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New Paradigm for the DNP. What do you think?

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KetafolDNP has 8 years experience as a CRNA and specializes in Anesthesia Critical Care.

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Hello,

I care about the nursing profession, and I think the DNP is an important step forward for our profession. I am a MS prepared CRNA. I am working on my DNP currently. I have some thoughts I'd like to offer. I welcome all input. This is not meant to be inflammatory, only constructive. I care deeply for our profession so please keep that in mind as you offer your critique. With the DNP Essentials task force meeting on advanced practice education coming up, I have been collecting some thoughts I intend to voice. Here they are:

The American Association of Colleges of Nursing (AACN) Position Statement on the Practice Doctorate in Nursing (2004) identified 7 areas of “core content” for the DNP. I have organized these into what I consider to be the primary competencies and secondary competencies. I loosely define primary competencies as the knowledge and skills needed to care for the patient in front of you. Secondary competencies are the knowledge and skills needed to care for a healthcare system. These competencies are taken directly from the AACN.

Primary Competencies

  • Scientific underpinnings for practice
  • Advanced nursing practice
  • Analytic methodologies related to the evaluation of practice and the application of evidence for practice

Secondary Competencies

  • Organization and system leadership/management, quality improvement and system thinking
  • Health policy development, implementation and evaluation
  • Interdisciplinary collaboration for improving patient and population healthcare outcomes
  • Utilization of technology and information for the improvement and transformation of healthcare

1. Movement from MSN to DNP has expanded secondary competencies, but NOT primary competencies, which is very disappointing. My opinion is that movement to a practice doctorate should include greater content in primary competencies.

2. More and more nurses are becoming APRNs earlier in their careers, and the secondary competencies are less meaningful to them at this point. Teaching these secondary competencies (e.g. systems leadership) to those who are most focused on honing their clinical decision making and who are less concerned for these secondary competencies, is unlikely to be effective.

4. Only training APRNs who are fully interested in these secondary competencies is unlikely to meet the demand of society for APRNs, would be difficult to identify during the application process, and would lead applicants to be inauthentic.

5. Training paths exist for those who wish to pursue non-APRN DNP in systems leadership, informatics, nursing education etc. There are also leadership/informatics certificates, as well as CNL courses of training. I recommended unburdening APRN-DNP programs from some or all of these secondary competencies so that the programs may focus on primary competencies.

6. Not every APRN can/will be a healthcare leader. Many of us need to be healthcare soldiers. and we need to receive all the tools in our education to do that. That HAS to be our primary objective for APRNs. If we don’t accomplish this, then the leadership competencies are meaningless.

7. I recommend DNP-APRN programs focus on the primary competencies. DNP programs that do not prepare students for APRN roles (leadership, nursing education) should emphasize the secondary competencies. This way, DNP prepared nurses receive the expertise in their areas of interest, instead of partial knowledge in both types of competencies.

 

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sleepwalker has 16 years experience as a MSN, NP and specializes in Occupational Health.

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I think this is a nice summative oration regarding  the long-standing anecdotal observation that the DNP  lacks a strong clinical focus in relation to enhancing APRN practice. 

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KatieMI has 6 years experience as a BSN, MSN, RN and specializes in ICU, LTACH, Internal Medicine.

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On 5/20/2020 at 12:27 PM, KetafolDNP said:

Primary Competencies

  • Scientific underpinnings for practice
  • Advanced nursing practice
  • Analytic methodologies related to the evaluation of practice and the application of evidence for practice

Secondary Competencies

  • Organization and system leadership/management, quality improvement and system thinking
  • Health policy development, implementation and evaluation
  • Interdisciplinary collaboration for improving patient and population healthcare outcomes
  • Utilization of technology and information for the improvement and transformation of healthcare

1). Are they FINALLY going to teach APRNs biochem, normophis, pharma and patho at the level they really need to know them? If not, then I personally do not care about any other "underpinnings" whatever they might mean. 

2) Hm... what exactly I am doing as an MSN hospitalist if not already practicing "advanced nursing practice"? I do not feel I need any theoretical courses to just continue to do that. 

3). Could be a good thing if started from those "scientific underpinning". For example, from Bayesian statistics. But you need at least Calculus II to understand it... oh, bother, we do not have time for that, we need to fit in 20 more credits of Introduction into Basics of Advanced Nursing Theory levels I, Ii and IIII!

