So much for DNP being clinical doctorate

llg, PhD, RN · Nov 19, 2011

I'm not familiar with that particular school. So, I won't comment on that aspect...but ...

I don't see anything wrong with the DNP (in general) being considered a "practice" doctorate rather than a "clinical" doctorate. That's what a lot of people have wanted all along.

The DNP movement started with the Nurse Practitioners, CNS's, CNM's, and CRNA's ... but the nursing profession has been trying to establish a "practice doctorate" (as opposed to a "research doctorate") for several decades. That was the original idea behind the DNS and DSN degrees. However, most of the DSN and DNS programs morphed into research degrees. That left people who worked in the practice arena rather than in the academic arena (including administrators and professional development specialists) without a suitable doctorate.

Many people (including me) hope that the DNP will "stick" and not morph into a research/philosophy - focused degree. That would give the profession a clear pair of doctoral degrees -- the DNP for those not interested in an academic career -- and the PhD for those interested in academics, research, and/or philosophy.

Nursing practice includes more than just the "advanced practice" roles of NP, CNS, CNM, and CRNA. People in those other nursing practice roles need a doctoral option, too -- and the DNP is well-suited for them. So, why not?

unplannedRN · Feb 9, 2012

You know, back in the days when "Doctors of Osteopathy" were part chiropractor, part allopathic physician, part naturopathic physician, allopathic MDs didn't worry much about them. They were seen almost as chiropractors. They were low in numbers, the schools didn't compete with medical schools, and they tended to expect much less money and prestige. It was coincidence their markets overlapped, mostly. They typically did the rural health care few MDs wanted., though, and their schools cost them less.

Then things evolved, and now DOs can practice in any specialty an MD can, and sadly, many of them do NOTHING "osteopathic" once they leave school. Far fewer of them do rural care, and they expect the same money and power MDs have. While MDs sometimes look down on them as people who "couldn't get into medical school", frankly some insecure MDs say that about foreign grads, podiatrists, dentists, PAs, chiropractors, and of course NPs. In other words, just about everyone whose training and work overlap MDs to any extent.

But even back in those days, DOs were "Doctor", too, even when it might have been quite confusing. And all along, there have been Doctors of Optometry (OD), and as a diabetes educator I can vouch that few patients understand the difference between DO, OD, and MD. Yet we don't worry our patients will be confused. We have Doctors of Psychology, Podiatry, Dentistry, etc., and few complain that they shouldn't use the title doctor, even when there might be a dentist and medical doctor in the same clinic. Or psychiatrist and psychologist.

The modern APN is no longer single faceted. We are branching in many directions, so we are as as different as podiatrists and dentists. Just as in medicine, you have the teaching/research huge area, and then everything else. (There are PHD doctors of medicine who are not qualified to practice in the field.)

Primary Care NPs will be one area, and I believe many of these will take over the gap left by DOs, caring for under-served and rural populations, because we, too, have that same culture. We will continue to grow in complexity, and scope of practice just as DOs did. (I pray we don't dump the philosophy that makes us unique as some DOs do. Those ARE MD wanna-bes.)

I firmly believe that MOST Primary Care Practitioners will be NPs in 20 years, because doctors can't bear the time pressure, the control from the insurance plans, etc. The pay doesn't suit them, either, with med school costing as it does. These things must happen, too, because NP school is getting expensive, and if we need 8 or more years to enter practice, then we need a way to pay for school, too.

I for one think the goal in clarifying the NP role and title is to proudly wear and use the "Doctor" an eight-year education deserves, embrace the practice guidelines that demand a doctorate...and wear a NAME TAG that SPELLS OUT the entire title.

Patients will ask, pamphlets will be printed, discussions will ensue, TV commercials and movies can be used as they are now to educate the public.

Nursing is not and never will be "medical doctoring". Like the "real Osteopaths" once did, we have our own holistic approach, and caring for the body is and has been only a modest part of that, for decades now. We have the right to evolve and expand, and to have a unique style of practice that now, yes, very much includes some diagnosing and prescribing and treating as part of a new type of practice.

