Doctoral degree to become an NP???

menetopali · Mar 17, 2009

Doctoral degree to become an NP???

- Would be nice if the training from state to state was essentially the same.
- Would be nice if regulation from state to state was the same.
- Would be nice if the schools included more clinical training.

I don't know all the details but there have been diploma than ASN/BSN, MSN, PHD, and now DNP...
So whats next???

on the first three points - no argument from this corner and I wholeheartedly agree that standardization is the way to go and the continued fracturing of specialty NPs that become codified needs to stop.

as for the last point:

Diploma nurses were the standard and student nurses provided most of the hospital care while registered nurses generally worked privately. a report (Goldsmith) came out in the 1920s recommending a move into academia - it was ignored until the 1950s. In the 1950s a move toward having academic programs attached to the diploma schools failed and the academic programs started to rise at two different levels, the ADN & BSN with academics pushing the BSN while membership and hospitals pushed for ADN. that argument continues to this day with BSN and ADN sitting for the same test to become an RN. The APRN developed separately as a hospital based program (CRNA) in the 19th century [side note - physicians wishing to learn anesthesiology went to nursing school to do it], separate school from nursing entirely (as was the case for midwifery and then CRNM) in the 1920s & 1930s with the FNS, and academic program for mental health (CNS & PMHNP). In the late 1950s Duke college of nursing started a master's level NP program in partnership with the college of medicine which folded after NLN failed to provide accreditation as they had physician faculty. later Duke revived the program without nursing (this became the PA profession) and Ford started a certificate program in Colorado without seeking nursing's approval (this is credited as the first NP program by many sources, even though Duke was first by seven years or so). the DNP has evolved from this last thread with the CRNA, CRNM, and CNS coming into the fold relatively recently.

for the lay public, including policy makers in many cases, the myriad of levels and alphabet soup does nothing but confuse the roles that different nurses play and skills that different nurses have.

the short version is:

education:

ADN - bedside nurse

BSN - bedside nurse, extra education in epidemiology, public health, management

MSN - role specific, may or may not be an APRN

PhD - research / academic doctorate - while may or may not be an academic doctorate - they are primarily academics

DNP - 'practice doctorate', unfortunately - may or may not be an APRN - resulting in even more confusion

license:

CNA - certified nursing assistant - assists a nurse be performing delegated tasks (unlicensed)

LPN - Licensed Practical Nurse - performs many duties of an RN under the delegated authority of the RN

RN - Provides ongoing nursing assessments and nursing treatments as well and may carry out specific orders from authorized providers in their care of patients - is responsible for the care of that patient during their shift

NP - Nurse Practitioner - depending on the state - provides independent care of patients including diagnosis and treatment

certification:

nurses and nurse practitioners may have a number of different certifications which denote special training and experience

while moving toward more consistency between education and level of practice would be helpful, it is unlikely and all of us out in the rest of the world (not academia or nursing "leadership") need to recognize the confusing mess nursing has created for itself and work to untangle it while educating the public.

JDCitizen · Mar 17, 2009

on the first three points - no argument from this corner and I wholeheartedly agree that standardization is the way to go and the continued fracturing of specialty NPs that become codified needs to stop.
as for the last point:
Diploma nurses were the standard and student nurses provided most of the hospital care while registered nurses generally worked privately. a report (Goldsmith) came out in the 1920s recommending a move into academia - it was ignored until the 1950s. In the 1950s a move toward having academic programs attached to the diploma schools failed and the academic programs started to rise at two different levels, the ADN & BSN with academics pushing the BSN while membership and hospitals pushed for ADN. that argument continues to this day with BSN and ADN sitting for the same test to become an RN. The APRN developed separately as a hospital based program (CRNA) in the 19th century [side note - physicians wishing to learn anesthesiology went to nursing school to do it], separate school from nursing entirely (as was the case for midwifery and then CRNM) in the 1920s & 1930s with the FNS, and academic program for mental health (CNS & PMHNP). In the late 1950s Duke college of nursing started a master's level NP program in partnership with the college of medicine which folded after NLN failed to provide accreditation as they had physician faculty. later Duke revived the program without nursing (this became the PA profession) and Ford started a certificate program in Colorado without seeking nursing's approval (this is credited as the first NP program by many sources, even though Duke was first by seven years or so). the DNP has evolved from this last thread with the CRNA, CRNM, and CNS coming into the fold relatively recently.
for the lay public, including policy makers in many cases, the myriad of levels and alphabet soup does nothing but confuse the roles that different nurses play and skills that different nurses have.
the short version is:
education:
ADN - bedside nurse
BSN - bedside nurse, extra education in epidemiology, public health, management
MSN - role specific, may or may not be an APRN
PhD - research / academic doctorate - while may or may not be an academic doctorate - they are primarily academics
DNP - 'practice doctorate', unfortunately - may or may not be an APRN - resulting in even more confusion
license:
CNA - certified nursing assistant - assists a nurse be performing delegated tasks (unlicensed)
LPN - Licensed Practical Nurse - performs many duties of an RN under the delegated authority of the RN
RN - Provides ongoing nursing assessments and nursing treatments as well and may carry out specific orders from authorized providers in their care of patients - is responsible for the care of that patient during their shift
NP - Nurse Practitioner - depending on the state - provides independent care of patients including diagnosis and treatment
certification:
nurses and nurse practitioners may have a number of different certifications which denote special training and experience