4). I personally (and many other APRNs) are not in any degree interested in leadership, quality, schmality, policies and schmolicies. I am a clinician. I come to work to treat people, not to sit my pants through while making others' lives even more hell than they already are. Anything wrong with it? Plus, I've just seen a whole line of those who did not survive Physical Assessment course and transferred to Nursing Leadership and now looking for jobs. If they were learning those schmolicies and stuff for two years, isn't it their job to develop, implement and evaluate all that? 

5). Re. "interdisciplinary collaboration", they better teach APRNs how correctly consult/refer out. It is no good when an APRN who know the patient better than any other provider cannot do peer-to-peer because she just doesn't know how to speak with a specialist, gets all whipped up out of sheer panic and appeals to that one-size-fits-all excuse of "scope of practice". 

6). To be a user, you need to just use the technology that is already available. To develop programs and apps, you need to be an IT, not a DNP (not that these two things were mutually excluding but I hope you got the idea). And if you do not know how to use Zoom for tele visits, ask any teenager, most of them are hangin' on it 24/7. My 16 years old taught me how to do it in exactly 5 minutes.

Does it all worth tens of thousands of dollars and several years? For me, definitely not. I will never consider DNP unless it becomes at least 80% clinical and get level of training as close to M.D. as possible. 

Edited by KatieMI

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KetafolDNP has 8 years experience as a CRNA and specializes in Anesthesia Critical Care.

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40 minutes ago, KatieMI said:

1). Are they FINALLY going to teach APRNs biochem, normophis, pharma and patho at the level they really need to know them? If not, then I personally do not care about any other "underpinnings" whatever they might mean. 

2) Hm... what exactly I am doing as an MSN hospitalist if not already practicing "advanced nursing practice"? I do not feel I need any theoretical courses to just continue to do that. 

3). Could be a good thing if started from those "scientific underpinning". For example, from Bayesian statistics. But you need at least Calculus II to understand it... oh, bother, we do not have time for that, we need to fit in 20 more credits of Introduction into Basics of Advanced Nursing Theory levels I, Ii and IIII!

4). I personally (and many other APRNs) are not in any degree interested in leadership, quality, schmality, policies and schmolicies. I am a clinician. I come to work to treat people, not to sit my pants through while making others' lives even more hell than they already are. Anything wrong with it? Plus, I've just seen a whole line of those who did not survive Physical Assessment course and transferred to Nursing Leadership and now looking for jobs. If they were learning those schmolicies and stuff for two years, isn't it their job to develop, implement and evaluate all that? 

5). Re. "interdisciplinary collaboration", they better teach APRNs how correctly consult/refer out. It is no good when an APRN who know the patient better than any other provider cannot do peer-to-peer because she just doesn't know how to speak with a specialist, gets all whipped up out of sheer panic and appeals to that one-size-fits-all excuse of "scope of practice". 

6). To be a user, you need to just use the technology that is already available. To develop programs and apps, you need to be an IT, not a DNP (not that these two things were mutually excluding but I hope you got the idea). And if you do not know how to use Zoom for tele visits, ask any teenager, most of them are hangin' on it 24/7. My 16 years old taught me how to do it in exactly 5 minutes.

Does it all worth tens of thousands of dollars and several years? For me, definitely not. I will never consider DNP unless it becomes at least 80% clinical and get level of training as close to M.D. as possible. 

Hey KatieMI,

Thanks for your reply. I think it expresses a common and important opinion. Those DNP policies listed were created by the American Association of Colleges of Nursing to include all DNP competencies - meaning for BSN-DNP programs. My general argument is that only the first three “primary competencies” are what matter for a clinically focused practice doctorate for APRNs. It sounds like you agree?

theres a meeting approaching with the powers that be to discuss the future of the DNP. Part of this post was to see if others feel the way I do about the DNP in that it needs to more rigorous focus on physiology, Patho, and clinical medicine.

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KatieMI has 6 years experience as a BSN, MSN, RN and specializes in ICU, LTACH, Internal Medicine.

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24 minutes ago, KetafolDNP said:

Hey KatieMI,

Thanks for your reply. I think it expresses a common and important opinion. Those DNP policies listed were created by the American Association of Colleges of Nursing to include all DNP competencies - meaning for BSN-DNP programs. My general argument is that only the first three “primary competencies” are what matter for a clinically focused practice doctorate for APRNs. It sounds like you agree?

theres a meeting approaching with the powers that be to discuss the future of the DNP. Part of this post was to see if others feel the way I do about the DNP in that it needs to more rigorous focus on physiology, Patho, and clinical medicine.

