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Readers are encouraged to respond to Paul Blumenthal, MD, Deputy Editor of MedGenMed, for the editor's eyes only or for possible publication via email: pblumen@stanford.edu
To the Editor,
The purpose of my response is to question whether Ms. Wendy Vogel, in her Webcast Video Commentary posted on October 6, 2006 in MedGenMed,[1] has accurately interpreted the October 2004 American Association of Colleges of Nursing (AACN) Position Statement on the Practice Doctorate in Nursing.[2] I understood Ms. Vogel's interpretation to be that the AACN, the nonaccrediting national voice for America's baccalaureate- and higher-degree nursing education programs, has mandated that advanced practice nurses (APNs) be required to complete a doctor of nursing practice (DNP) program in order to continue practicing as an APN. This interpretation inspired me to take a closer look at the Position Statement. Of interest, my review revealed no such mandate. To the contrary, the Position Statement recommends that APNs who wish to develop their leadership skills and acquire positions with expanded responsibility and authority to improve outcomes of care are given the opportunity to pursue a practice doctorate “in a relatively streamlined fashion with credit given for previous graduate study and practice experience.[2]”
My take on the AACN position statement is that it is a vision for the future of advanced nursing education in light of the transforming healthcare environment. There is a critical need for clinicians to have advanced competencies for increasingly complex clinical, faculty, and leadership roles, and AACN believes that an additional option for attaining a terminal degree in the nursing discipline is the appropriate way to meet this need.[2]
The DNP appears to have momentum toward achieving this AACN vision. According to AACN's Web site,[3] as of July 2006, there are 24 established DNP programs in the United States (up from 7 practice-focused nursing doctorates in 2004) with 190 institutions in the process of developing DNP programs.
I hope that, by taking a closer look at the content in the AACN Position Statement, any concerns in regard to the mandatory acquisition of a terminal degree by established APNs were assuaged. The DNP has not been designed as a replacement for the masters-prepared APN, but rather is an evolutionary result of the anticipated healthcare needs of the 21st century.
That's my opinion.
To the Editor,
In my opinion, if APNs like the idea of DNP they should go to medical school and get a medical degree. A nurse is a nurse and still needs to follow doctors' orders! Plain and simple.
Thank you,
To the Editor,
This is insane!![1] Nursing needs to get down from the clouds and recognize where the real problems are – namely, hands-on nurses who actually take care of patients! I qualify to comment as I graduated with a BSN in 1961 and have seen the quality of patient care deteriorate to a frightening level – both from a professional standpoint and from a personal standpoint. I also hear this frequently from other clinical nurses who have a few years in the trenches rather than having spent their entire career in the ivory towers. And they wonder why nurses are exiting the profession in droves! The nursing profession really shot itself in the foot when it discarded the 2- and 3-year nursing schools – which, in my opinion, prepared the best hands-on nurses. Now the patients are subjected to “medical assistants” (or whatever you want to call them) who have no clue what they are doing and don't give a damn – with the possible exception of a small handful who have at least some ability. So many of them have really bad attitudes and are lazy, lazy, lazy. These nurses with high degrees need to spend a few months in the trenches where the real work is done, and maybe their eyes will open and see the truth. I live in fear that I may get really sick and have to go into the hospital and be at the mercy of incompetents.
To the Editor,
Like everyone, I, too, have an opinion in regard to the proposal.[1] I agree with Ms. Vogel about the fact that no one has even asked me, let alone the nurse practitioners in the rest of the country, how we feel about this. It seems that the ANCC [American Nurses Credentialing Center] has not done their homework on this issue. After completing my MSN as a family nurse practitioner, I chose to get my PhD in psychology. This decision was based on the fact that rural areas, especially, have inadequate access for patients dealing with mental health issues. I also love to teach and have done so in the past. If universities want to require this type of education to teach at the advanced level, so be it. Don't put my license and credentials in a vulnerable state by mandating such a proposal. It is bad enough, having lived in Florida, that midlevel practitioners are being threatened with practice control issues. When you read the statistics about the future shortage of family physicians, who do they think will pick up the slack? We already have a hard enough time getting physicians to work in rural areas. I have been in this field for many years, and it is all about money. Nurse practitioners are the backbone of rural health. If it works, don't fix it. Give us some credit. We are highly educated professionals who have proven ourselves statistically in the quality of care we render as well as patient outcomes. Let the practitioners practice. If you believe that educators need to be specially educated as doctors of nursing practice, have at it.
