What is the difference between NP and DNP?

dgenthusiast · Mar 10, 2010

Mundinger's original vision for the DNP was a clinical doctorate. if you review columbia university's curriculum for the DNP, it is more clinical focussed than other DNP programs. She is absolutely pushing for DNP independence, following her model.
When NPs wanted independent practice, people complained they were not doctorally prepared, Mundinger responded by developing a clinically focussed doctorate. Then people complained there was not a certification process for DNP, and she responded with a test developed by and using the same questions from USMLE step 3, yet people still complain. There will always be people threatened by or criticizing the advancement of DNP.
Not understanding how informatics can be applied to your practice does not attest to its usefulness, rather it demonstrates a lack of knowledge regarding how to apply it. In other words, until you take the class (with the rest of the DNP courses) you simply can not know what you dont know. To say those classes are worthless and will have no affect on clinical practice without having gone through them is statement born in ignorance. (ignorance=lack of knowledge on a particular subject)

Pointing out flaws in something is not complaining. You should really make a note of the difference. There will always be people criticizing the NP/DNP because there are huge number of flaws in these programs that the nursing community seems to consistently fail to address. Rather than fixing what's already there, you guys push for more and more independence.

Regarding that certification process, 50% failed a diluted form of the easiest Step exam that physicians take. They didn't use the same questions as Step 3; they took those questions and made them much easier. And like I said, it's the easiest Step exam physicians take and they have 97-98% pass rate (if I remember correctly). Kind of scary that the cream of the crop students (from Columbia) did so horribly on the exam then.

It's funny that you say if someone doesn't take DNP classes, they don't know what they don't know. It's kind of similar to how NPs/DNPs have never taken a medical school course, never did enough clinical hours, never did residency, never went through all the rigorous checks and balances in place (NBME shelf exams, Step 1, Step 2 CS/CK, Step 3, in-service exams, board certifications, recertifications, etc). These NPs/DNPs don't know what they don't know. There's a vast amount of information that they literally cannot know because you can't cram 7+ years of intense medical training into 2-3 years. It's literally impossible.

So, borrowing from you, to say that NPs/DNPs should be allowed to practice independently with at most half the amount of training physicians receive shows you don't know how much you don't know and is a statement born in ignorance.

PICUPNP · Mar 10, 2010

Why would any np feel threatened by dnps? These are going to be nps who spent extra thousands on an education that doesnt do anything to prepare them for patient management. If this is a clinical doctorate for advancing independent practice, where's the beef?? advance patho, pharm, physiology, etc?? Informatics may lend toward a well rounded education but does it prepare you manage someone on a vent in APRV mode? Do the theory classes help with managing the abx regimine for a cystic fibrosis patient? How to dx Kawasakis disease? The obvious answer is NO. The dnp may help you to better manage a practice but not patients. A clinical doctorate should advance ones knowledge of their patient population not how to complete some ridiculous capstone project.

llg, PhD, RN · Mar 10, 2010

"Clinical" does not necessarily mean "the diagnosis and treatment of one particular patient." The DNP is still "clinical" in that it is focused on the assessment/evaluation of of the care of a population of patients on a broader scale. Thus the DNP is still "clinical" in comparison with a PhD that has little (if any) focus on that. Most PhD programs focus on the topics such as the nature of knowledge, methods of knowledge development, etc.. That's what makes it a research degree rather than a practice or "clincial" degree.

Sure, there are differences from one DNP program to another -- and not evey DNP program is consistent with Mundringer's ideas. It will take a while to sort some of these issues out. But that's to be expected whenever a new degree is introduced.

Personally, I have a PhD -- even though I have almost always worked in hopsitals, not academia. For me, a PhD was/is a good fit because my interest lies in philosophy and research. But I can understand that many people who want a doctoral level education might not be interested in those topics and want to do doctoral level work focusing more on practice issues. The DNP is a better fit for them.

And it is not NP's who are getting DNP's. The DNP is expanding beyond the NP focus to be the doctoral program for those in all roles that do not want to focus on research, theory, and philosophy. There are CNS's, administrators, and educators who are DNP's -- without picking up an NP along the way. The DNP is a doctoral level degree focusing on advanced practice, that may or may not include the Nurse Practitioner role. It is not an exclusively NP thing. Nurses in other roles are also getting DNP's -- in which case the whole "are they equal to physicians" question is kind'a irrelevant. If the NP folks want to require the DNP as the minimal entry level for NP certification, that's a different issue -- one that is only a portion of the whole DNP picture.

wowza · Mar 10, 2010

Mundinger's original vision for the DNP was a clinical doctorate. if you review columbia university's curriculum for the DNP, it is more clinical focussed than other DNP programs. She is absolutely pushing for DNP independence, following her model.

