Medicine decries nurse doctorate exam being touted as equal to physician testing - page 3

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  1. by   ivanh3
    I spoke with Mary Mundinger, who is a member of the CACC and the dean of the Columbia University School of Nursing (which has a DNP program), about the exam. Mundinder stressed during our interview that the exam is not meant to make a DNP more like a physician. She said the following:
    I don’t think the DNP is a goal to be more like a physician; what we are doing with this exam is testing the medical knowledge that an advanced-practice nurse at the doctoral level has to achieve to give comprehensive care.
    I am fast approaching my last semester of FNP school. I am a Graceland University student, and I love my school. My instructors are working, knowledgeable FNPs who really care about the profession. I have done my clinical rotations with FNPs, a PNP, and a MD. All have been excellent. All, including the MD have been caring and holistic in terms of patient care. During my clinical rotations I have worked with other NP students, medical students, and medical interns/residents. Almost without fail, all have been sharp and motivated. I found that most of the NP students I have spoken with, either here, at my workplace, or on the clinical sites are all similarly satisfied with their chosen NP programs.

    In my limited experience with advanced nursing practice (I am still a student, not even a novice yet) I see a common theme. All of us (preceptors, students, residents) have been there to learn and to help. When it come to advance practice nursing, I can not honestly see the "nursing" model like I do on my regular RN (PICU/NICU nurse) job. The assessments are the same, the questions are the same, the treatments are similar, medical diagnosis are made, and interventions (some with drugs) are very similar. Nomenclature aside, the "practice" is almost identical.

    So what is my point?

    I think the idea of a test that assesses our medical knowledge is a good idea. If the test has been modified and adapted from a test that is frequently used to assess students/residents I think that is great. I think if NP students are only passing at a 50 percent rate then that is telling for two reasons:

    1) The test still needs to be adapted more to fairly reflect what is taught.

    2) The test is demonstrating that what is being taught ALSO needs to be modified.

    I have made other posts on this, but I will briefly state my stance again. I feel that NP programs need to drop some of the classes that are covered quite well in other nursing specialties such as master's level educator/leadership degrees and also many PhD programs as well. Even spending 10 to 12 credit hours on some of these classes is what I would call "duplication of services". I would not go so far as to call these classes "fluff", but I truly do not feel they help NPs where the rubber meets the road, so to speak. NP students need to take more patho and/or more clinical hours. Perhaps there should even be a formalized NP residency post graduation.

    Personally I am not for the DNP, but I respect those who are. Instead I would like to see the masters level degree beefed up a bit. Just because a PhD is considered a research degree does not mean by any stretch of the imagination that a PhD student would not be increasing their clinical skills. I would like for there to be one nursing doctorate, the PhD, which, in my humble opinion, is a doctorate that carries weight in both academic and clinical settings. A PhD in my mind deserves to be called Doctor, and the AMA can just learn to move on as far as titles are concerned since historically PhDs have been Doctors for a long long time.

    I am not familiar with Dr Mundinger, and I hope this test is not really being touted as physician equivalency, but I applaud her efforts to help design a test that will raise the standards.

    Ivan
    Last edit by ivanh3 on Jun 11, '09
  2. by   dgenthusiast
    Quote from ivanh3
    I think the idea of a test that assesses our medical knowledge is a good idea. If the test has been modified and adapted from a test that is frequently used to assess students/residents I think that is great. I think if NP students are only passing at a 50 percent rate then that is telling for two reasons:

    1) The test still needs to be adapted more to fairly reflect what is taught.

    2) The test is demonstrating that what is being taught ALSO needs to be modified.

    ...A PhD in my mind deserves to be called Doctor, and the AMA can just learn to move on as far as titles are concerned since historically PhDs have been Doctors for a long long time...

    I am not familiar with Dr Mundinger, and I hope this test is not really being touted as physician equivalency, but I applaud her efforts to help design a test that will raise the standards.