Interesting.

ADN / BSN every hospital I have worked in here in Georgia blurred to differences: ADNs in supervisory positions etc. and/or the $1 difference in pay.

while moving toward more consistency between education and level of practice would be helpful, it is unlikely and all of us out in the rest of the world (not academia or nursing "leadership") need to recognize the confusing mess nursing has created for itself and work to untangle it while educating the public.

As long as the unlikely part sticks around untangling the mess probably will continue to drag nursing down for years to come...

PICUPNP · Mar 17, 2009

This has become ridiculous. If we, nurses, want to be called DOCTOR, we need to go to medical school! No shortcuts. This has become likened to "beating a dead horse". I am a PNP and am totally opposed to the DNP and the use of the title. There is enough confusion in the medical field already and this will only add to it. By doing this, the advanced practice world will end up pricing themselves out of jobs. Why hire a DNp when you can hire a new grad physician who requires no oversight. I have no idea, after looking at these different programs, how the DNP would add to my current practice. More classes and clinical hours doing EBP projects and leadership classes, etc, etc......how does this equate to Dr? Can someone explain to me why a NP should be called Dr?

menetopali · Mar 17, 2009

Interesting.
ADN / BSN every hospital I have worked in here in Georgia blurred to differences: ADNs in supervisory positions etc. and/or the $1 difference in pay.
As long as the unlikely part sticks around untangling the mess probably will continue to drag nursing down for years to come...

this difference between a ADN and BSN is very blurry indeed. most places i've worked don't have a pay difference between them. from the hospital view - an "RN" is the important part, not the ADN or BSN (or frankly any other degree like a BA, BS, MBA, MA, MS, or even PhD that a given RN may have). when i got my first nursing job, my BA didn't mean squat, it was the RN that determined my pay. on my third nursing job, neither my BA or BSN meant anything - it was my RN + number of years as an RN that mattered. in my first management gig, the BSN helped me get the job but i was still paid based on the RN + # years as an RN + # years as a manager.

the mess will continue as long as nursing "leadership" fails to take decisive and binding action to put some standardization in place for the different degree levels and different license levels. with the DNP they took a step in the right direction but unfortunately included non-clinical (non-APRN) nurses in the DNP model.

menetopali · Mar 17, 2009

This has become ridiculous. If we, nurses, want to be called DOCTOR, we need to go to medical school! No shortcuts. This has become likened to "beating a dead horse". I am a PNP and am totally opposed to the DNP and the use of the title. There is enough confusion in the medical field already and this will only add to it. By doing this, the advanced practice world will end up pricing themselves out of jobs. Why hire a DNp when you can hire a new grad physician who requires no oversight. I have no idea, after looking at these different programs, how the DNP would add to my current practice. More classes and clinical hours doing EBP projects and leadership classes, etc, etc......how does this equate to Dr? Can someone explain to me why a NP should be called Dr?

if anyone want to be addressed as "Dr" they should complete a doctorate program.

if they want to be called "nurse" they should go to nursing school, if they want to be called "physician" then they should go to medical school, if they want to be called "pharmacist" they should go to pharmacy school, if they want to be called "engineer" they should go to engineering school, if they want to be called "Marine" then they should go to MCRD Parris Island (or OCS Quantico or MCRD San Diego).

the difference is academic title versus professional designation. for example "Dr. XXXX, PsyD - psychologist"; the "Dr" identifies completion of a doctorate program, the "XXXX" is the individual's name, the "PsyD" identifies the type of doctorate, and "psychologist" identifies the profession. Dr. Jones, DNP - Family Nurse Practitioner does the exact same thing while Dr. Smith leaves the question wide open - is this person an college professor, administrator, podiatrist, dentist, chiropractor, optometrist, nurse, physician, psychologist, veterinarian, theologian, or some other kind of doctor?

while physicians seem to object to identifying themselves, nobody else seems to have an issue with it.

