 weeks with a total of 936 student contact hours. An additional 571 hours are spent in electives, which on average add 16 weeks to the program. The contact hours scheduled per week are 36. The total program is 5200 hours."
If you look at didactic contact hours for the first two years it works out to 1815 over two years. The issue in comparing it with nursing is that nursing coursework is measured in semester not contact hours. A typical FNP course will have approximately 40-45 didactic semester hours and 12-15 clinical semester hours (representing ~600 clinical hours). Here is a fairly typical program:
The usual conversion from semester to contact hours is 16 contact hours per semester credit so the 41 semester credits in the Minnesota program represent 656 contact hours.
The Minnesota DNP adds 36 credits to the FNP with 24 of those being didactic and 12 being clinical (representing 400 clinical hours). The 24 credits represent 384 contact hours.
For direct comparison
FNP + DNP (University of Minnesota) Didactic 1040 contact hours clinical ~1000 hours for a total of 2040 hours.
MD didactic 1815 hours clinical 3385 hours for a total of 5200 hours.
To practice medicine in most states also requires an intern year which in our institution is 70.4 hours x 48 weeks or another 3379 hours. What most people miss is there is an average of 12.7 hours of formal didactic instruction per week in internship. So this adds up to another 597 didactic hours and 2800 hours of clinical work. Total minimum to practice medicine in most states (for a US grad) 2412 didactic hours and 6815 clinical hours.
To say that both the DNP and the MD are four year degrees after undergraduate school is technically true. To imply that the DNP and the MD are equivalent in either didactic or clinical training is simply false.
I don't really have a hard time supporting physicians in this, I do have a hard time supporting you. Nursing will now have to make up a new term when horizontal violence is practiced by a former nurse now practicing medicine. I precept medical students, PA students and NPs. I understand the difference in educational models and how to respect people.
What? Medical School and CME's are not the same thing? You understand this right?
Re: Do you think NP's are "midlevels"?
Originally Posted by DRFP
As I said I'm an
RN
, for 20 years, Trauma, ICU, ED and Homecare.
Uh I have been to medical school and I gotta tell you, you are far from the truth here, Nursing is different then Medical School and did not prepare me well for it, it is not the same and the other Nurses and even 2 NP's who went to my school said the same thing.
Just curious, did you have to go through medical school after being a nurse for 20 years and consult with others to discover that the nursing and medicine are a bit different?
YES, I did need to go to medical school to understand this, like many other nurses here I thought there was not so much difference, now I understand there are differences, a RN is not almost a MD like some believe.
Originally Posted by DRFP
Nursing focuses on more Psych social and care delivery issues, as well as prevention, Medicine focuses on Diagnosis and Treatment more, just the way it is.
and the amount of knowledge, heck I study all the time and just about never stop.
And these fundamentals underscore the importance and popularity of NP's with the consumer. You see, some clients actually want more than a label and a pill.
I think the public want accurate treatments and Diagnosis, what good is care delivery if it is the wrong treatment and the Patient Dies,
Plus many MD's and DO's treat the whole Patient not just "Push Pills" this is very condescending and cynical, nurses do more then "Just clean Butts too" we can through insults all day.
Originally Posted by DRFP
Look I'm not here to argue but this "I'm a Doctor" Just like a MD scares me and is not lawful, you will not be Licensed to practice medicine as a physician but be licensed as a Nurse Practitioner.
It scares me, too. Thats why policy, regulation and statute has to be enacted to protect the consumer. All physicians should have to clearly state with each pt. encounter that they are not trained DNP's and that their doctorate degree is only in medicine and they have no training or license to practice nursing, either on a basic or advance level.
Doctors do not usually say they are Nurses, but do give Nurses orders and in my state NP's and DNP's,
Plus I guess I can say I'm an RN too since I am and I hold a current License.
Originally Posted by DRFP
Some states have already enacted laws that Physicians are to be called "Doctor" in the clinical setting to help with the confusion.
To true. And at one time there were no states in which APN's could practice independently. Thank goodness wisdom, experience and common sense (coupled with consumer-support based on outcomes and evidence) continues to prevail which is why NP's can practice independently in 23 states.
I have already done the research on this and its not 23 states, its about 4. Advocates want to count states where NP's can write scripts as independent practice, when in all but 4 NP's must have collaboration with MD's at least! this is not 100% independent, I doubt on a Nursing forum I will ever get agreement. But this is a fact. A recent study was done that has charts to prove this...
Originally Posted by DRFP
NP's, PA's DNP's can be and are valuable care givers and are needed in the health care system but this should not be to replace Physicians, it is not meant to do that, it is meant to deliver a higher level of care to the public, that scheme includes Physcians not excludes them.