    Ivan
    The problem is, though, that the DNPs from one of the top schools (Columbia) had a 50% pass rate on an extremely easy exam (USMLE Step III) that was made even easier for the DNPs AND they lowered the standards of passing. That's pretty telling of the DNP program. If they make the exam any easier, then why bother taking it at all?

    Also, no one has argued that PhD's don't deserve to be called doctor. But I don't see my literature professor walking around the hospital calling himself a doctor. Like I mentioned in my previous post, a PhD is different than a clinical doctor. If you say you're a doctor in a clinical setting, people assume you're MD/DO.

    And here's a quote from Mundinger, which kinda shows that she's the one being driven by greed, not the AMA:

    'Mary O'Neil Mundinger, DrPH, RN, dean of Columbia University School of Nursing in New York, was quoted as saying: "If nurses can show they can pass the same test at the same level of competency, there's no rational argument for reimbursing them at a lower rate or giving them less authority in caring for patients."'

    We know that it was NOT the same test and that it was NOT passed at the same level of competency.
  3. by   ivanh3
    Quote from dgenthusiast
    The problem is, though, that the DNPs from one of the top schools (Columbia) had a 50% pass rate on an extremely easy exam (USMLE Step III) that was made even easier for the DNPs AND they lowered the standards of passing. That's pretty telling of the DNP program. If they make the exam any easier, then why bother taking it at all?
    Which is exactly why I put my second point in bold. I think that could be addressed in a comprehensive reflection on NP training. As far as being "easy", the USMLE step three is given after the first two steps and taken after the first year of residency. So, put another way: 4 year degree with hard pre-reqs, 4 years of medical school, USMLE step 1, USMLE step 2, 1 year of residency, then USMLE step 3. If there are those who consider the test "easy", I can see why. Also, this stuff is still evolving, that is the nature of health science, it is always in flux.

    Quote from dgenthusiast
    Also, no one has argued that PhD's don't deserve to be called doctor. But I don't see my literature professor walking around the hospital calling himself a doctor. Like I mentioned in my previous post, a PhD is different than a clinical doctor. If you say you're a doctor in a clinical setting, people assume you're MD/DO.
    If ran into any of my PhD professors in a hallway at a hospital, I sure would address them as "Doctor" if that is how I address them on campus, regardless of the subject they taught, but that is just me.

    People assume a lot things. I have a strong southern accent. Don't get me started on the assumptions people made about me when I lived in Chicago. I am a male nurse that looks very much like a nerd. I get called a doctor all the time by my patients in my RN practice as an ICU nurse. I wish I had a dollar for every time a parent in the middle of a phone conversation said, "I have to go now, the doctor is here" as I was walking in the room to introduce myself. What I am supposed to do? Should I have not become a nurse because of silly outdated stereotypes that still exist about doctors being male and nurses being female? I can't help their assumptions. I find it a better solution to show that not all nurses are female, just as women are showing how well they can succeed as physicians.

    Again, things are changing, as a RN, and as a future FNP, I will simply correct them with politeness and tact. As FNPs and PAs are becoming more and more visible, the "doctor" confusion is irrelevant, and there has been nothing to demonstrate that it has had a deleterious effect on patient care or outcomes.

    Quote from dgenthusiast
    And here's a quote from Mundinger, which kinda shows that she's the one being driven by greed, not the AMA:

    'Mary O'Neil Mundinger, DrPH, RN, dean of Columbia University School of Nursing in New York, was quoted as saying: "If nurses can show they can pass the same test at the same level of competency, there's no rational argument for reimbursing them at a lower rate or giving them less authority in caring for patients."'