Dr. Tammy, FNP/GNP-C · Mar 17, 2009

This has become ridiculous. If we, nurses, want to be called DOCTOR, we need to go to medical school! No shortcuts. This has become likened to "beating a dead horse".

What if I want to go to dental school? Are dentists doctors? Is going through dental school a short cut?

What if I want to go to optometry school? Are optometrists doctors? Is going through optometry school a short cut?

What if I want to go to be a clinical psychologist? Are doctorate-prepared clinical psychologists doctors? Is going through a doctorate-prepared clinical psych program a short cut?

I am a PNP and am totally opposed to the DNP and the use of the title. There is enough confusion in the medical field already and this will only add to it. By doing this, the advanced practice world will end up pricing themselves out of jobs.

If the DNP were not adopted and the decision to do the same were not a nursing-based decision, and we left these important matters up to the medical establishment, you would be correct in stating that we are all in "the medical field." That is we, as nurses, would belong to the field of medicine and not to nursing. Perhaps you would feel more comfortable with nursing changing to become more of an adjunct technician role of medicine, but the vast majority of nursing would not.

Why hire a DNp when you can hire a new grad physician who requires no oversight.

Are you kidding? Are you really not aware that there are 23 states, and growing, where NP's work independently without any oversight? Do you even understand how your argument is counterproductive to the very autonomy that you state does not exist?

I have no idea, after looking at these different programs, how the DNP would add to my current practice. More classes and clinical hours doing EBP projects and leadership classes, etc, etc......how does this equate to Dr? Can someone explain to me why a NP should be called Dr?

Perhaps you should start my first looking at the BSN to dnp programs as to compare a MSN to DNP program is really misrepresenting the intent of the DNP program and is extremly dishonest.

PICUPNP · Mar 17, 2009

I am actually embarassed by any of my NP colleagues who think they are equivalent to physicians. Once again, if you want to be a physcian then go to medical school. As far as being dishonest... all I would like to know is how the DNP will help me to better care for critically ill children? I have no intent on being dishonest. I want someone to explain to me how the courses in the majority of DNP progs. will further my clinical career. Duke's post master's program lists the following as classes for their version of the DNP: Health Systems Planning, Transforming the Nation's Health,Effective Leadership, Data Driven Health Care Improvement, etc. so....tell me how this will improve my ability to maintain a child with Bi-level ventilation, stablize a person in septic shock, manage ECMO patients, etc, etc.??? As far as autonomous practice is concerned, I think that it's a HUGE liability for nurses to manage patients in an independent role with physician backing. An Np in your Doctor's office is one thing but an independent practitioner is another.

menetopali · Mar 17, 2009

I am actually embarassed by any of my NP colleagues who think they are equivalent to physicians. Once again, if you want to be a physcian then go to medical school. As far as being dishonest... all I would like to know is how the DNP will help me to better care for critically ill children? I have no intent on being dishonest. I want someone to explain to me how the courses in the majority of DNP progs. will further my clinical career. Duke's post master's program lists the following as classes for their version of the DNP: Health Systems Planning, Transforming the Nation's Health,Effective Leadership, Data Driven Health Care Improvement, etc. so....tell me how this will improve my ability to maintain a child with Bi-level ventilation, stablize a person in septic shock, manage ECMO patients, etc, etc.??? As far as autonomous practice is concerned, I think that it's a HUGE liability for nurses to manage patients in an independent role with physician backing. An Np in your Doctor's office is one thing but an independent practitioner is another.

first, in many states (including Arizona) NPs currently work independently without any "back-up" from a physician and in many cases the "Doctor's office" is actually an NP's office with no physician around.

second, one of the failures of the DNP implementation was the failure ti include more clinical time and make the MSN-to-DNP a lot of non-clinical material. i certainly don't disagree with that assessment of many programs (including UofA), there are a few that include a lot more clinical time in the DNP including Columbia and a school in Tennessee (ETSU i think) and those that include a little more clinical time (like ASU). as the BSN-to-DNP structure continues to evolve, it will be interesting to see how the clinical aspect develops across programs. if you are looking for more clinical education in a DNP, i recommend you check into Columbia instead of Duke.

