The Doctor of Nursing Practice: Recognizing a Need or Graying the Line Between Doctor and Nurse?

Abstract

The distinction between doctor and nurse has been historically visible to patients, and the scope of practice for each healthcare provider has been clearly marked by a wall of separation rooted in state law. In fact, even the titles by which these providers have been addressed have remained constant, with the term “doctor” being reserved for reference to physicians. With the advent of the new doctor of nursing practice degree, however, the clear distinction between doctor and nurse is in jeopardy. Moreover, accompanying the push toward a practice doctorate for advanced nursing practice is a call for the expansion of the scope of advanced nursing practice. The urgent questions at hand are the following: First, is a practice doctorate necessary or even appropriate for advanced nursing practice? Second, should the scope of advanced nursing practice be extended at this time? In addition to the increased educational requirements placed on aspiring advanced practice nurses and the associated increase in costs of obtaining the requisite education, requiring a practice doctorate for advanced practice nursing risks blurring the line between doctor and nurse and creates a potential for patient confusion. A true need for requiring a practice doctorate for advanced practice nursing has not been demonstrated. Moreover, the states should tread carefully when considering expanded roles for advanced practice nurses to avoid creating conflict within the medical community. Considering the level of qualification of today's medical school applicants, perhaps we should be training more physicians to meet the demand head-on rather than creating a separate practice doctorate to fill the gap.

Introduction

The role of advanced practice nurses (nurse practitioners, nurse anesthetists, nurse midwives, and clinical nurse specialists)[1] seems to be in a state of flux. Not quite doctors but more than registered nurses, these providers render services that fall somewhere in between.[2] Just how proximate advanced practice nurse duties are to the scope of physician practice varies by the type of advanced practice nurse[3] and by each individual state.[4–6] Currently, however, the role of advanced practice nurses appears to be expanding at a lightning-quick pace.[7] “At least 24 states are already considering bills or are expecting measures to be introduced this year” to “address issues such as independent practice, doctor supervision of nurses, prescribing authority, or [to] extend prescribing, including of controlled substances.[7]” Although the push for expanded roles for advanced practice nurses has been ongoing for some time now,[5,8] the current expansion seems to be progressing with hastened steps.

Today, advanced practice nurses usually do not hold doctorate degrees because a master's degree has typically been required for entrance into these disciplines.[1] Arguably, and despite the overall variance in the functions that these providers perform state by state, their identity today is relatively clear to patients: They do more than nurses, but they are not “doctors” as that term is commonly understood. This may change, however, as the pointed delineation between physician and nurse seems to stand in jeopardy in the wake of the push for requiring the doctor of nursing practice (DNP) degree for advanced nursing practice.

The American Association of Colleges of Nursing (AACN) advocates requiring advanced practice nurses to hold a professional doctorate degree, specifically the DNP, by the year 2015.[9] The American Association of Nurse Anesthetists (AANA) followed suit by supporting doctoral training for entry into nurse anesthesia practice by 2025.[10] Colleges and universities have responded to the respective positions of the AACN and AANA as evidenced by the recent proliferation of DNP degree programs. The AACN currently lists 73 DNP programs accepting students with more than 140 additional programs under consideration for a total of 212 current and prospective DNP programs.[11] Columbia University, New York, NY, was the first institution in the nation to offer the DNP degree, just 4 short years ago.[12]

Expanded roles for nurses have been both lauded and criticized since inception of the concept of advanced practice nursing. Proponents have cited the pending physician shortage, particularly with respect to family practice physicians,[13,14] as well as a litany of additional arguments in support of the call for expanded roles.[15–17] Skeptics, on the other hand, have been leery of allowing nonphysicians to tread on grounds historically tended exclusively by physicians.[18]

Supporters of advanced roles have claimed that advanced practice nurses have made significant contributions to healthcare.[19] Studies have indicated that intervention by advanced practice nurses has led to improved patient outcomes combined with reduced costs.[20] Moreover, advanced practice nurses have been identified as key players in improving patient safety.[21] However, the question remains: How far should the scope of practice be expanded, if at all?

