New Paradigm for the DNP. What do you think?

[KetafolDNP]

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.

[ProgressiveThinking, MSN, CRNA]

21 hours ago, KatieMI said:

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.

Never have I ever met a physician who cared so much about the nursing admissions process to comment that one should pursue advanced practice after 3 years.

Also, a lot of the basic mistakes that you mentioned that BSN-DNP nurse made is learned at the bedside with ICU being one of the prime areas to learn this stuff. I never experienced lateral violence or anti-intellectualism at the bedside. We were encouraged to take courses that would help us grow clinically, and our hospital would pay for it. If anything, there was an unspoken competition about who could get more "certifications," and who was capable of taking care of the sickest of the sick, e.g. crashing trauma, septic patient on multiple vasopressors about to code, etc. This bedside experience is something I still use today and fall back on when anesthetizing sick patients.

Granted, I worked in unionized California hospitals where nurses had nurse-to-patient ratios and were paid 100k+, which may have attracted a different demographic to the field than a hospital in a state without ratios that pays 25/hour would.

If anything, working in a nursing home as a LVN passing medications for 30+ patients taught me time management. Working in med-surg allowed to learn to quickly sift through information, analyze it and respond accordingly. Working in step-down prepared me to work in the ICU. My ICU experience nicely prepared me for anesthesia school and my current practice is a culmination of all of my experience and education.

Sure, you might not need this type of experience as a FNP practicing in primary care, but would I rather have a FNP with 10+ years of cardiothoracic and ER experience be my PCP, or a brand new BSN-DNP without any prior experience be my PCP if they graduated from the same program? I would personally choose the former.

I think the beauty of nursing is that people can advance their education and change their specialty rather easily. I don't think that creating more barriers for people to improve their situation and learn more is the answer. I do however think that the quality of programs and their curriculum should be examined and beefed up academically as long as its relevant to their specialty. Use the extra months and credits to give CRNAs more regional/cardiothoracic/US/TEE, FNPs more clinical hours and specialty rotations, nurse leaders more admin rotations that are relevant , etc. Better this than doing an irrelevant capstone project.

[WestCoastSunRN, MSN, CNS]

20 hours ago, ProgressiveThinking said:

Never have I ever met a physician who cared so much about the nursing admissions process to comment that one should pursue advanced practice after 3 years.

Also, a lot of the basic mistakes that you mentioned that BSN-DNP nurse made is learned at the bedside with ICU being one of the prime areas to learn this stuff. I never experienced lateral violence or anti-intellectualism at the bedside. We were encouraged to take courses that would help us grow clinically, and our hospital would pay for it. If anything, there was an unspoken competition about who could get more "certifications," and who was capable of taking care of the sickest of the sick, e.g. crashing trauma, septic patient on multiple vasopressors about to code, etc. This bedside experience is something I still use today and fall back on when anesthetizing sick patients.

Granted, I worked in unionized California hospitals where nurses had nurse-to-patient ratios and were paid 100k+, which may have attracted a different demographic to the field than a hospital in a state without ratios that pays 25/hour would.

If anything, working in a nursing home as a LVN passing medications for 30+ patients taught me time management. Working in med-surg allowed to learn to quickly sift through information, analyze it and respond accordingly. Working in step-down prepared me to work in the ICU. My ICU experience nicely prepared me for anesthesia school and my current practice is a culmination of all of my experience and education.

Sure, you might not need this type of experience as a FNP practicing in primary care, but would I rather have a FNP with 10+ years of cardiothoracic and ER experience be my PCP, or a brand new BSN-DNP without any prior experience be my PCP if they graduated from the same program? I would personally choose the former.

I think the beauty of nursing is that people can advance their education and change their specialty rather easily. I don't think that creating more barriers for people to improve their situation and learn more is the answer. I do however think that the quality of programs and their curriculum should be examined and beefed up academically as long as its relevant to their specialty. Use the extra months and credits to give CRNAs more regional/cardiothoracic/US/TEE, FNPs more clinical hours and specialty rotations, nurse leaders more admin rotations that are relevant , etc. Better this than doing an irrelevant capstone project.