Dr. Tammy, FNP/GNP-C · Mar 19, 2009

Once again, if you want to be a physcian then go to medical school.

Good work. In just two career postings you now understand the difference between the terms "doctor" and "physician." Remember, just a day ago you said:

If we, nurses, want to be called DOCTOR, we need to go to medical school!?

all I would like to know is how the DNP will help me to better care for critically ill children?

The DNP is designed to aid nurses in translating best evidence into clinical practice.

As far as autonomous practice is concerned, I think that it's a HUGE liability for nurses to manage patients in an independent role with physician backing. An Np in your Doctor's office is one thing but an independent practitioner is another.

Fortunately, best evidence is followed and, anti DNP agenda on this board notwithstanding, best evidence does drive the fact that ANP's, and yes even DNP's are independent practitioners in 23 states. Again, your claims are clearly biased opinion and not based on fact or evidence.

physasst · Mar 20, 2009

Sorry for the delay in responding, I was at policy meetings in DC and subsequently Chicago. Then I had to work 4 shifts straight in the ED.

I have policy related concerns about the DNP degree, of which BTW, many of your own colleagues agree with, and NO ONE, with the exception of Menopetalli (?sp) has even attempted to answer. I guess because I was against the war in Iraq, I am an anti-american????? See how silly that sounds.

Every committee, including pharmacy, finance, midlevels, etc.etc.etc. at Mayo Clinic is led by a physician. Every single one. Ours, the midlevel committee, is led, and chaired by an anesthesiologist. Mayo has significant concerns regarding the use of the title for several reasons, none of which are about any NP bias. Mayo has concerns because MANY of our patients are international patients who come expecting the world famous clinic to solve their complicated medical problems, some of these patients will not even know what an NP or PA is. Also, we tend to have higher profile patients, some of whom have quite a bit of wealth, they have certain expectations regarding their care, for better or worse.

Mayo is an extremely conservative, Physician led and run institution, for many years, and yes, I have been here too long I think sometimes, we had a policy in place that stated that ANY patient who was new to Mayo Clinic MUST be seen by a physician. When we were attempting to get our fast track hallway off the ground in the ED, Mayo initially mandated that a physician staff it with us. It was like fighting against a brick wall, but finally, we got them to concede that problem focused exams and treatment for new patients could be accomplished independently by PA's and NP's. This policy has now changed, and states that any new self referred patient can be seen and managed independently by a midlevel provider as to their departments discretion. And believe me, this varies WIDELY by department. The policy also states that any new physician referred patient, must be seen by a physician, no exceptions. Mayo is very conservative, and for a long time, was considered, a "black hole" for midlevel providers, as advancement was considered very difficult, and autonomy is very limited. This has improved considerably, and in the ED, we have more autonomy than almost anywhere else in the institution.

I also have to concede that the policy at Mayo has not been enacted yet. Largely, because we only have one DNP on staff, and she is an administrator whom I know well. In fact, we are having lunch this coming Thursday to discuss several other issues. I thought after our meeting in October, the language that was crafted would be enacted as policy, and in fact was told just that by our physician leadership, so just the other day I ran into one of our physician leaders, and asked him about this. His reply was that the language was still there, and the policy was waiting to be approved, BUT, that the Clinic was waiting to see how things played out in DC. I think personally, the leadership is hoping that congress will pre-empt them, and they won't have to be potentially seen as anti NP and subsequently have to deal with it. At any rate, it is not policy currently, contrary to what I was told, and I am a big enough person to admit when I was wrong. As far as Mayo-Scottsdale or Jacksonville, their policies can vary considerably from what Rochester does, as although they are under the Mayo umbrella, they function as distinct and separate entities. Please be aware, that although this is not policy currently, it was written, it is sitting with the Board right now, while DC plays out there game.

The "Truth and Transparency" act has been introduced twice..First as HR5568 in the 05-06 congress, and then as the more recent introduction that is sitting in the house subcommittee. To think that the AMA will not puch forward with this again, after trying twice is folly. They are changing the language to remove opposition from other groups (Chiros, Optometry, Psych, Podiatry, etc), they are also making the language tougher as pertains to midlevels. And this affects PA's too. Those PA's that graduate from the Baylor EM program will be restricted as well.