Making it clear that, yes, unfortunately for doctors we're competing for some of the same business market, but no, we have no interest or intention of "trying to be equal" "trying to be MDs", "usurping the MD role", etc. Suggesting that we are is a red herring, a tactic used to avoid territory encroachment.

That can't be helped...but the territory is patient care of populations, not medical care nor a particular role. Advanced practice NURSING care is a whole new profession, not demi-"doctoring". There's just a new type of practitioner in town, and giving us our independence is the only way to go for all concerned. And with that independence must come a burial of the phobic taboo written into State Practice Acts saying, "Under no circumstances does a nurse diagnose or prescribe..." meant to remind a nurse she is not a doctor.

And when I say new profession, I mean so only in the sense of "doctoral-degreed profession", which is the meaning it has when you fill out a form asking you if you have a "professional degree". I mention this because RNs are professional nurses, period, in the broader sense.

Yes. you do have a "professional degree", DNPs. It's a doctoral degree. You are "Dr. So-and-so, the Advanced-Practice Professional Nurse", a specialty the public really knows very little about. There's no excuse in practicing nurses not understanding and getting the word out. Hiding your name tag will only muddy the waters when some do and some don't!

If you have to go to school 8 years to be something that earns half the money--at the most--a doctor does for similar work, but you went that route anyway, a doctor is less likely to think you wanted his job that, but didn't want the 2 extra years of residency, nor to earn the extra 50% pay...So the DNP requirement may help settle that old confusion.

unplannedRN · Feb 9, 2012

I should add that I am an older nurse planning to enter an N pogram, and dread the extra DNP years, which I will add on after getting the last-minute (pre-2015) NP under the MSN. I will be very good at what I do.

At this point most DNP programs are rush jobs, trying to be the first and grab the market share of new NP students, and their programs reflect that with a lot of stuffy filler, rehashing research models, nursing theory, and healthcare policy without adding anything substantive. There are some exceptions, though...I think U of MO might be one. It certainly doesn't seem to be tied to "Big name" vs. modest schools...!

So, to those excellent Master's-prepared NPs out there, let me make it crystal clear that I know your new DNP NP peers-in-practice really won't be ahead of you. It's why taking all those fluff courses will be torture for me--boring and a sham--unless I can afford one of the good programs. Frankly, since you had to pioneer in your area of nursing, and have been the cutting edge, you should be grandfathered in as DNPs, not just allowed to keep your NP practices! One of the most brilliant women I know is a hematology NP who got her MSN after she started her NP practitice. (Yes, JC, that's you!)

There will be tons of fighting and screaming over the DNP vs MSN-NP competence, and all for nothing. The DNP in these early dayas won't be an upgrade. But even if I never get it, embracing it for the future of the profession helps upgrade nursing as a profession now, and the DNP programs will evolve.

KurtDNP · Jun 14, 2013

I'm not dogmatic about this, but I suspect having a third doctoral option that is truly clinical would be beneficial. As a currently practicing MSN-prepared NP, currently enrolled in (and near the end of my matriculation though) a DNP program, I can say that the DNP curriculum is not "fluff" like some of my post-ADN BSN classes were. The DNP curriculum focuses on quality improvement (QI), an extremely important aspect of nursing practice to be sure, but not really what most advanced practice nursing clinicians are interested in. To that extent, DNP-prepared NPs are no more clinically advanced with respect to management and treatment of individual patients than MSN-prepared NPs. The DNP prepares the clinician for wider evidence-based application of clinical knowledge to systems, populations, and cohorts. One day, the surgeon general of the United States will likely be a DNP-prepared NP, CNS, CNM, or CRNA (for example).

While doctoral-level QI expertise is extremely important, so is doctoral-level clinical expertise that is founded on the holistic values of nursing. As both a natural and social science with more emphasis on the social than medical and osteopathic practitioners, nursing clinicians bring a unique perspective that adds to the overall quality of healthcare in a way that no other discipline does. Allopathic and osteopathic practitioners, with regards to doctoral-prepared clinicians in disciplines with relatively wide scopes of practice and subspecialties (as opposed to podiatrists, chiropractors, psychologists, doctors of optometry, etc.), also offer unique perspectives that are beneficial to overall healthcare. The addition of nursing to that mix improves access, options, perspectives, and innovation and should, therefore, not be seen as competition but, rather, complimentary.