    We know that it was NOT the same test and that it was NOT passed at the same level of competency.
    Good for her. If we strive for greater competency then why not be reimbursed for it? If you want to call it greed then go ahead, and there is some merit there, but I think that is too strong of a word. You are right. It was not the same test and not the same level, and that is why we move forward to improve ourselves, individually and collectively.
    Last edit by ivanh3 on Jun 11, '09
  4. by   yelnikmcwawa
    Quote from dgenthusiast
    a phd is not the same as a clinical doctorate. you're comparing phd's to dnp (a clinical doctorate).
    no, i am not comparing phds to dnp. i am talking about doctorate preparation in a variety of fields...and there are way more titles than phd...such as psyd, do, edd, deng, etc. different professions have different doctorate preparation and many of them use different titles to delineate that preparation from a doctorate of philosophy.

    there are different titles to describe different theoretical perspectives associated with each degree, and nursing is a profession that is long overdue for doctoral preparation. this issue is just a turf war, and in no way shape or form should the field of nursing be deprived of an opportunity to have doctorate professionals anymore!

  5. by   Ranier
    Quote from yelnikmcwawa
    no, i am not comparing phds to dnp. i am talking about doctorate preparation in a variety of fields...and there are way more titles than phd...such as psyd, do, edd, deng, etc. different professions have different doctorate preparation and many of them use different titles to delineate that preparation from a doctorate of philosophy.

    there are different titles to describe different theoretical perspectives associated with each degree, and nursing is a profession that is long overdue for doctoral preparation. this issue is just a turf war, and in no way shape or form should the field of nursing be deprived of an opportunity to have doctorate professionals anymore!
    huh? nursing already has the phd and edd as well as various nursing science/practice degrees like the nd, dsn, dns, dnsc, and now the dnp and drnp.

    not everyone with specific concerns regarding the dnp (particularly its lack of rigor and clinical science) and mundinger's characterization of dnp-prepared nurses has a problem with nurses having the opportunity to earn doctoral degrees in general. don't conflate the issue.

    an excellent article referenced in an earlier post that summarizes my opposition to this particular degree as well as anything i could write:
    the case against the dnp: history, timing, substance, and marginalization afaf i. meleis, phd, drps (hon), faan; kathleen dracup, fnp, dnsc, faan (september 30, 2005)

    i hope you read it and then maybe re-think your position that all opposition to the dnp (much of which comes form within nursing itself) can be summarily dismissed as "just a turf war."
  6. by   ivanh3
    Quote from yelnikmcwawa
    nursing is a profession that is long overdue for doctoral preparation. this issue is just a turf war, and in no way shape or form should the field of nursing be deprived of an opportunity to have doctorate professionals anymore!
    i have to agree with ranier on this. the only people depriving nurses from doctorate degrees are nurses. many nurses can't (or won't) justify the lack of financial incentive, stating that nurse educators are not compensated well enough to make it worthwhile to purse the additional education. i don't know if it is fair to compare bedside nurse salaries/benefits to nurse educator salaries/benefits. i think is better to compare what other academic phds make compared to nurse phds. i know some will disagree on that. if finacial gain is the sole motivation, then i suspect it would not be worthwhile to earn a phd of any kind.

    i think it is fair to point out that many people who pursue other academic phds often had that goal in mind from the beginning of their studies. compare that to nurses who often "test the water" at each level of education before trying to determine if moving on is worthwhile based on their individual circumstances.
  7. by   yelnikmcwawa
    Quote from ranier
    huh? nursing already has the phd and edd as well as various nursing science/practice degrees like the nd, dsn, dns, dnsc, and now the dnp and drnp.
    no, what i should have clarified is that no longer should nursing be deprived of clinical doctorate professionals. i am of course aware of the various doctorate degrees available to nurses, but i feel that the clinical application of a nursing doctorate should be available to nurses.

    most therapeutic professions have both philosophical as well as clinical doctorate preparation nowadays, so why leave nurses out??? clinical fields are changing, and so are the degrees. psychologists used to only have phds available to them, but they now can choose a more therapy based degree (psyd) over a philosophy degree. physical therapists now have a doctorate clinical preparation, and occupational and speech therapists are getting the same. you are of course aware that an md and do have the same clinical privileges, but their preparation is rooted in differing perspectives.

    my original point was that nurses should not have their degree options limited because physicians do not want another "doctor" in the same facility with them. it is no longer okay to have nurses with higher levels of education in the classroom or boardroom only. (that to me is like keeping women barefoot and in the kitchen) they should be allowed to be in the clinical setting and have doctorate levels of clinical preparation. it is a turf war...plain and simple.