I agree, and I also feel that there is even room and a place for physicians too.
I expect open hostility from Nurses towards Physicians, a copy of this should go to congress un altered to show the logic of some nurses, I do not know why you want to try and replace MD's and DO's and the high level of education required to practice medicine, how does this better medical care? :argue:
I am not going to deny that there is much that doctors can learn about patient satisfaction from nurses however patient satisfaction has very little to do with the competency of the provider. Let's not front like it does. There are doctors out there that have a terrible bedside manner but are the absolute leader in their field. Would you rather have someone hold your hand as you die or be callous as they cure you? What I am trying to say is that they are neither mutually inclusive nor exclusive. They are unrelated.
Now the assertion that a DNP program is equal in scope and information to a FP doc is ridiculous. The sheer fact that DNPs do not take the same licensing exams and are asking the NBME to create a separate exam affirms this point.
Now for the breakdown:
Look at the clinical hours required. From my brief research, all of the programs I have found range from 800-1000 hours of clinicals. That is the equivalent of 10-15 weeks of residency. Hardly adequate.
Many of the programs assert that a full time student can finish the program in 3 semesters... not exactly the same time frame as 4 years of medical school and 3+ years of residency. There is a reason that medical residencies have been lengthened; you just cannot have adequate knowledge to be a primary provider with less. As more is learned, the residencies will have to be lengthened.
The part time nature of some of the programs and the distance learning is equally troubling.
I am all for DNPs if the didactics are equivalent and are accredited by an equally stringent board like the LCME. Lord knows that many medical students are being pushed away from primary care by rising education costs and decreasing reimbursements. An adequate replacement needs to be found. This is about what is best for the patient. Decreasing the time spent learning is not an adequate solution. It is not as if medical school is wrought with superfluous information and wasted time. Cutting out didactics, time spent in clinicals and basic sciences and calling it equivalent is irresponsible.
The underlying assumption of these programs is that NPs do not have enough training to be the primary caregiver and that these programs will fill in the gaps to make an adequate PCP. I selected a program where it was easy to find their classes (Wright State) and took a look.
You find a few classes that are clearly as they should be: like nursing theory and determinants of health. These make up 6 credits.
The rest resemble an MPH or an administrative program: leadership, informatics, policy leadership and ethics, information technology, statistics, epidemiology, and entrepreneurship. These make up 34-38 credits.
To get clinical specialty certification you add clincals plus 3 credits of pathophysiology and 3 credits of pharmacology.
core0, it must frustrate you that dnp's, np's and pa's will not by law be called doctor in the clinical setting, if you want that there is medical school.
as far as training for full license here's ga law for an example
2. graduates of united states medical schools must complete post-graduate year one in a program approved by the accreditation council for graduate medical education (acgme), the american osteopathic association (aoa) or the royal college of
physicians and surgeons of canada or the college of family physicians of canada (cfpc).
i bolded the one year part since you seem to have missed it.
i put in bold the 3 years.
this is typical of many states laws and should be the standard posted.
you see medical students do not pick the lowest standard as a rule we pick the highest.
good luck
medical students have nothing to do with the standard for practicing medicine. medical boards do. for your further edification, a quick perusal of the fsmb website shows that approximately 40 states allow a us medical graduate to practice with one year of internship. only one state require a physician to actually complete a residency. imgs can practice in 21 states with two or less years of residency.
if you read above you know my feelings about being referred to as "doctor". you seem to project a lot of your own feelings to me and make a lot of assumptions.
pa's in ga are kept under close physician supervision even in satellite offices:
snip
in regular settings:
snip
if you are not practicing this way in ga ( as the other pa's ) then the law is being broken.
not a good thing.
thank you for posting the georgia pa practice act. yes it needs some improving. we're working on that. if you really want to see a backward practice act you should review the np practice act. once again that projection assumption thing. show me once where i state that i am practicing at variance with georgia law.
one more general comment. most physicians (that is medical school graduates who are board certified in their specialty) are very secure in their place in the medical hierarchy. most could give a heck about the dnp. they do resent when the ana tries to present it as equivalent in order to get more $$$. considering you are halfway through your medical education you might learn from that.
btw sorry for derailing the thread, i still dislike the mid level term. i find the comments on the npp interesting. in the uk they toyed with the term medical care practitioner for pas there which i find fairly descriptive.
I understand from reading your SDN posts that you dislike PAs.
WOW you are 100% off the mark here. I support PA's and NP's 100% I do not support that a PA and a NP or DNP are equals to MD's and DO's not as a Nurse or a MD.