I agree. The problem is, currently students in BSN/DNP programs cannot be taught physo, patho, pharma and other theoretical base subjects at the level required for their future practice because they have no base knowledge and no basic critical thinking/analytical skills to understand and apply them. They do not study organics, biochem, physics and mathematics/statistics beyond the basic college level, which is simply not sufficient.

Because the students cannot learn what they need to learn, leave alone the fact that there will be a acute paucity of instructors and facilities able to provide such level of teaching with oversupply of faculty from Ivory Towers of "nursing science", and all the powers know that, the "scientific underpinnings" they propose  will more than likely consist of yet another round of fluff and buff. And the things will stay where they are now despite all the best efforts. 

 

Edited by KatieMI

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KetafolDNP has 8 years experience as a CRNA and specializes in Anesthesia Critical Care.

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2 minutes ago, KatieMI said:

I agree. The problem is, currently students in BSN/DNP programs cannot be taught physo, patho, pharma and other theoretical base subjects at the level required for their future practice because they have no base knowledge and no basic critical thinking/analytical skills to understand and apply them. They do not study organics, biochem, physics and mathematics/statistics beyond the basic college level, which is simply not sufficient.

Because the students cannot learn what they need to learn, leave alone the fact that there will be a acute paucity of instructors and facilities able to provide such level of teaching, and all the powers know that as well as me and you, the "scientific underpinnings" they propose  will more than likely consist of yet another round of fluff like "nursing science" and "nursing research". And the things will stay where they are now despite all the best efforts. 

 

For current students you might be right. For future students I am more hopeful. If that means there will be less faculty for a while and less programs than so be it, but that should not stymie progress. 
 

one example - while I did take Chemistry, organic, biochem, bio/microbio etc as an undergrad - I did not take physics. Anesthesia requires a sound knowledge of physics and Chemistry. My program very effectively had a course called physics and Chemistry for  anesthesia practice. Integrating necessary scientific underpinnings CAN be done in DNP programs but we need to agree that they’re important and make room for them. 
 

Thanks again for your input!!

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336 Posts; 5,326 Profile Views

Thanks for sharing your thoughts. I agree with a lot of what has been said. But I think there is another pressing problem facing all of advance practice education (be it at the MSN or DNP level), namely that the approach to advancing nursing education has generally revolved around requiring more coursework and is heavily focused on the didactic mode of education. I think a critical flaw in the inconsistency and general lack of rigor in clinical education. There is only so much you can learn about any practice disciple in a classroom (including an online classroom where most of this content is now being delivered). What is really lacking is quality clinical education with ample opportunities to apply this knowledge with the support of quality clinical mentors. 

I think another major shortcomings is in Essential 1: Scientific Underpinnings for Practice. For example, in my MSN program at a top-ranked program, we had a course called Scientific Underpinning for Advanced Practice Nursing but it was co-taught by 2 faculty members, neither of whom were APRNs and the content of the course was entirely on "nursing science" without any regard for clinically-relevant sciences. Our first class was on the philosophy of science with discussions of Kuhn, Popper, and Feyerabend. The remainder of the course was understanding nursing research including lectures on sampling, literature reviews, study design, etc... Now I think there is certainly value in some of this content especially in being a critical consumer of research but I would content this has more to do with Essential 3: Clinical Scholarship and Analytical Methods for Evidence-Based Practice. I think when you say "scientific basis for nursing practice" to PhD prepared nurses (who, let's be honest, created and are still the most influential in the content and structure of DNP programs), that means something very different that it means to a clinician.

I really think this content is over-represented in most programs at the expense of clinically-oriented sciences like physiology, pathology, even relevant ideas from the social sciences. I think this shortcoming has also cost advanced practice nursing a lot of ground in the minds of other healthcare providers who have vastly more clinical sciences as part of their training. 

I think there is incredible value in, what the OP termed the secondary competencies and cringe a little every time someone refers to these as "fluff". Nevertheless, I think these dominate far too much of most programs while simultaneously not being done well (as KateMI suggested with interdisciplinary collaboration). I think a quality approach in when this content is developed through clinical practice and not through lectures, papers, or readings. Certainly, some didactic education is foundational but the best way to learn and improve on interdisciplinary collaboration, for instance, is to do it in authentic situations with supportive feedback and lots of opportunities to practice and improve. I think the same applies to policy, technology in healthcare, quality improvement, and leadership. Physicians, for example, learn these same skills through thousands of hours of clinical experience with feedback and support for more experienced clinicians and utilizing them in the actual practice of medicine rather than in a lecture hall or discussion board. 