Well let's look at Columbia's program since you aid to review it http://sklad.cumc.columbia.edu/nursing/programs/dnp.php

Still, of the 40 credits, only half of them are clinically useful. So barely over a semesters worth of work gives you a clinical doctorate? And that is a program that is more clinically focused?

When NPs wanted independent practice, people complained they were not doctorally prepared, Mundinger responded by developing a clinically focussed doctorate. Then people complained there was not a certification process for DNP, and she responded with a test developed by and using the same questions from USMLE step 3, yet people still complain. There will always be people threatened by or criticizing the advancement of DNP.

Something cannot be "clinically focused" when just 50% is actually directed at clinical knowledge. If we use medical education as the gold standard, about 95% of medical school is clinically focused (even when you don't consider clinical biochemistry as a clinical course). I have already shown that the DNP basically adds very little clinically to the NP.

Second the DNP exam was NOT equivalent (or even close) to Step 3 yet Mundinger touted it as equivalent. This is why people complained- because she was lying. The reality of the CACC exam was that it was a watered down version of an NBME exam where the harder questions were thrown out (the CACC handpicked the questions), the minimum passing score was lowered (by the CACC), and the most difficult portion of step 3 (patient management simulations) was taken out.

Well the first and second round of results are back. In both rounds ~50% failed despite adequate time to study. In comparison, interns who take the real step 3 have a 95% pass rate despite no time to study for it.

Not understanding how informatics can be applied to your practice does not attest to its usefulness, rather it demonstrates a lack of knowledge regarding how to apply it. In other words, until you take the class (with the rest of the DNP courses) you simply can not know what you dont know. To say those classes are worthless and will have no affect on clinical practice without having gone through them is statement born in ignorance. (ignorance=lack of knowledge on a particular subject)

I mean really? You're grasping at straws now.

dgenthusiast · Mar 10, 2010

"Clinical" does not necessarily mean "the diagnosis and treatment of one particular patient." The DNP is still "clinical" in that it is focused on the assessment/evaluation of of the care of a population of patients on a broader scale. Thus the DNP is still "clinical" in comparison with a PhD that has little (if any) focus on that. Most PhD programs focus on the topics such as the nature of knowledge, methods of knowledge development, etc.. That's what makes it a research degree rather than a practice or "clincial" degree.
Sure, there are differences from one DNP program to another -- and not evey DNP program is consistent with Mundringer's ideas. It will take a while to sort some of these issues out. But that's to be expected whenever a new degree is introduced.
Personally, I have a PhD -- even though I have almost always worked in hopsitals, not academia. For me, a PhD was/is a good fit because my interest lies in philosophy and research. But I can understand that many people who want a doctoral level education might not be interested in those topics and want to do doctoral level work focusing more on practice issues. The DNP is a better fit for them.
And it is not NP's who are getting DNP's. The DNP is expanding beyond the NP focus to be the doctoral program for those in all roles that do not want to focus on research, theory, and philosophy. There are CNS's, administrators, and educators who are DNP's -- without picking up an NP along the way. The DNP is a doctoral level degree focusing on advanced practice, that may or may not include the Nurse Practitioner role. It is not an exclusively NP thing. Nurses in other roles are also getting DNP's -- in which case the whole "are they equal to physicians" question is kind'a irrelevant. If the NP folks want to require the DNP as the minimal entry level for NP certification, that's a different issue -- one that is only a portion of the whole DNP picture.

Actually, clinical does refer to the treatment/management of patients. Just because the DNP has more clinically relevant courses than a PhD doesn't mean that the DNP is a clinical degree. As myself and others have pointed out repeatedly, the DNP is essentially a glorified MPH. Is the MPH a clinical degree? I doubt anyone would say it is. Also, even though there is a separate PhD, why are there so many research oriented courses in the DNP curriculum? Do you really need several stats courses, several research-based courses, etc in what is touted as a clinical doctorate? In addition, I fail to understand how barely 2 semesters' worth of courses make up a doctorate. I can't think of any other doctoral degree (PhD, MD, DO, etc) that's as easy to attain; all of these appear to be substantially more rigorous, more time consuming, cannot be attained online/part-time, etc.

If the DNP is not clinically oriented, and a cursory glance at various DNP curricula proves this to be true, then you shouldn't be allowed to call yourself a doctor in a clinical setting any more than a person with a PhD in history should. It's as simple as that.