Having said that, the current doctoral options (research as PhD or practice as DNP) do not satisfy the needs of the advanced practice nurse who is interested in further advancing clinical expertise and less interested (or totally disinterested) in practice on the population or systems level where QI is the emphasis. Perhaps postgraduate internships/clerkships/residencies (or whatever we want to call them) are the solution but I would venture to guess that most NPs interested in a clinical doctorate would prefer at least a little more anatomy and physiology, microbiology, pathophysiology, health management, disease management, and training in clinical procedures. Some QI training (as recommended by the Institute of Medicine) would remain but not as the central focus. Then post-graduate rotations can further and optionally augment clinical expertise, particularly with regards to subspecialization.

So, perhaps there will be another movement in the coming years (or decades) to add a clinical doctorate so that nurses have three pathways to scholarship and expertise within the values of the discipline: the research doctorate (PhD), the practice doctorate (DNP), and a clinical doctorate (I don't know, DRNP, DCN, DCNP, DNPc, DNPAACNP, just kidding). What do you think?

KurtDNP · Jun 14, 2013

By the way, DNPACNP=Doctor of Nursing Practice As A Clinical Nurse Practitioner

Trauma Columnist · Jun 14, 2013

Kurt - are you sure you are not on the AACN board? lol

Gee whiz, if WE cant understand all these initials, who the heck can?

prairienp · Jun 14, 2013

Keep the DNP as base edcuation for NP, explore paid residencies to allow increased clinical expertise (like are MD friends)

IcySageNurse · Jun 14, 2013

I say make DNP entry to practice, and use all this extra time in school for NPs to add actual science classes. Microbiology, gross anatomy, more skill classes, etc. Also use the time to increase clinical time. The leadership and EBP classes are a waste for most people, similar to the osteopathic manipulative medicine classes taken in DO schools - i.e. there to keep it a DO school but useless in practice.

I would love to go for my DNP, but I am looking to go to a master's program right now simply because I refuse to get my DNP while it's still this nursing theory and other fluff type stuff. When it's a clinical doctorate with actual increased practice hours and in-depth classes, I'll go for it.

NJprisonrn · Jun 15, 2013

I agree, the DNP should add clinical experience, more science, and assessment to the curriculum. While EBP and theory have their purpose, let that be an elective or the focus of the PhD. I'll have an MSN in another year. I am considering getting the DNP, but dreading those non-science classes. If I do go for it, you can be darn sure I'll be using the doctor title that I very well earned with nurse practitioner clearly spelled out on my badge.

KurtDNP · Jun 17, 2013

One of the main problems I see with the DNP (as it currently is) being the base education for NPs (and then relying on paid residencies for increased clinical expertise) is that current DNP curricula still "wastes" valuable hours (typically 500+ hours not counting study and class time) focused on quality improvement (QI) instead of point-of-care clinical health and disease management. Again, QI is very important, but not what most NPs are interested in. Thus, it would make sense to teach us about it without the crux of our time and energies being spent on actually doing a QI project when we know full well that we will likely never do it again (QI leadership).

I am glad that I now have a much better understanding of QI and its significance on cohorts as well as on hospital, local, state, national, and international systems. However, I truly have little interest in actually conducting, directing, or significantly participating in the leadership of QI programs. I would much rather improve my clinical skills--especially the relevant clinical sciences such as A&P, patho, and micro. I would benefit more from increased exposure to other specialties such as cardiology, ortho, radiology, rheumatology, nephrology, oncology, ophthalmology, otorhinolaryngology, or even surgery. I also think some of the QI classes could be condensed in a clinically focused version of the DNP to make room for the increased clinical content.

IcySageNurse · Jun 17, 2013

Let's face it, the DNP is not really about improving clinical skills...it's about making money while increasing political clout of the NP lobbyists.

MSN + Residency >>>>> DNP>> MSN