Respectfully,
To the Editor,
The recent decision of the American Association of Colleges of Nursing (AACN) to increase the required level of education for the advanced practice nurse (APN) is spawning many legitimate questions from existing APNs.[1] First, the AACN needs to explain to existing APNs the need for more education. Does research show that APNs prepared at the masters level are incompetent, unsafe, or ineffective in their current role? If the answer were yes, the need for the DNP [doctor of nursing practice] would be obvious. However, the answer is no; therefore, the DNP mandate needs to be seriously questioned.
Is the additional time and expense to obtain a doctorate justifiable when the DNP will never compete with the MD for pay, clinical prestige, and autonomy? How will replacing the APN with the DNP increase pay or scope of practice from what current APNs enjoy?
One of the reasons the AACN gives for supporting the DNP is to increase the number of APNs in the academic role. Is the DNP being designed for clinical practice, appropriate for academic settings? Can the DNP, without emphasis on research, compete with the PhD in the academic role?
Mandating the DNP will also cause problems for the thousands of existing APNs. Without very specific laws for grandfathering, mandating the DNP will further cripple the future role, pay, and job market of existing masters-prepared APNs. Another concern for current APNs is that those who choose to upgrade will face a considerable expense without any improvement in pay or scope of practice.
AACN's mandating the DNP has already damaged the reputation of masters-prepared APNs because whether it was intended or not, the mandate promulgates to the medical community that current APNs are undereducated. Current board certification already requires continuing medical education (CME) for APNs. What will 2 additional years of classroom education provide to clinical practice that regular pursuit of relevant CME will not?
The main reason AACN gives for the mandate is not research, but that other medical specialties are moving their requirements to the doctorate level. I personally believe that doctorate envy is not a legitimate reason to mandate that thousands of practicing and future APNs invest time and money pursuing something that will not profit them and research demonstrates is not necessary.
To the Editor,
This letter is in response to the doctor of nursing practice (DNP).[1] I am currently studying to become a primary adult nurse practitioner. I have to admit that initially I was stunned to learn that by the year 2015, all new advanced practice nurses (APNs) in the United States will be educated at the doctoral level. My mind went into overdrive with questions, such as “Should I do this if my master's may not count?” I knew there had to be more to it; there had to be some rational decisions behind such a change; and after reviewing the American Association of Colleges of Nursing (AACN) position statement, I believe these changes need to be supported.
The patient care that we provide today has increased greatly in complexity. I can remember when first starting out as a nurse over 16 years ago, patients were not as complex. Nursing practice has simply changed. How many of us consistently look for research evidence-based studies to use in caring for these complex patients? How common was that practice back then? The complexity has demanded an increase in our knowledge. It only makes sense that nurses in specialty positions, such as APNs, have the highest level of scientific knowledge and practice expertise. That highest level should be the doctorate level.
The AACN recognizes that many of the nursing masters programs carry a load that is equivalent to doctoral degrees in other healthcare professions. Many of these programs have increased their educational loads to keep up with the rapidly increasing expansion of knowledge. Is it not fair that those individuals who complete such workloads are acknowledged and given that credit? Many argue over the “doctorate” title that accompanies this level of education and argue that it will only confuse our patients. My experience in working with APNs is that they proudly emphasize that they are nurses and have a different role from those in medicine. I believe that nurses will continue to do so at a doctorate level of education. With time and education, our patients will also understand that difference as more nurses become educated at the doctorate level in a practice-focused setting.
The AACN, by introducing the DNP, are allowing those of us nurses who want to focus on the clinical/practical part of nursing as opposed to the research-based program. Nursing is simply moving in the direction of other healthcare professions, such as pharmacy, physical therapy, and audiology, that offer practice-based doctorates. All of our practices are evolving, and authorities, such as the Joint Commission on the Accreditation of Healthcare Organizations and the Institute of Medicine, have called on health professions to meet the needs of our current complex healthcare delivery system. We need to focus on giving our patients the best care and not get hung up on the “doctor” titles.
I encourage all nurses to review the position statement on the practice doctorate in nursing with an open mind. It is important to remember that our goal in nursing is to provide the best patient care, and the best way to achieve this is through education. Hopefully, we can all work together and empower our profession as we move forward with the doctorally educated APNs.
To the Editor,
I have just finished reading the letters posted in response to “Introducing the Doctor of Nursing Practice.[1]” I am sure that many want to add their “2 cents” to this commentary. I have been an FNP [family nurse practitioner] for 6 years, and all of those years have been spent in the practice of neurology. There came a point when I realized that I needed, and wanted, additional knowledge in my specialty field. I did not want a PhD to prepare me to teach or research; I wanted clinical experience. My only option, until the DNP, was to study on my own or, because I was seeking guided study, to consider medical school. In my case, the DNP provides the opportunity to seek higher level courses in the neurosciences, and to complete a residency in my chosen specialty. I have no political cause; I realize that my “alphabet soup” is going to get more flavorful; it is unlikely that insurance companies will reimburse me more because of a terminal degree. I am grateful for the ability to remain in nursing and be offered the opportunity to seek a terminal degree in a practice field.