PS. I already know what a bunch of people are now going to say: physicians don't own the doctor title, DNPs should be allowed to call themselves doctor in the clinic because they've "earned" that title, and so on. However, if you look at what I wrote, I haven't said anything about any other profession not being allowed to have the doctorate title. Focus on what I wrote instead of drawing up strawmans as is very common on these forums. I'm saying fix what you already have before pushing for more.

dqbanrn · Mar 11, 2010

Physicians also take many courses that can be argued to have limited clinical application. No singular course makes the difference between NP and DNP. Its joining together of all these that give the student a specific body of knowledge. This body of knowledge then gets applied to their clinical practice, even if the DNP never enters the patients room saying "im going to use informatics on you".

Mundingers exam uses retired questions, not rewritten. The pass rate you reference was based off the first time the exam was taken. Unlike med students, there is not a near infinite repository about the exam for the DNP students to reference before testing.

Just to be clear, i have stated that i don't think the DNP has evolved enough to merit independent practice (ive said this in several post)

llg, PhD, RN · Mar 11, 2010

Actually, clinical does refer to the treatment/management of patients..

The above quote was made in reponse to a statement of mine -- one that you apparently misunderstood. I didn't say the word "clinical" did not refer to the treatment/management of patients. I was making the distinction that between the treatment/management of 1 patient and the treatment/management of a population. My point was that the core NP courses (the ones that are the same whether the program is a MSN program or DNP program) are those that focus on the care of 1 patient at a time. The additional courses for the DNP do not seem to add much, if anything, to those skills. However, they expand the focus of the role to include a focus on the care of a population of patients and the incorporation/provision of care on a system-wide basis.

My point was that both individually focused care -- and population/system level care are rightly considered "clinical." My comment was made in response to a previous poster who claimed that those other courses were not really clinical and therefore did not belong in a clinical doctoral program -- that the additional DNP courses were not "clinical" because they were population focused -- making the degree not a clinical degree. I was saying that the DNP is still a clinical degree even though the focus of those particular courses is population-based (as opposed to the research-focused PhD.)

No hard feelings. I don't want a flame war. I just wanted to clarify the point I was trying to make.

wowza · Mar 11, 2010

Physicians also take many courses that can be argued to have limited clinical application. No singular course makes the difference between NP and DNP. Its joining together of all these that give the student a specific body of knowledge. This body of knowledge then gets applied to their clinical practice, even if the DNP never enters the patients room saying "im going to use informatics on you".

No they don't. In the MD curriculum, less than 10% of the courses in the first and second years are non-clinical. No hospital rotations (3rd and 4th year) are non-clinical. Here is the medical curriculum at my school (estimated credits using 14h in the classroom as a single credit- ie how every university does it.)

First 2 years:

Clinically related 104 credits

Medical Genetics

Anatomy

Physiology

Histology

Immunology

Behavioral sciences

Neuroanatomy-

Foundations of clinical medicine

Geriatrics

Microbiology

Pharm

Intro to pathogenesis- 1 credit (almost all path is in the organ systems)

Systems: takes pathophys, pharm and micro involved in the organ system

Heme/onc

Endocrine

Renal -

Resp-

Cardio

Behavioral/psych-

Neurology-

Women's health/OB-

GI-

MSK/ortho-

Less clinically related 11 credits

Pop med (statisitcs, etc)

Medical Biochemistry

Ethics

Clinical Hours for which you do not get "credits" in 3rd/4th year

Pediatrics 600 hours

Surgery 650 hours

Neurology 200 hours

Family med 200 hours

OB/GYN- 400 hours

Pysch- 300 hours

IM- 720 hours

ICU- 250 hours

Medicine 2- 300 hours

Electives (min allowed) 640 hours

Total 3rd year clinicals (not including most of 4th year electives) : 4250 hours of clinicals

llg, PhD, RN · Mar 11, 2010

Y'know ... All this talk about how MD and DNP curricula is really irrelevant. The 2 fields don't have to be the same or even contain "equal numbers of direct care provider hours" for the DNP to be a legitimate doctoral degree. Different disciplines are different -- that's why they are called different disciplines.

NP's (at any level of education) do not HAVE to be the same as physicians to be worthy of respect and to be entrusted by society with the provision of certain types of care. What matters is that NP's have been shown to provide a needed, valuable service at a reasonable cost. As long as that is true ... then nursing's internal debates about increasing educational standards are none of the medical-world's business. MD's don't ask nursing to approve the particular's of their curricula.

Disinherited · Mar 12, 2010

llg - it is NOT irrevelant to me as a patient. If NP/DNPs are allowed to see patients without any type of physician supervision (as they are in 11 states), then to me they are 'practicing medicine'. Seems to me that the inflationary move toward DNP as the entry level degree for NP's is an attempt to 'justify' their increasingly independent role in the medical system.