Well said! I think capstones should be a part of the DNP and can be completely relevant, though. I think any doctorally prepared nurse should be well familiar with how to conduct research - and for that reason, I'm glad my program is run by PhDs (who have that philosophy). Also, part of our clinical hours are spent on gaining clinical competency we did not have to have in our MSN program. This is very individualized and not well-structured, however, the opportunity and expectation is there. Like much of higher ed, you get out of it what you put into it. This is true for medical students and resident physicians, as well.

I don't think advanced practice nursing should be modeled after medical education. There is ample room for improvement in admission standards and program content, no doubt, but if one has the desire to practice with the full knowledge and scope of a physician, they should go to medical school. Advanced practice providers play an important role in healthcare - it need not mimic medical education (though we should definitely borrow from it where it makes sense!). More time spent in patho and pharm -- YES! But honestly, I did not need more "hard science" to understand my patho and pharm -- I just would have liked more time devoted to it.

But there are many ways we could improve DNP education for APRNs. I like how the OP is thinking outside the box.

[FiremedicMike, RN, EMT-P]

On 5/24/2020 at 4:26 PM, KatieMI said:

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.

I took a basic statistics class that only required algebra. I do think I'm pretty strong in math, but that's neither here nor there.

I feel like my basic statistics class taught me enough to be able to evaluate the strength of a study in order to guide my thinking.

I'll admit this may be a case of "I don't know what I don't know" - but I'd love to hear why a more advanced understanding of statistics is necessary for medical practice, unless your goal is medical research?

[KatieMI, BSN, MSN, RN]

2 hours ago, FiremedicMike said:

I took a basic statistics class that only required algebra. I do think I'm pretty strong in math, but that's neither here nor there.

I feel like my basic statistics class taught me enough to be able to evaluate the strength of a study in order to guide my thinking.

I'll admit this may be a case of "I don't know what I don't know" - but I'd love to hear why a more advanced understanding of statistics is necessary for medical practice, unless your goal is medical research?

Even my superficial understanding of Bayesian analysis really helped me to be less panicky during COVID19 pandemy, because it showed early that "catastrophic models" predicting hundreds of millions contacts and millions of deaths were with over 90%+ probability not gonna to get real.

My kiddo started book named "How to lie with statistics" when she was 7 or 8 (it made our lives much less comfortable for a while). Now she is 16, and I tried to bring her the study ads from drug reps just out of interest. She found statistical "inconsistencies" in over 75% of them, which made me reading thr stuff much closer before jumping into yet another bandwagon.

[FullGlass, BSN, MSN, NP]

On 5/24/2020 at 1:26 PM, KatieMI said:

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.

Calculus is not required to understand statistics or epidemiology. While physics is useful for some specialties, it is not relevant to most clinicians.

We, as APRNs, need better clinical education. I was in primary care and am now moving into mental health. Physics is completely irrelevant for me. I don't need calculus to understand the statistics and epidemiology required for my specialties.

[Neuro Guy NP, DNP, PhD, APRN]

To be honest, the PhD in Nursing does not reinforce clinical content beyond the APRN specialty either, so to a large extent people are misunderstanding the purpose of a doctorate. If the content doesn't interest, then just don't go get a doctorate. Plain and simple. But don't belittle the degree or assume it has little value. It just doesn't interest you, doesn't mean it's valueless. A degree in accounting isn't appealing to me, but I'd never say it's meaningless.

But to continue the discussion, it would be interesting to have the practice doctorate include more clinical content applicable to daily practice, but the theoretical and practice change content should remain. That way it can still focus on the translational aspect of incorporating evidence and change management better. That's the intent of the degree, and again, people need not register if they don't appreciate the degree. Remain educated at the master's level - nothing wrong with that. Just my two cents.

[KetafolDNP, DNP, CRNA, NP]

16 hours ago, Neuro Guy NP said:

To be honest, the PhD in Nursing does not reinforce clinical content beyond the APRN specialty either, so to a large extent people are misunderstanding the purpose of a doctorate. If the content doesn't interest, then just don't go get a doctorate. Plain and simple. But don't belittle the degree or assume it has little value. It just doesn't interest you, doesn't mean it's valueless. A degree in accounting isn't appealing to me, but I'd never say it's meaningless.