    i don't argue that the preparation will need some close scrutinization as time goes on, and quite possible some tweaking, but it's about time that option is available at least!
  8. by   ivanh3
    Quote from yelnikmcwawa
    no, what i should have clarified is that no longer should nursing be deprived of clinical doctorate professionals. i am of course aware of the various doctorate degrees available to nurses, but i feel that the clinical application of a nursing doctorate should be available to nurses.
    i guess where i disagree with you is that there seems to be a perception that the phd somehow does not contribute to clinical excellence or at the very least the knowledge gained during phd studies would not enhance clinical skills.

    consider that where the bulk of additional clinical know how will come from is on the job experience that is fueled and guided by a motivated individual. so it just seems to me that learning directed by phd level education and training would increase an nps ability to practice, research and lead. all of which are interconnected and imho not separable.
  9. by   Ranier
    Well, your response does clarify a little better and some of it makes sense to me. But the only theme I'm getting from your argument is that nurses should have clinical doctorates just because every other field (DPT, PharmD, PsyD, etc.) is getting them too. That's a poor justifcation IMO. And I think you'll find, within each of the other fields mentioned, similar debates about the need for doctoral-level degrees as well. Pharmacy just took what used to be a four year bachelor of pharmacy curriculum, renamed it a doctoral-level curriculum, starting requiring 60 credits of non-pharmacy undergraduate work (not even a bachelor's degree) for entry... and voila, a brand new doctorate degree was born. Is the content and rigor of the PharmD any different from the old bachelor's of pharmacy if you line their curriculums up side by side for comparison? Not really. It's degree inflation, it's a way to keep students in school longer, spending more money at pharmacy colleges to enter a field that isn't going to pay them any higher salary than before, and most importantly it's a step toward earning more political clout and petitioning for expanded scopes of practice. You will find plenty of physical therapists and pharmacists who have similar reservations about the "doctorization" of their allied health professions. So I would ask why- other than the fact that "everyone else is doing it"- is this degree necessary for nurses?

    Anyway, what I still think you are failing to either appreciate or acknowledge is that there is more than one camp in the anti-DNP movement. There are also lots of us who support the notion of doctoral education for clinical nurses in theory, but find the DNP and its propoganda to be executed improperly. In the long run I don't think it serves nursing's interests well to have a DNP "doctoral" degree that does not meet the level of rigor historically associated with other doctoral degree programs. The curriculum for many existing DNPs is laughable. It's a 40 credit collection of MPH, MBA and nursing theory courses on leadership, administration, statistics, etc. with very little science or clinical "meat." The exit exam, which is being discussed here, is a failure IMO. DNPs that can be done online are an embarassment IMO, as are the accelerated direct-entry DNP programs that take non-nurses and spit them out as doctoral NPs in three years flat. Not to mention there are now non-clinical DNP degrees tracks for non-NPs to earn a DNP in "nursing leadership" and such; so is this even a clinical doctorate anymore or not?

    I just want you to understand that one can be "anti-DNP" for reasons other than protecting physician turf or trying to keep nurse clinicians from earning doctoral degrees, and those who insist upon characterizing opposition to the degree in that light ("oh, it's just about greed and ego") so they can easily dismiss such opinions are misguided.
  10. by   Ranier
    Quote from ivanh3
    I guess where I disagree with you is that there seems to be a perception that the PhD somehow does not contribute to clinical excellence or at the very least the knowledge gained during PhD studies would not enhance clinical skills.

    Consider that where the bulk of additional clinical know how will come from is on the job experience that is fueled and guided by a motivated individual. So it just seems to me that learning directed by PhD level education and training would increase an NPs ability to practice, research and lead. All of which are interconnected and IMHO not separable.