Discussion

The push toward the DNP degree is a significant issue right now. Although some nurses have pursued doctorate-level degrees in the past, most of these have been the PhD, which is geared more toward research and teaching than an advanced practice role.[1] Other doctorate-level degrees in the nursing field have existed from time to time, but the current trend, spurred on by the AACN and AANA, seems to favor a clinical practice doctorate in a consistent format, the DNP.[1]

Accompanying the move toward a clinical doctorate for advanced practice nurses is a call by certain groups for an expansion of the scope of practice. Advocates have been arguing for more autonomy for advanced practice nurses since before the inception of the DNP.[22] The result is a conflict between professions, as illustrated in a recent American Medical News article outlining the disagreement between the physician community and the nurse community as to whether care delivery by advanced practice nurses should remain physician-led.[7] The article cited the increased number of advanced degree programs as a causal factor in the drive to expand the scope of advanced nursing practice.[7] The conflict cited in the American Medical News article seems particularly problematic because, as one article discussing advanced nursing roles in Germany reported, “the expansion of roles will only work if physicians do not feel threatened by the shift of territory and responsibility.[23]”

One study has indicated that 12 tensions, under the categories of autonomy and interdependence, professional role expectations, flexible role enactment, proactive problem solving, and action learning, could affect the quality of collaboration between physicians and advanced practice nurses.[24] These tensions have been summated in a recent article on physician and nurse practitioner views in regard to primary care delivered by nurse practitioners:

There appears to be a fine line between NP's desires for autonomy and being pushed beyond their scope of practice in a large system with many complex patients. Meanwhile physicians want someone to reduce their workload without usurping their professional territory. These findings suggest a potential conflict between MD and NP perceptions of the NP role.[25]

With advocates urging a broadened scope of practice for advanced practice nurses, driven by and in conjunction with the call for the DNP degree, the questions at hand concern the appropriateness of requiring advanced practice nurses to hold a doctorate degree and the extent to which advanced nursing practice should be extended, if it should be extended at all.

The American Medical Association (AMA) has expressed its apprehension through the passage of Resolution 211, which sets forth the AMA's concerns with regard to nurses and other nonphysicians holding doctorate degrees and representing themselves as “doctors” to patients.[18] The AMA, via Resolution 211, directly quoted from one DNP program's advertisement comparing the DNP as “similar in concept to practice doctorates in other professions such as medicine (MD), law (JD), and dentistry (DDM).[18]” Citing various concerns, the AMA cautioned that the “quality of care rendered by individuals with a nurse doctoral degree is not equivalent to that of a physician,[18]” and made the bold statement that “[p]atients led to believe that they are receiving care from a ‘doctor,’ who is not a physician (MD or DO), but who is a DNP may put their health at risk.[18]” Furthermore, the AMA stated that nurses and other nonphysician providers holding doctorates and representing “themselves to patients as ‘doctors’ will create confusion, jeopardize patient safety and erode the trust inherent in the true patient-physician relationship.[18]” The AMA has gone as far as to resolve to “work jointly with state attorneys general to identify and prosecute those individuals who misrepresent themselves as physicians to their patients and mislead program applicants as to their future scope of practice.[18]”

The physician community is not alone in expressing concern over requiring the DNP for advanced nursing practice, nor are critics of the DNP confined outside of the field of nursing. Scholars within the nursing profession itself have expressed concern over mandating the DNP.[26–28] Nurse advocates who are critical of the DNP have cited concerns, such as an erosion of nursing as a scientific discipline and a widening of the chasm between nurse-scientists and clinicians.[26] Moreover, one representative class of advanced practice nurses has taken the position that the DNP should not be required with the American College of Nurse-Midwives (ACNM), stating that the “(DNP) may be one option for some nurse-midwifery programs, but should not be a requirement for entry into midwifery practice.[29]”

