NPs practicing as DRs

[SkiBumNP]

This has been a heated discussion between some of my friends and I, so I thought I would bring it to the forum.

Should people who are going through a DNP programs and taking the SAME test we all took for our MSN - NP for national certification think their education 'doctorate" is a clinical doctorate?

Until there is a national standard and an elevation of the test (think along the USMLE) then I think anyone who thinks their DNP is a clinical doctorate is a joke.

your thoughts. . . . .?

[PMFB-RN, RN]

it is difficult to discuss the pros and cons of a dnp with someone who does not have a dnp and is not an np.

*** i will take that to mean that you have no counter arguments to my points.

how can you intelligently discuss it when you have no idea what it entails?

*** not really accurate. i do have some idea of what it entails. i don't claim to understand to the same degree those of you why have "been there, done that". in any event i am not attempting to bring the perspective of a dnp prepared advanced practice nurse. that's your roll. my perspective is as a potential future advanced practice nurse, a consumer of services provided by advanced practice nurses, and as a person who works closely with several types of advanced practice nurses. i have learned to appreciate different perspectives. i suggest you do too.

all you have is what you perceive about np and the dnp program. how can you intelligently give any information about dnp being entry level for a np?

*** first all of my comments have been in relation to dnp as entry to advanced practice nursing, not just np. second i have not provided "information". i have asked questions (none of which have you chosen to address) and brought up discussion points. i will assume since you have thus far refused to discuss and of the points i have addressed, or answered any of my questions, and that you have made it clear you don't wish to discuss this issue with anyone who isn't a dnp prepared advanced practice nurse, that you have no valid arguments.

you are not either.

*** nope, but i am a stake holder. this issue has great effect on my career and on the health care system i and my family depend on. the same is true for many other rns. i doubt that many people will agree with you that unless one is a dnp prepared advanced practice nurse they can not ask questions or bring up discussion points. like it or not you are part of a larger health care team and others who do not have your exact qualifications will have questions and perspectives.

i welcome a discussion with nps and/or dnp nps who have walked the walk and actually know what it entails.

*** if you are unable to counter any of my points, or answer any of my questions i welcome you to not respond at all. this is a public board and there are others who may have the capability.

[PMFB-RN, RN]

The authors of the article still believe an MD supervision model is still safer and not supervising CRNA's in a trauma hospital is not an option.

*** I work in a trauma hospital. There is no MDA supervision of CRNAs at night. This despite having a whole bunch of MDAs on staff. When a level I or II trauma comes in and needs to go to the OR the on call (in house) CRNA provides any anesthesia care required. I don't know if our staff MDAs agree with the authors of the article, but if they do one wonders where they are during these traumas?

When I work in a trauma hospital in San Diego there didn't seem to be any shortage of MDAs at any time. In rural WI or SD there seems to be, or that is how it seems to me. MDAs argument in favor of supervision of CRNAs would carry more weight if more of them were willing to provide services in undeserved areas.

[msn10]

I work in a trauma hospital. There is no MDA supervision of CRNAs at night. This despite having a whole bunch of MDAs on staff. When a level I or II trauma comes in and needs to go to the OR the on call (in house) CRNA provides any anesthesia care required.

You must mean the one in MN because the other ones that you stated that you worked at are not level I trauma hospitals. In any case, in a level I, MDA's must be available 24 hours a day and in every state that I know of they have to be in house. In Wisconsin they have to be within 20 min of the hospital when they are on call. Either your CRNAs are not doing level I cases or the MDAs are not practicing properly.

Also, in rural WI there is a shortage of MDAs because there is nothing above a level III and most are level IV so there really is no need for an MDA. There isn't enough to do and those hospitals - especially the CAH -are losing money on the CRNAs alone because of a lack of surgical procedures and a >85% medicare rate.

[morte, LPN, LVN]

it is difficult to discuss the pros and cons of a dnp with someone who does not have a dnp and is not an np.

*** i will take that to mean that you have no counter arguments to my points. this was my preception as well.

how can you intelligently discuss it when you have no idea what it entails?

*** not really accurate. i do have some idea of what it entails. i don't claim to understand to the same degree those of you why have "been there, done that". in any event i am not attempting to bring the perspective of a dnp prepared advanced practice nurse. that's your roll. my perspective is as a potential future advanced practice nurse, a consumer of services provided by advanced practice nurses, and as a person who works closely with several types of advanced practice nurses. i have learned to appreciate different perspectives. i suggest you do too.

all you have is what you perceive about np and the dnp program. how can you intelligently give any information about dnp being entry level for a np?