    I agree wholeheartedly. I'd prefer that we scrap this byzantine system of graduate nurse education which has sprouted so many different degrees with varying standards and little cohesive oversight. I'd like to see two graduate degrees: the MSN and the PhD in nursing. Let's stop inventing these 40-credit/ online/ part-time/ direct-entry/ fluff-filled/ no-research "doctorates" that pale in comparison to the rigor of a PhD and then play victim when the rest of the medical world fails to respect it.
  11. by   yelnikmcwawa
    Quote from ivanh3
    so it just seems to me that learning directed by phd level education and training would increase an nps ability to practice, research and lead. all of which are interconnected and imho not separable.
    ask a do if he thinks that his training is not separable from an md. and do the same with a psyd with regards to phd trained psychologists. each person chooses educational preparation based on how they feel their skills should be utilized...and the skills of a do vs md, or psyd vs phd will vary. but both of those professions have clinical privileges attached to those degrees.

    my issue is that what seems to be happening is physicians do not want another type of "doctor" practicing next to them, because it blurs people's perspectives of who does what. if you want to get into semantics, then mds and dos should ask to be referred to as physicians rather than doctors. if a physical therapist, speech therapist, occupational therapist, and psychologist can all have doctorate levels of clinical preparations, then why not give that same right to nurses...who by the way can save your life faster than anyone!

    i stand by the statement that this whole issue is merely a turf war. physicians simply want the term "doctor" reserved for themselves, and they do not want another "doctor" practicing side by side with them. they want the phd nurses to quietly keep to themselves in the classroom, boardroom, or research facility in case, heaven forbid, a patient calls someone else "doctor".
  12. by   yelnikmcwawa
    Quote from ranier
    the curriculum for many existing dnps is laughable. it's a 40 credit collection of mph, mba and nursing theory courses on leadership, administration, statistics, etc. with very little science or clinical "meat." the exit exam, which is being discussed here, is a failure imo. dnps that can be done online are an embarassment imo, as are the accelerated direct-entry dnp programs that take non-nurses and spit them out as doctoral nps in three years flat. not to mention there are now non-clinical dnp degrees tracks for non-nps to earn a dnp in "nursing leadership" and such; so is this even a clinical doctorate anymore or not?
    i do very much agree with you that the current dnp programs need to be scrutinized, and i said that earlier. i also agree that doctorate education is getting silly and the online formats need to be seriously debated. i for one, would never get a degree from an online university as i just don't feel good about the quality of education. i am commuting 2 hours each way for my current state college bsn program i'll take that over uofp or chamberlin any day!

    however, i still feel it is ridiculous to say that nurses should not have doctorate clinical degrees available to them...and to be honest...yes, it is because everybody else is doing it. don't leave us out! but you're absolutely right that the degree should match the clinical expectations of it's graduates. it's an issue, i give you that. so let's be a part of the solution rather than sitting idly by and letting everyone else get their clinical doctorates!
  13. by   sonnyluv
    [quote=Ranier;3676690]Why use the example of an intern and an experienced nurse to demonstrate that nurses know "as much" as physicians? Interns (and residents) aren't supposed to know everything. Of course a seasoned nurse can assist physicians in any stage of training, but this isn't evidence that they "know" more. Would you accept comparisons between the knowledge level of a student nurse practitioner to a veteran attending physician in an attempt to demonstrate who "knows" more?

    You miss my point and argue semantics. M.D.'s insist that it is their pre-requisite premed education and medical school education that immediately establishes the foundational difference in job duties and ALL POTENTIAL CAPABILITIES FOR THE DURATION OF THE CAREER IN ALL INVOLVED IN THE MEDICAL SCHOOL. But the argument is full of holes. 1) Have you looked at the pre reqs for competitive NP programs, even competitive BSN programs?-they are rapidly closing in on identical med school requirements. I suppose it comes down to MCAT vs. GRE+being a nurse in the advanced ed. scenario. "Interns and residents aren't supposed to know everything", then I would say to you, why can't educated and experienced nurses know everything?

    Would you accept comparisons between the knowledge level of a student nurse practitioner to a veteran attending physician in an attempt to demonstrate who "knows" more?