I think you bring too much emotion into this. and your posts prove this fact.
To practice medicine in most states also requires an intern year which in our institution is 70.4 hours x 48 weeks or another 3379 hours. What most people miss is there is an average of 12.7 hours of formal didactic instruction per week in internship. So this adds up to another 597 didactic hours and 2800 hours of clinical work. Total minimum to practice medicine in most states (for a US grad) 2412 didactic hours and 6815 clinical hours.
To say that both the DNP and the MD are four year degrees after undergraduate school is technically true. To imply that the DNP and the MD are equivalent in either didactic or clinical training is simply false.
I don't really have a hard time supporting physicians in this, I do have a hard time supporting you. Nursing will now have to make up a new term when horizontal violence is practiced by a former nurse now practicing medicine. I precept medical students, PA students and NPs. I understand the difference in educational models and how to respect people.
You want to insult me and discriminate against me because I have an opinion and belief that is in contrast to yours? WOW I do not know how to respond friend? The exchange of beliefs and Ideas are part of being an educated individual.
Doctors in the state of GA that went to the Caribbean cannot be Licensed in a year of residency, you refused to acknowledged that, its a plain fact I posted it yet you still say I'm wrong.
I posted the DNP program for the University of Maryland and you post another state, they may be different, If you post one medical school and another they may differ some but not as much as you posted the with the two dnp programs.
DNP's are not licensed to practice medicine, they are not under the board of Medicine but the state Nursing board,
MD and DNP are not equal, and because I do not agree that DNP and MD (Or DO ) should be equals that makes me a BAD PERSON and someone to be put into a new catagory WOW
WOW all because I have an opinion that is important to me.
WOW I hate all PA's and NP's
How do you get this? WOW I do not know what more to say
One more general comment. Most physicians (that is medical school graduates who are board certified in their specialty) are very secure in their place in the medical hierarchy. Most could give a heck about the DNP. They do resent when the ANA tries to present it as equivalent in order to get more $$$. Considering you are halfway through your medical education you might learn from that.
BTW sorry for derailing the thread, I still dislike the mid level term. I find the comments on the NPP interesting. In the UK they toyed with the term Medical Care Practitioner for PAs there which I find fairly descriptive.
David Carpenter, PA-C
While you can technically practice medicine after 1 year you will have a heck of a time finding a job with any hospital or group. Outside of that you are right on the money. It is doable but it is not often done anymore.
As to the 'security' schpeil someone needs to stand up and acknowledge that the 2 are not the same. Politicians, who unfortunately control the outcome are more worried about limiting costs than ensuring quality is maintained or improved. So while DRFP may get overzealous at times and may call some people some names (which (s)he shouldnt) he is just standing up for what he believes is right and true.
CORE0, you are missing what I posted, I did say 1 and 3 years for License, LOL
Did you miss it? I'm a FMG MD I have 3 years like other FMG MD's
not all MD's can get a full License in a year, and show me a Doctor allowed to practice without finishing a residency in the last 10 years?
(one who left a residency with one year in the last 10 years able to get full License and practice?) I do not know of one myself.
Even if we cannot agree I would not think you a bad person I have no idea why you think this of me?
The license after a year helps the residents in that they can get DEA numbers and moonlight, but not leave residency. Without Board certification private practice is hard.
One more general comment. Most physicians (that is medical school graduates who are board certified in their specialty) are very secure in their place in the medical hierarchy. Most could give a heck about the DNP. They do resent when the ANA tries to present it as equivalent in order to get more $$$. Considering you are halfway through your medical education you might learn from that.
This is not about being secure, as a physician and a Nurse I have the responsibility to uphold the high standard of care in the USA.
If you think other physicians do not agree with me then you are wrong, I know of more then a few I have talked to in person and on the internet that are willing to voice this same concern.
I'm here to learn what other nurses think. I know some agree with some of what I think and some completely disagree, thats ok, but I should be allowed my opinions and thought without being insulted.
FNP + DNP (University of Minnesota) Didactic 1040 contact hours clinical ~1000 hours for a total of 2040 hours.
MD didactic 1815 hours clinical 3385 hours for a total of 5200 hours.
In all fairness a BSN is required (except for master/entry programs) for FNP entry. How does the approx 120 semester units of ADN/Upper BSN coursework figure with direct comparison?
Dr. Tammy, FNP/GNP-C
618 Posts
In keeping with your pattern, you are again misinformed. As far as the title "Doctor" for DNP's, out of all 50 states and DC there are only 7 non-enlightened states (relax, Georgia is one of them) by which have restrictions for NP's using the title doctor.
http://www.webnp.net/ajnp.html