*** first all of my comments have been in relation to dnp as entry to advanced practice nursing, not just np. second i have not provided "information". i have asked questions (none of which have you chosen to address) and brought up discussion points. i will assume since you have thus far refused to discuss and of the points i have addressed, or answered any of my questions, and that you have made it clear you don't wish to discuss this issue with anyone who isn't a dnp prepared advanced practice nurse, that you have no valid arguments.

again, have to agree with you.

you are not either.

*** nope, but i am a stake holder. this issue has great effect on my career and on the health care system i and my family depend on. the same is true for many other rns. i doubt that many people will agree with you that unless one is a dnp prepared advanced practice nurse they can not ask questions or bring up discussion points. like it or not you are part of a larger health care team and others who do not have your exact qualifications will have questions and perspectives.

i welcome a discussion with nps and/or dnp nps who have walked the walk and actually know what it entails.

*** if you are unable to counter any of my points, or answer any of my questions i welcome you to not respond at all. this is a public board and there are others who may have the capability.

exactly! if someone can't explain something so that i can understand it, i have to question their capacity to explain, or, as in this incidence their knowledge base.

[PMFB-RN, RN]

you must mean the one in mn because the other ones that you stated that you worked at are not level i trauma hospitals.

*** uh i didn't say it was a level i trauma hospital. it is level ii but they get level i traumas in all the time. where else are they going to go? nearest level i is way down in madison.

in any case, in a level i, mda's must be available 24 hours a day and in every state that i know of they have to be in house. in wisconsin they have to be within 20 min of the hospital when they are on call. either your crnas are not doing level i cases or the mdas are not practicing properly.

*** our crnas are for sure doing level ones. can't speak for the appropriateness of the mdas behavior.

also, in rural wi there is a shortage of mdas because there is nothing above a level iii and most are level iv so there really is no need for an mda. there isn't enough to do and those hospitals - especially the cah -are losing money on the crnas alone because of a lack of surgical procedures and a >85% medicare rate.

*** are you saying that if the numbers of cases were available there would be plenty of mdas willing to practice in rural, undeserved areas? your information that the cahs are losing money on crnas further argues against dramatically increasing the cost of training crnas as the dnp as entry for advanced practice folks wish to do.

[msn10]

are you saying that if the numbers of cases were available there would be plenty of mdas willing to practice in rural, undeserved areas?

yes, there would be more, there just isn't enough to do right now.

your information that the cahs are losing money on crnas further argues against dramatically increasing the cost of training crnas as the dnp as entry for advanced practice folks wish to do.

yeah, it is a valid argument.

side note, i meant to say level ii has to be 20 minutes.

it is level ii but they get level i traumas in all the time.

a level i trauma is a hospital status and mode of accident or injury.it is not an anesthesia term - it is an er term but i know some hospitals refer to patients that way in the or. are you referring to a patient's asa physical status classification level? then i think you mean an asa level iii or ive or even ve (e=emergency) if it is a trauma

for instance: a gunshot wound is a level i trauma, but they may not need surgery, but a patient - who fell from a 8 foot ladder -and broke his arm initially is listed as level ii but then turns out to need surgery.

asa physical status classification system

asa physical status 1 - a normal healthy patient

asa physical status 2 - a patient with mild systemic disease

asa physical status 3 - a patient with severe systemic disease

asa physical status 4 - a patient with severe systemic disease that is a constant threat to life

asa physical status 5 - a moribund patient who is not expected to survive without the operation

asa physical status 6 - a declared brain-dead patient whose organs are being removed for donor purposes (not used as much anymore)

[nomadcrna, DNP, CRNA, NP]

I asssume you are familar with the many peer reviewed studies that show anesthesia provided by solo CRNA is as safe as sole MDA or MDA/CRNA?

I have always practiced independently. I do the exact same procedures and cases that MDAs do. I even had an MDA PARTNER for a couple of years at one point.

The point you are missing is the MDAs are proponents of the team approach, MDA/CRNA. Why? Because it makes them money. If you were in the inner circle of anesthesia providers( a CRNA), you would know that the MDA/CRNA team is ONLY for billing purposes. It is ONLY so they can bill extra for "supervison". It has NOTHING to do with state law or regs.

You would also know that the MDA in that team is rarely around. Most do not meet the 7 TEFRA requirements for billing although they bill as such. That is the point of the article.

Once again, no offense intended to you as you seem to be very reasonable and articulate.

You need to be "one of the boys", so to speak to understand the issues.

nomancrna

I have read the article, but be careful before you start quoting Dexter, Franklin M.D., Ph.D.,

He is a brilliant researcher and his wife if a surgeon. He is known in anesthesia circles as such a smart man that most people in anesthesia cannot adequately speak to his research and he is so mathematically intelligent that many statisticians cannot properly quote his research either.