    No, but I would accept a comparison between an experienced nurse practitioner vs. an experienced attending.
    Ranier, stop vagaling. Think-"Attending" big impressive word, right? All nurses ever are is "nurses". How audacious of us to steal terminology like "residency" and wear lab coats. I love it when an MD gets all anxious when they can't find the lab coat. They look like they are waking up in a dream naked. Their paperwork is right in front of them but THE COAT MAN! MD's do not have sole exclusive right to ANY aspect of medicine or "nursing". I don't how may times people in my nursing class were told to "stop thinking like doctors" as we learned to anticipate potential complications and negative outcomes of disease process. Man, nursing diagnosis is ridiculous and a complete apology for understanding medicine. We had to be taught not to use "clinical terminology" or never use the word "infection" because that might be, shudder!, a diagnosis! We had to disregard common sense and drag the ******* asleep intern over to the septic pt cuz the bleeding pus abscess-okay sorry I'm trying to write after the 12 hour overnight- I'll shake that one off- okay-onward!

    As for how "they" treat DOs... you do realize that the AMA represents both the allopathic and osteopathic community, right?
    I work at hospitals affiliated with USC and UCLA: They have a saying, "D.O. no go". Unable to locate residencies for the D.O. graduates. The AMA can represent whoever it wants- M.D.'s only respect M.D.'s.

    Finally, to your last point, DNP candidates have already started taking the watered-down USMLE-lite exam, and only 49% of them passed last fall.
    You're pretty harsh on a bunch of trailblazers who had not had the opportunity of previous levels of similar testing- it was a dry run! Once the DNP candidates understand the test better, just like residents know what they are in for (I.E. six weeks at Kaplan), scores will sky rocket.
    Again, the pervasive attitude of nurse leadership seems to be"we are good enough and we are going to show you" Which is really the whole problem anyway-self esteem. Trust me, they will kick the test's butt. But ultimately, the test is ridiculous. Nurses should stop calling themselves nurses, co-opt some more MD terminology and let the gender-rooted inferiority complex go.
    Henry Ford realized that the best way to build cars was to have individual workers get really good at their own station, master it inside and out. I have an intern who wants to be an ophthalmologist doing his ICU rotation now. It's pointless. Medicine is the same way. MD's want to be the big boss man, fine. But when the big boss man, AS A PROFESSIONAL CULTURE throws temper tantrums, yells, speaks to patients as if they are retarded, demonstrates insensitivity to the needs of their CLIENTS, bills some pretty hefty bills on the basis that they went to school for a long time and not on the job they performed, regularly disregards the outcomes of their care and let's themselves get walked on by pharmacy and the insurance lobby then HENRY FORD IS GOING TO FIRE YOUR BUTT!

    She calls the 10-credit, 800-hour clinical portion of Columbia's DNP program a "residency" when in reality they are just clinical rotations like any other MSN NP student or MS-III/IV would complete.
    Uhhhh, a residency without crappy hours? Sounds smart to me. It's a residency. Stop presuming that M.D.'s own words or have them trademarked or licensed. And by the way, those 12,000 hour residencies are often filled with vast incompetence, periods of remarkable lackluster performance and nurses bailing out their arses the whole way through. Some stars shine. Other are pieces of rock burning up in the atmosphere. I just want to express the concept that if nurses were given the autonomy of MD's, after advanced education it's not difficult to understand how they would readily be as competent, just as, say, an intern or resident who is learning via on the job training and taking classes. Nurses are proposing to do it in the opposite order.

    Nurses do it all the time on the other end, fighting to keep medications assistants from passing meds, CNAs from doing nursing tasks, paramedics/EMTs from working in hospitals, etc all in the name of "patient safety." All professions, if they are smart, would do the same.

    I have no idea of what you are talking about here-I'm not sure what "fighting"is going on, or legislation. I worked in an ER for the bulk of my time as an E.M.T.-just not sure what you are saying.

    Good comments though-I see your points-it's a weird thing when an industry finds itself changing overlaping into new territory everyday. Kind of like puberty, hmmmm.

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