For that matter, the primary competencies also require lots of mentored clinical practice to develop. I think nursing could do a much better job of laying the foundations but probably the biggest failure is in rigorous, quality clinical experience with adequate mentoring and supervision to integrate these competencies into practice and get feedback and opportunities to improve.  

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KetafolDNP has 8 years experience as a CRNA and specializes in Anesthesia Critical Care.

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29 minutes ago, pro-student said:

I think another major shortcomings is in Essential 1: Scientific Underpinnings for Practice. For example, in my MSN program at a top-ranked program, we had a course called Scientific Underpinning for Advanced Practice Nursing but it was co-taught by 2 faculty members, neither of whom were APRNs and the content of the course was entirely on "nursing science" without any regard for clinically-relevant sciences. Our first class was on the philosophy of science with discussions of Kuhn, Popper, and Feyerabend. The remainder of the course was understanding nursing research including lectures on sampling, literature reviews, study design, etc... Now I think there is certainly value in some of this content especially in being a critical consumer of research but I would content this has more to do with Essential 3: Clinical Scholarship and Analytical Methods for Evidence-Based Practice. I think when you say "scientific basis for nursing practice" to PhD prepared nurses (who, let's be honest, created and are still the most influential in the content and structure of DNP programs), that means something very different that it means to a clinician.

I really think this content is over-represented in most programs at the expense of clinically-oriented sciences like physiology, pathology, even relevant ideas from the social sciences. I think this shortcoming has also cost advanced practice nursing a lot of ground in the minds of other healthcare providers who have vastly more clinical sciences as part of their training. 

 

Thank you for your comment! It is very constructive. I agree with everything you said. I'd summarize it as:

(1) Overemphasis on secondary competencies in DNP programs, at the expense of primary competencies.

(2) Non clinicians shaping clinical DNP programs can be problematic

(3) Room to improve quality and quantity of clinical experiences.

In particular I appreciate your point about scientific underpinnings for practice. I always interpreted this as advanced physiology/patho, pharmacology, health assessment, etc. But it seems like programs take a wide interpretation on this. Hearing your experience is frustrating and likely very common! I think DNP programs should have a year of physio/patho. 

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ProgressiveThinking has 7 years experience as a MSN, CRNA and specializes in Anesthesia.

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I'm a MS prepared CRNA as well, and I completely agree that the DNP lacks application to most advanced practice nurses.  While I don't necessarily think that a non-APRN who wants to obtain a degree with a specialization in say, leadership should have to repeat any hard sciences, I do wish that an BSN-DNP FNP or BSN - DNAP (CRNA) would add additional clinical hours (mainly for NPs though since CRNAs have a minimum of 2000 clinical hours), or applicable courses that can actually be applied to clinical practice, e.g. extra regional anesthesia, cardiothoracic anesthesia, or transesophageal echocardiography, etc. instead of fluff courses that require bogus capstone projects.

The post-master's DNP program that I'm pursuing will have zero application to anesthesia, but I'm doing it because it's a hybrid program (not completely online) at a big name institution and I'm hoping it will open more doors for me in the future through networking.

The problem with making a post-master's DNP more difficult, especially for working professionals is less people will apply, and at the end of the day these programs exist to make the institution money, unfortunately. This is especially applicable to individuals like me who went to a CRNA program that was heavy in the chem/biochem/o-chem, patho, pharm and graduated with 3000+ clinical hours. 

I think a good idea would be to add more hard sciences to BSN-DNP programs, and have post-master's programs that will help an APRN improve clinically. 

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KatieMI has 6 years experience as a BSN, MSN, RN and specializes in ICU, LTACH, Internal Medicine.

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6 hours ago, ProgressiveThinking said:

While I don't necessarily think that a non-APRN who wants to obtain a degree with a specialization in say, leadership should have to repeat any hard sciences...

I just recently had a dialogue with one dudette from nursing leadership of the large tertiary academic center. As pretty much anywhere else, the policy for bedside nurses here is to access  and document the effect of PRN pain meds within certain period of time, 60 to 90 minutes depending on the unit and circumstances. 