Franklin is a proponent of effective and efficient anesthesia care, but he is an even bigger proponent of anesthesiologists. He has done more work on efficiency in the OR than any other anesthesiology researcher out there and he is an internationally known anesthesia consultant. This article merely reveals what his plethora of work reveals, OR's are not always efficient. He gives many suggestions for improving efficiency and this article merely states that start times should be staggered. In this article he even states:

"patient safety could be affected when there are coincident critical physiologic events"

Or

"At a ratio of one anesthesiologist to three anesthesia providers, it will not be possible to start all ORs simultaneously and have sufficient anesthesiologists to supervise all critical portions of cases on most days." So he suggests staggard start times as he has in many other articles.

Of course the AANA president has a bias, but misquoting Dexter's research doesn't make the case against supervision that much stronger. The authors of the article still believe an MD supervision model is still safer and not supervising CRNA's in a trauma hospital is not an option.

[nomadcrna, DNP, CRNA, NP]

A normal CRNA gets

4 years BSN

1 year ICU internship

3.5 years of CRNA school (7 semester) This is a masters program. DNP is longer.

If you don't count our ICU then we don't count the radiologist or ortho surgeons internship year. Do you really think we learn nothing working ICU? Have you thought there may be a reason ALL CRNA programs require this?

That is 8.5 years minimum, most have more.

I have the above plus

1.5 years FNP

3 years DNAP = 13 years. And yes, my DNAP program had more doctoral level pharm, biochemistry and pathophysiology.

The DNP is a new degree and still evolving. If you have watched, it is slowly changing. Many programs are evolving towards specialization and more clinical content and less EBM.

There are some that offer fellowships in pain or critical care medicine. It is a whole new world and I am dismayed to see RNs fighting against these changes instead of pushing for improvements as the DNP will help our profession.

[nomadcrna, DNP, CRNA, NP]

Case in point of someone not being "involved in anesthesia". I understand it is hard to look in from the outside and try to discuss something intelligently. This is why we say you need to be "a part of club" so you understand the issues.

CRNAs do level 1 trauma EVERY DAY in all parts of the country. The MDA does NOT have to be in house if a CRNA is there.

11-1 Anesthesiology services are promptly available for emergency operations.

TYPE I

∙

11

11- 2

11-2 Anesthesiology services are promptly available for airway problems.

TYPE I

∙

11

11- 3

11-3 There is an anesthesiologist liaison designated to the trauma program.

TYPE I

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11

11- 4

11-4 Anesthesia services in Level I trauma centers are available in-house 24 hours a day.

TYPE I

∙

11

11- 5

11-5 When anesthesiology chief residents or CRNAs are used to fulfill availability requirements, the staff anesthesiologist on call is (1) advised, (2) promptly available or all times, and (3) present for all operations.

[msn10]

You need to be "one of the boys", so to speak to understand the issues.

'

The reason I talked about this article specifically is that Franklin Dexter is a past colleague of mine. He was a consultant on a project I did in Wisconsin to make an OR more efficient.

The point you are missing is the MDAs are proponents of the team approach, MDA/CRNA. Why?

Oh believe me not all of them are. The largest hospital group in the state has eliminated every CRNA position system wide and went to an all MD group. They hired over 50 MDAs to replace the CRNA's.

You would also know that the MDA in that team is rarely around.

Yes, the team approach makes more money, but there is a lot of push back recently. It depends on the group and the culture at said hospital. In fact a group in our state fired all of the MD's (or eliminated their contract because they were independent) because they would not come in at night to supervise the CRNAs which led to some serious problems. Another group took over and it is in their contract to be in-house while any surgery is happening.

It makes my blood boil when MDA's don't fulfill their obligations and I am sure there are many competent CRNA's out there. I would think with this DNP push, however, they would consider a fellowship for specialties. I know they have a pain one, but I think our MDAs who are cardiac, peds, regional, etc., fellowship trained are superior to anyone practicing and if me or my kids were going to be put to sleep, they would be the provider.

[msn10]

CRNAs do level 1 trauma EVERY DAY in all parts of the country. The MDA does NOT have to be in house if a CRNA is there.

That is not what I said. I said that a level I hospital must be staffed.

[Tinabeanrn]

I am glad that you went to a DNP program that is improving our profession. I think that whole issue is that most are not. Most have no basis in the clinical arena at all. I looked into 5 DNP programs here in Michigan and none were like the one you went to. Once it evolves and is more based in clinical matters, then I will be all for it. But the programs around me are just not, so I can't see myself taking a bunch of classes that won't help me in the field. Its mind boggling to me. Unless you want to teach or want a terminal degree in nursing. I certainly wont stand in anyone's way that wants a DNP. I think its great for those who want it and have advanced from it. As for me, I don't see the benefit right now as is. Just saying.