Some proponents of a practice doctorate for advanced practice nurses have pointed to other areas, such as pharmacy, audiology, and physical therapy, in support of requiring the DNP.[17,30] What these advocates have failed to address with respect to a practice doctorate for nurses is the proximity of these midlevel providers to an already-existing profession that requires a practice doctorate today. In other words, the practice of medicine already requires a practice doctorate (in the form of a doctor of medicine or doctor of osteopathic medicine degree) for physicians, whereas fields – such as pharmacy, audiology, and physical therapy – were exclusive of an existing practice doctorate prior to the current requirements for practice in those fields. Perhaps a more relevant comparison is found by looking at the patient confusion documented with respect to eye care providers.[31] Patient confusion has been reported with respect to the roles of opticians, optometrists, and ophthalmologists.[31] It has been noted that many patients cannot differentiate between these 3 eye care providers.[31] The realm of vision care and the patient confusion with respect to providers therein is more akin to the current situation with regard to the DNP degree. Just as vision care is provided by individuals holding 2 separate and distinct practice doctorates (ie, optometrists and ophthalmologists) so too will medicine be faced with separate, and perhaps competing, practice doctorates (and professions) if advanced practice nurses are required to hold the DNP. The resulting patient confusion will be comparable, if not worse, to that seen today with respect to vision care providers.

A review of some current DNP program offerings reveals that many institutions tout “part-time,[32]” “low residency,[33]” “distance education,[34]” and “online[35]” in their program descriptions. In fact, some programs' curricula are as much as two thirds Web-based.[32] These programs also vary greatly from school to school. This variation in DNP programs from one institution to another lies in stark contrast to the rather uniform approach of many US medical schools[36] and colleges of osteopathic medicine.[37] Moreover, the DNP features of part-time, low residency, and online training again differ significantly from the rigorous regimen faced by physicians in training.[38–40] The education of nurse practitioners in the United States has been described as “half that of a medical doctor and entry into the workforce is less restrictive.[41]” Moreover, as one commentator, arguing for expanded roles for advanced practice nurses, stated, “basic medical education has been truncated.[16]” Others have described the DNP curriculum as containing leadership and management attributes.[42] In contrast, full-time coursework coupled with hands-on learning form the backbone of a physician's training, as evidenced by the Liaison Committee on Medical Education's rejection of curricula that are based substantially on distance education.[43]

The variability among the DNP programs, as well as the structure of many programs, works to bolster the skeptic's viewpoint. Only an anticipated expansion of the scope of practice, state by state, compels the need for an advanced degree, and requiring an advanced degree conversely, as proponents hope, compels expanding the scope of practice in each state. Although accreditation of DNP programs (as contemplated by the AACN[9]) would certainly lead to more universally uniform programs, such a step is only relevant if a true need for requiring a practice doctorate for advanced practice nurses is demonstrated and if other cited potential conflicts can be alleviated.

Although the licensure of physicians and nurses, including advanced practice nurses, is governed by state law, there is much less uniformity among the states with respect to the licensure of advanced practice nurses than exists with respect to the licensure of physicians.[44,45] The AACN seems to have acknowledged this lack of uniformity at the present time.[46] Perhaps this lack of uniformity is explained by the relatively youthful existence of advanced practice nurses compared with the long-standing role of the physician in American medical history. Nonetheless, careful consideration should be given when defining the scope of practice for those individuals holding the DNP degree to avoid inviting conflict.

As previously stated, one of the often cited reasons prompting the expansion of advanced nursing practice, and the resulting proliferation of DNP programs, is the pending physician shortage.[47] Projections have called for a 30% increase in medical school matriculation from 2002 to 2012 to meet demands.[48] Additional breakdowns by state and by specialty cite specific increasing demands for more physicians.[49]

Currently, as reported by the Liaison Committee on Medical Education, there are 129 accredited MD-granting US medical schools in the United States.[50] The American Osteopathic Association's Commission on Osteopathic College Accreditation reported 25 DO-granting US colleges of osteopathic medicine, with an additional 3 branch campuses granting the DO degree.[51] This equates to 157 US schools currently training physicians. Considering the projected rate of DNP program development (the AACN reports 212 current and prospective DNP programs[11]), it appears quite likely that the number of DNP programs will surpass that of MD- and DO-granting programs in short order.