Sincerely,
To the Editor,
The MedGenMed editorial endorsing the mandatory doctor of nursing practice (DNP) for advance practice nurses has elicited much discussion.[1] The recent response by Wendy H. Vogel, MSN, FNP, AOCNP (no relation), clearly expressed concerns from advance practice nurses related to the impact on the profession.[2]
There is another area of concern that also needs to be addressed. That is the impact on the healthcare consumer. Healthcare has become exceedingly complex, and individuals are faced with many choices and conflicts related to their health needs. Nursing has not made this any easier. The general public finds the array of nurses and the levels of nursing confusing. There are licensed practical nurses (LPNs), 3 levels of education for RNs (ADN, BSN, and diploma), and advanced practice nurses, who may be either nurse practitioners (NPs) or clinical nurse specialists (CNS). To further complicate the situation, the advanced practice nurse may or may not have prescription authority. Now the American Association of Colleges of Nursing (AACN) proposes adding another degree – the DNP. How will healthcare consumers interrupt this, and how will they be educated about the meaning of this degree? How will the average individual seeking healthcare distinguish between the physician and the advanced practice nurse with a DNP?
As an advanced practice nurse and a nurse holding a PhD, I have always had grave concerns about how I represented myself. While in clinical practice with prescribing authority, I chose to be very careful about the use of the title doctor, so as to not confuse the patients I provided care for. I have seen very little discussion about how the advanced practice nurse with a DNP would be represented to the public and to other healthcare providers. Providing quality, informed healthcare is the goal of the advanced practice nurse, and a DNP is not needed to do that.
I agree completely with Wendy Vogel and with other advanced practice nurses who oppose the addition of the DNP to advanced practice nursing.
Sincerely,
To the Editor,
Kudos to you and your physician colleagues for supporting the idea (whose time is long overdue) of a well-educated nurse!!![1] I have always believed that if the AMA [American Medical Association] said, “We want all nurses to be minimally prepared at the masters level and all advanced practice nurses to be prepared at the doctoral level (research and/or practice) by 2015,” that it would happen! I am sorely disappointed in APNs [advanced practice nurses] for not seeing the 21st-century medical future of technology, cellular biology, and the physics of space and hope that the AACN [American Association of Colleges of Nursing], physicians, and nurse futurists hold to their guns about the DNP [doctor of nursing practice] ideal. As an “old” diploma nurse, home health nurse, and former professor of nursing, I have always believed that many of the issues between physicians and nurses stemmed from the education gap between these 2 disciplines. I was never sympathetic to nurses' complaints about a perceived lack of respect from physicians when the majority of “professional” nurses spend 2 years learning their trade and physicians spend 13–15 years learning theirs. Education is a great equalizer, for respect and salary. Too bad those early nurses didn't also hire Flexner for some advice.
To the Editor,
I wish to call attention to two of the errors in Ms. Vogel's posting because they are the types of statements that tend to be repeated without validation.[1] The first of these is the implication that currently practicing APNs [advanced practice nurses] will be required to obtain further education. “Requiring a workforce of over a half a million APNs to obtain further education…,” I have seen nothing in the statements of AACN or other groups that support the DNP that indicate additional education of practicing APNs will be required if the DNP becomes the established degree for those who in the future prepare for advanced practice roles. The second is the statement “The AACN is not the only accrediting agency….” AACN is not and never has been an accrediting agency.
To the Editor,
I am against any mandate to require a DNP [doctor of nursing practice] for advanced practice.[1] Currently, I am completing my advanced degree to work as an FNP [family nurse practitioner]. I agree with many of the concerns that I have heard:
You have nurses who have been working very effectively in an advanced registered nurse practitioner (ARNP) role for many years and now this is not good enough?
The ARNP serves a very important role in addressing primary healthcare and disease prevention on many levels. This service to patients and their outcomes could be seriously compromised.
Nurses working in the ARNP role will not likely be compensated for the additional education that they would be required to see. I doubt that increased pay would be attached to the DNP. Look at your nurse educators as an example.
Nurses changing this policy and practice would only hurt nurses practicing as ARNPs, and discourage others from becoming ARNPs due to the additional years of sacrifice and financial hardship that some nurses would not be able to incur.
DNP only serves to confuse the public as to whether we are “doctors” or nurses.
These are just a few of my concerns. I doubt that I am alone. I think if people choose to get their DNP, great. However, there should also be the choice for those not wanting to receive this degree to have the ability to continue to practice in a role that has done a great deal to enhance patient care.
To the Editor,
I am a nurse and have practiced as a physician assistant for the last 18 years.