To me, a patient, the only folks who should practice medicine 'independently' is a PHYSICIAN, the guy/gal who comes into my room and says "Hi, I'm Doctor Roberts, what are you here for today". DPTs don't practice medicine, they practice physical therapy. While I think the whole DPT thing is a joke as well, at least they are limited to practicing 'physical therapy' and not 'medicine'. The same with pharmacists, dentists, and optometrists. They practice pharmacy, dentristy, and optometry. Seems like the nursing profession is trying to 'practice medicine' independently, via the NP/DNP route, without going to medical school.

I'm going to guess that some would reply to that with "but we're practicing 'nursing', not medicine". I'm sure that is true in many cases, but the NP, and especially the premise of the Doctor-Nurse DNP, is dissipating the line between medicine and nursing. While this line may be clear to you, it is NOT clear to your patients. I am an educated and highly successful person, but I can't come up with a clear delination between nursing and medicine, so I'll posit that 98% of your patients couldn't either.

I realize NPs are valuable members of the health care team. So are PAs, AAs, RNs, LPNs, CNAs, physical therapists, pharmacists, and janitors. But this team should be led by a physicain trained medical doctor who is ultimately responsible for the quality of medical care provided.

After the education I have received during my time visiting these posts I have certainly changed my view of certain portions of the healthcare system. I will NEVER again allow a member of my family to be seen by a NP without a few minutes of questioning that NP's education and experience. I guarantee if he/she walks in and introduces him/herself as a Doctor, I will immediately ask for a physician instead.

I hope the DNP goes in one of two directions. Either it becomes a true "clinical doctorate" with substantial medical education - - more like a PA education - - and rises to the level of responsibility which your nursing associations have already carved out for it, or the public (like myself) gets wise to the fact that the DNP education is geared more toward administrative/management/leadership/research and refuses to see DNPs.

One last thing, llg brings up the NP/DNP providing care at a "reasonable cost". This was one reason I was always a proponent of the PA/NP ideology. PA/NP services costs CMS (ie- the taxpayer) 85% what it costs for a physician to perform the same services....I like it! But with the inflation of NP to a DNP, I gotta wonder if the powerful nursing lobby's next step will be to require pay parity....after all, both are 'doctorate level' providers....right??

llg, PhD, RN · Mar 12, 2010

Disinherited ... You don't have to see an NP if you don't want to. You are free to choose -- just as many people prefer to see an NP rather than a physician. They are free to make that choice as well. And nursing is free to create doctoral degrees just as other academic disciplines are free to do that.

Does anybody know the answer to this question? Are there a bunch of nurses who go to medical forums and harass them? Is that what draws med students over here to heckle nurses? I mean it's not like we practicing nurses don't have a lot of "dirt" on shoddy medical practice that we could throw back at them.

psychonaut · Mar 12, 2010

Does anybody know the answer to this question?

Yes.

Are there a bunch of nurses who go to medical forums and harass them?

Rarely.

Is that what draws med students over here to heckle nurses?

No (and I know I won't be telling you anything that you don't already know). What draws them here is this strange phenomenon of converging themes, arising from:

-a few medicos who are passionately disturbed by the entire concept of independent advanced practice nursing

-a larger cadre of (mostly) pre-meds and med students, insecure about their futures, and eager to parrot the themes of the above group

-both the above groups mimicking the style and substance of the very ugly CRNA vs MDA debates

-throw in a few self-loathing nurses, and some "patients" with no skin in this game who just like to pile on; most of this latter group essentially copy-and-pasting the same themes from those "medical forums" you reference above

-mix it all in a pot, with a generous dose of internet anonymity/expertise/hostility, and voila!

I certainly have been one to openly question aspects of the NP and DNP issues, especially in terms of the educational models used. I really don't question NP practice, simply because it works. I work with NPs who have a great deal of independence in patient management, my PCP is an NP, and the horrific outcomes (eagerly) anticipated by the NP foes just don't seem to materialize.

The DNP issue is easier for the foes to get a wedge in, precisely because it is an issue which we nurses are still debating amongst ourselves. I wager that this could lead to a more united front in support of the DNP by nurses, simply in reaction to relentless attacks by the DNP foes, especially if the attacks move beyond the realm of internet tough guys and into the realm of legislative and propaganda attacks on our APN colleagues (as has been promised by some of the foes, and has happened in the CRNA realm).

I personally would prefer to continue the (internal) DNP debates, but I can honestly support the concept because, at the very least the DNP is an NP, and I feel the NP concept has a demonstrated track record of success.