Lastly, I was recently approached about precepting Acute Care NP's as part of an ACNP clinical rotation at Mayo, and I said yes wholeheartedly.....

WitnessRN · Mar 21, 2009

Physasst: I read your blog online and you are very bias in your opinion regarding this subject.

Sorry for the delay in responding, I was at policy meetings in DC and subsequently Chicago. Then I had to work 4 shifts straight in the ED.
I have policy related concerns about the DNP degree, of which BTW, many of your own colleagues agree with, and NO ONE, with the exception of Menopetalli (?sp) has even attempted to answer. I guess because I was against the war in Iraq, I am an anti-american????? See how silly that sounds.
Every committee, including pharmacy, finance, midlevels, etc.etc.etc. at Mayo Clinic is led by a physician. Every single one. Ours, the midlevel committee, is led, and chaired by an anesthesiologist. Mayo has significant concerns regarding the use of the title for several reasons, none of which are about any NP bias. Mayo has concerns because MANY of our patients are international patients who come expecting the world famous clinic to solve their complicated medical problems, some of these patients will not even know what an NP or PA is. Also, we tend to have higher profile patients, some of whom have quite a bit of wealth, they have certain expectations regarding their care, for better or worse.
Mayo is an extremely conservative, Physician led and run institution, for many years, and yes, I have been here too long I think sometimes, we had a policy in place that stated that ANY patient who was new to Mayo Clinic MUST be seen by a physician. When we were attempting to get our fast track hallway off the ground in the ED, Mayo initially mandated that a physician staff it with us. It was like fighting against a brick wall, but finally, we got them to concede that problem focused exams and treatment for new patients could be accomplished independently by PA's and NP's. This policy has now changed, and states that any new self referred patient can be seen and managed independently by a midlevel provider as to their departments discretion. And believe me, this varies WIDELY by department. The policy also states that any new physician referred patient, must be seen by a physician, no exceptions. Mayo is very conservative, and for a long time, was considered, a "black hole" for midlevel providers, as advancement was considered very difficult, and autonomy is very limited. This has improved considerably, and in the ED, we have more autonomy than almost anywhere else in the institution.
I also have to concede that the policy at Mayo has not been enacted yet. Largely, because we only have one DNP on staff, and she is an administrator whom I know well. In fact, we are having lunch this coming Thursday to discuss several other issues. I thought after our meeting in October, the language that was crafted would be enacted as policy, and in fact was told just that by our physician leadership, so just the other day I ran into one of our physician leaders, and asked him about this. His reply was that the language was still there, and the policy was waiting to be approved, BUT, that the Clinic was waiting to see how things played out in DC. I think personally, the leadership is hoping that congress will pre-empt them, and they won't have to be potentially seen as anti NP and subsequently have to deal with it. At any rate, it is not policy currently, contrary to what I was told, and I am a big enough person to admit when I was wrong. As far as Mayo-Scottsdale or Jacksonville, their policies can vary considerably from what Rochester does, as although they are under the Mayo umbrella, they function as distinct and separate entities. Please be aware, that although this is not policy currently, it was written, it is sitting with the Board right now, while DC plays out there game.
The "Truth and Transparency" act has been introduced twice..First as HR5568 in the 05-06 congress, and then as the more recent introduction that is sitting in the house subcommittee. To think that the AMA will not puch forward with this again, after trying twice is folly. They are changing the language to remove opposition from other groups (Chiros, Optometry, Psych, Podiatry, etc), they are also making the language tougher as pertains to midlevels. And this affects PA's too. Those PA's that graduate from the Baylor EM program will be restricted as well.
Lastly, I was recently approached about precepting Acute Care NP's as part of an ACNP clinical rotation at Mayo, and I said yes wholeheartedly.....

cruisin_woodward · Mar 21, 2009

I really feel like we are beating a dead horse...we are all repeating ourselves...it's getting boring LOL...I think we all agree the DNP is in need of tweaking..I'm sure that will come with time...we are not going to agree to the use of the title "Dr", and unless the ACNP gets to lobbying....who knows. It is frustrating me that there is so many nurses, and not ONE strong voice...too many "chiefs" if you will...imagine what could happen if all of our voices were heard? This subject has already been covered too...