These responses/replies clearly articulate the absurdity of what the nursing profession is about today.[1] I am proud of being a nurse!! The profession continues in its attempts at validating what a nurse “does,” 25 years after I received an RN from a hospital-based nursing program. I have dealt directly with the issue of attempting to “quantify and defend” what I did. Papers were written, presented, discussed, even published, and we were told that “this was contributing to the professionalism of nursing basic literature.” In the 1980s, the nurse educators/profession organizations cried out that a BSN was needed by all RNs to be “qualified” to practice nursing.
I believe that the nursing profession has enabled and contributed to the current “healthcare crisis” in America because of this. I pose 2 questions to those professional/educational groups that continue in this rhetoric:
Have you as a group really articulated anything different from what Florence Nightingale wrote about?
Do you take any responsibility for the lack of/poor quality of healthcare in the United States?
I am a better PA [physician assistant] because of my nursing background. I use the knowledge that I obtained in my nursing training in 1978 every day I practice in 2007.
I owe a debt of gratitude to those RNs, with white caps, and an RN behind their name, who instilled in me the ability to use the nursing process in everything I do.
Because initials are influential, here are mine:
To the Editor,
Several universities have been granting a clinical doctorate in nursing for many years. Others are now wisely following, and a consistent title has been agreed upon – the DNP. I earned my ND (doctor of nursing) in 1996, from Rush University, several years after completing a masters there. This required an additional 5 quarters of more than full-time study, and a higher level research project than my MS. Due to the recent movement toward doctoral preparation for all NPs, the degree was retroactively changed to read “doctor of nursing practice,” or DNP. I'm glad to see the move toward this requirement for all NPs and advanced practice nurses, but the notion that this degree is just being “introduced” is misleading, and discredits those who have held this terminal degree for many years.
What is not addressed in the article is that this change of title is highly unlikely to make any difference in how one is regarded as a provider by colleagues or patients.[1] To think otherwise is folly. It is, in fact, still illegal in some states for a nurse practitioner to use the title doctor even if she/he has an earned doctorate in any field. I certainly don't want any patient to think that I am holding myself out as a physician, but the title doctor is not unique to physicians. I enjoy the reputation that nurse practitioners have with patients who recognize the title and have experienced the excellent care most often provided by them. My care is judged at face value, with or without the title “Dr.” before my name.
However, most of the patients I take care of (in the US Embassy system) think that I am a licensed practical nurse because of the word “practitioner” in the title, all the while commenting that they are getting some of the best medical care that they've ever received. However, many physician assistants (PAs) in our system (and male NPs [nurse practitioners]) tell me that they get called “Dr.” or “Doc” at post. The PAs certainly don't want to be called nurses, as are some of the female physician assistants in our system.
In official correspondence with regard to any other diplomat or visiting dignitary with a doctorate (earned or honorary), the title “Dr.” is used. When introduced at functions, I am still most often referred to as “the embassy nurse,” or more often “our nurse, Ruthanne.” When I introduce myself at such functions and use the term “Dr.,” my colleagues will often say, “You're not a doctor; you're just a nurse.” I then say, “Yes, I am a doctor; I hold an earned doctorate from an accredited university. I am not, however, a physician.” Then I am construed as egotistical, whereas others with earned doctorates are not. Until “nurse” is removed from the title “nurse practitioner,” people will not see us as the independent medical practitioners who we are. However, insisting on being called “doctor” is unlikely to achieve the desired effect either. In the meantime, I'll just keep doing the best I can for my patients.
To the Editor,
Wendy Vogel is incorrect when she says that no major nursing organizations have supported the DNP [doctor of nursing practice].[1] In fact, NONPF, the National Association of Nurse Practitioner Faculties, has absolutely endorsed the DNP. Almost 300 schools of nursing have begun to plan for the DNP, with target implementation no later than 2015. Credentialing boards are looking at credentialing of these advanced providers. Nowhere is it mandated that currently practicing APNs [advanced practice nurses] would have to return to school for their DNP. It is to be encouraged that their education continue to a higher level of education, which will enhance their practice, be it in direct patient care or in education. The DNP is not designed to pull providers from direct care. Schools of nursing planning for the DNP are looking at curriculum development that includes the post-masters advanced nurse provider who is already in practice, with online classes. The DNP is not designed to overthrow nursing practice, but to prepare the APN to be the strongest nursing care provider possible to patients, families, and communities, as well as to affect healthcare delivery. Should Wendy choose not to continue her education toward the DNP, she will no doubt continue to deliver high-quality patient care in her current practice. For those nurses who do choose to earn their DNP as initial preparation, or to return to school post-masters for their DNP, patients and communities will be able to expect so much more!