Now, trying to "improve satisfaction level", they produced an idea of doing it with all pain killers including extended release. If within those 60 minutes "client" is still "not satisfied", then the RN has an option to administer unscheduled PRN dose without order and repeat it in another 60 minutes and so forth till "satisfaction" is achieved. 

I tried for a whole hour to explain her that Duralgesic, OxyContin and other extended release forms will not work in 60 minutes because they designed this way. She openly admitted having no idea about "half life" and other stuff. Instead, her single argument was: "it is not my job to care about all that. I see the word "morphine", so it is supposed to work as morphine, and I do not understand why you always so brainy and insisting and messing our beautiful policies all up". 

Direct BSN to DNP leadership program victim, classic edition. Thanks God, her higher up worked as bedside RN for quarter of the century. 

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ProgressiveThinking has 7 years experience as a MSN, CRNA and specializes in Anesthesia.

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7 hours ago, KatieMI said:

I just recently had a dialogue with one dudette from nursing leadership of the large tertiary academic center. As pretty much anywhere else, the policy for bedside nurses here is to access  and document the effect of PRN pain meds within certain period of time, 60 to 90 minutes depending on the unit and circumstances. 

Now, trying to "improve satisfaction level", they produced an idea of doing it with all pain killers including extended release. If within those 60 minutes "client" is still "not satisfied", then the RN has an option to administer unscheduled PRN dose without order and repeat it in another 60 minutes and so forth till "satisfaction" is achieved. 

I tried for a whole hour to explain her that Duralgesic, OxyContin and other extended release forms will not work in 60 minutes because they designed this way. She openly admitted having no idea about "half life" and other stuff. Instead, her single argument was: "it is not my job to care about all that. I see the word "morphine", so it is supposed to work as morphine, and I do not understand why you always so brainy and insisting and messing our beautiful policies all up". 

Direct BSN to DNP leadership program victim, classic edition. Thanks God, her higher up worked as bedside RN for quarter of the century. 

I think that's more of an example that DNP programs should require experience for admission, or that hospitals shouldn't hire people into a role where they're expected to establish clinical guidelines without any clinical experience. It sounds like her undergrad nursing program failed her as well.

It also sounds like her DNP program's pharmacology course failed her as well. Perhaps the quality of the courses already given, since MSN and BSN-DNP programs are required to have pharm, patho, and physical assessment courses as part of their curriculum, should be evaluated. I don't know that one nurses mishap means we should add calculus and physics to a nursing leadership degree though. I definitely agree with you when you say that DNP curriculum is watered down needs revamping, though.

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KatieMI has 6 years experience as a BSN, MSN, RN and specializes in ICU, LTACH, Internal Medicine.

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1 hour ago, ProgressiveThinking said:

I think that's more of an example that DNP programs should require experience for admission, or that hospitals shouldn't hire people into a role where they're expected to establish clinical guidelines without any clinical experience. It sounds like her undergrad nursing program failed her as well.

It also sounds like her DNP program's pharmacology course failed her as well. Perhaps the quality of the courses already given, since MSN and BSN-DNP programs are required to have pharm, patho, and physical assessment courses as part of their curriculum, should be evaluated. I don't know that one nurses mishap means we should add calculus and physics to a nursing leadership degree though. I definitely agree with you when you say that DNP curriculum is watered down needs revamping, though.

One will never understand statistics without calculus. And all quality improvement, policy development and outcomes are  based, essentially, on statistics. 

I do not support the idea that bedside experience must be required for all advanced studies in nursing. Basic bedside skills (thecway they are actually practiced) have little to do with functions of any nurse with advanced degree. I even agree with point of view common among physicians that nurses should progress with advanced degrees at no more than 3 years from BSN because after it they generally run into bad habits like calling instead of thinking. In ideal world, those who want to go into advanced degrees from the very beginning could be separated into a cohort by rigorous admission procedures and pipelined through degrees with level of didactic of at least PA school and several thousands of hours of closely supervised, specialty-centered clinicals. This would allow talented and high-achieving students to avoid lateral violence, antiintellectualism and bullying of bedside nursing. Those who do not decide for "advanced track" may continue with their initial degrees; if at any point they want to proceed further with their education they must complete all required science coursework within limited period of time and with reasonably high scores before joining MSN or DNP program and then do all required coursework and clinical hours there. 

 

 

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