But to continue the discussion, it would be interesting to have the practice doctorate include more clinical content applicable to daily practice, but the theoretical and practice change content should remain. That way it can still focus on the translational aspect of incorporating evidence and change management better. That's the intent of the degree, and again, people need not register if they don't appreciate the degree. Remain educated at the master's level - nothing wrong with that. Just my two cents.

Thanks for your two cents. I agree that the DNP should include translational science as that is directly applicable to clinical practice. I’m reminded that in its inception - the AACNs 2004 position paper - the DNP was only meant to be for APRNs. Somewhere along the way it also became for nurse leadership, nurse informatics, etc. I’m not saying that’s a bad thing, but when they decided APRNs and non-APRNs should have the same requirements in terms of the “doctoral” portion I think that was a misguided choice in the name of compromise and uniformity.

What the DNP is ultimately gets decided by about 100 people. The purpose of this was to give the rest of us in the profession a voice in what we think it ought to be.

[ProgressiveThinking, MSN, CRNA]

I was just accepted to a DNP program at a public research university that's ranked top 10 for public schools, and is nationally ranked as well. I currently work as a staff CRNA at this particular university's hospital, so I'm getting a pretty nice discount. These are the only 2 reasons I'm pursuing the DNP: 1) Large discount in a program that created a cohort to cater to CRNAs who work for the university, and 2) Doing it at a school that is locally respected with a name I'd be proud to say that I graduated from.

I can't help but think about how I'm going to be wasting time and money pursuing this, and I've done A LOT of thinking about whether or not the DNP is really what I want. I'm still not sure, but I'm doing it for the aforementioned reasons.

I'm happy to have the opportunity to pursue a doctorate, particularly because of my negative past with academics when I was younger. I also know that I will never be content if I don't obtain a terminal degree, especially as more new grad CRNAs come out graduating with a DNP. It's just my personality.

However, I can't help but think that my doctorate won't be respected in the medical community. The curriculum is very lackluster, and I guess my point is that if you pursue a post-master's DNP you can't go into it expecting to become a better clinician, or expecting more respect from our physician colleagues. They'll never respect it. It's a turf war thing. I DO believe that the DNP curriculum will better prepare me function in the board room later on in my career, and it will help provide me with the tools to convince those in the C-suites to expand CRNA services......or at least I keep telling myself that to justify spending more money on another degree LOL

[Ellen NP, MSN, NP]

I did take all those hard sciences as well as 2 full years of Calculus (Calc 4). I can actually understand statistics, pharmacokinetics, read and interpret research.  I use those sciences (that too many nursing leaders dismiss) every single day.  I am distressed when I see nursing programs that have 'Chemistry for nursing students," and other science lite courses. no wonder we can't have more advanced sciences in graduate school. We do not have adequate basic science education. I'm skipping the DNP.  If I want more management, leadership, etc., I'll either finish the MBA that I've half completed or get an MPH/DPH.

[londonflo]

On 5/24/2020 at 6:28 AM, KatieMI said:

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

Today I was focusing on the current opinions of DNP programs and came across this issue on an old thread. Actually I am astounded that an RN would accept a belief that all morphine preparations have the same onset and duration since morphine is usually the prototype for opiod analgesics.

With regard to establishing a time frame for evaluation for pain relief it would not be feasible to set the time frame based solely on the specific agent used. It has never been my experience that a patient who needs continous, long term pain relief is started on, and only on an extended release from of morphine.  A pain medication plan  should integrate an immediate release medication which should be evaluated for efficacy in the usual time frame as Norco, Tramadol etc. That time frame would be advantageous to see if pain relief to a tolerable level was achieved in a reasonable amount of time.  Why was this not part of the education/discussion? 

[ForensicPMHNP, MSN, NP]

Personally I think turning the DNP into a residency/fellowship year in which students basically work as NPs under supervision with a capstone project at the end would make more sense. I am in my last semester of my PMHNP program and some of my class mates are choosing to do a 12 month fellowship to hone their skills, a DNP that structured that way would help prepare new grads and would warrant making the DNP degree the baseline requirement to become licensed. In it's current form the DNP does not provide that extra level of training that truly translates to real world work.

[Ellen NP, MSN, NP]

This would make it a clinically valuable degree. Of course, as it exists now, the DNP is open to non-clinicians.