An October 16, 2007 release by the Association of American Medical Colleges (AAMC) reported that the 2007 entering class to US medical schools is the largest in the nation's history.[52] The AAMC noted that in addition to a growing applicant pool, 11 of the 126 accredited medical schools boosted their entering class size by more than 10% this past year.[52] First-year enrollment has increased by more than 7% since 2003, the AAMC reported, which is when the AAMC first began investigating the possibility of a physician shortage.[52] Of interest, the AAMC report stated that “the academic credentials of applicants to medical school [for 2007] were stronger than ever before, with the highest MCAT® (Medical College Admission Test) scores and cumulative grade point averages on record.[52]” Therefore, despite the likelihood that DNP programs will leapfrog physician programs by volume, evidence exists that many qualified applicants to physician programs are seeking admission.

Although the boosts in enrollment do not match the projected required increases necessary to counter the pending physician shortage at this time,[48,49] the academic credentials of year 2007 matriculants demonstrate that sufficient qualified applicants are currently seeking admission to physician programs.[52] Commentators discussing the physician shortage have called for changes to allow for additional training, including more slots for residents.[53] With focuses currently on the future demand for physicians,[54] additional increases in enrollment appear warranted.

Proponents of the DNP also cite “growing complexity of health care, burgeoning growth in scientific knowledge, and increasing sophistication of technology[9]” as being causal factors leading to the necessity of a DNP for advanced practice nurses. Certainly, these changes reflected in modern healthcare affect not only advanced practice nurses but registered nurses (RNs) as well. However, a call for requiring RNs to hold a bachelor of science in nursing (BSN) has not been made, at least not with the fervor that the push for a DNP has received, despite research indicating that a 10% increase in the proportion of staff nurses holding a BSN can reduce both the likelihood of patient death and the odds of failure to rescue by 5%.[55,56] It is also worth mentioning that, as a pair of critics wrote, “There is no evidence to suggest that a practice doctorate will contribute to increased patient safety.[57]” These commentators also stated that “[p]roviding more content through more Credit hours is not the answer.[57]”

Studies have reported success of advanced practice nurses functioning with master's degrees today.[58] In fact, advocates of increased autonomy for advanced practice nurses often cite studies that, as one commentator conceded, “were somewhat limited” that purportedly show high-quality outcomes when care is rendered by advanced practice nurses.[59] One such often-cited article written by Mary Mundinger, in which she advocates a collaborative approach, went as far as to conclude that care provided by advanced practice nurses is as good as or even better than care rendered by physicians in a primary care setting.[16] If Mundinger's “less is more” approach with respect to medical education, at least in the primary care setting, is to be accepted, then why require advanced practice nurses to earn a practice doctorate? Of note, Mary Mundinger is now Dean Mundinger of the Columbia University School of Nursing,[60] the first such program to offer the DNP.[12] Notwithstanding Mundinger's claims that advanced practice nurses can deliver better care than physicians, if the studies comparing care provided by physicians and advanced practice nurses, which, of course, looked at care rendered under the current master's degree-required model, prove accurate and advanced practice nurses do deliver comparable care in the primary care setting, then why require the DNP? In other words, if the current system works, then why try to fix it? Even the ACNM stated that “[t]here is inadequate evidence to support the DNP as the entry-level requirement for midwifery education.[29]”

From the aspiring advanced practice nurse's standpoint, will the increased education requirements associated with the DNP negatively affect enrollment in DNP programs? We are currently in the grip of a nurse shortage, with projections indicating that the shortage will continue into the future.[61] Moreover, this shortage seems to include advanced practice nurses as well because an insufficient number of nurses are pursuing advanced degrees today (again, at the master's-degree level).[62] The ACNM, in its position statement, echoes concerns of a negative impact on the applicant pool by mandating the DNP, stating that “it is clear that the requirement of an additional degree will result in a substantive increase in expense and time to the students and the educational institutions. In a time of critical shortage of midwives and other women's healthcare providers, the requirement of an additional degree decreases their availability in the workforce.[29]”

The AACN nonetheless proposes even more stringent requirements on aspiring advanced practice nurses including 3 calendar years of study, including summers or 4 years on a traditional academic calendar.[1] Is it wise to then require increased education for those nurses wishing to take on more advanced roles as care providers?

Although studies have indicated that intervention by advanced practice nurses has led to improved patient outcomes combined with reduced costs,[20] again such studies have reflected outcomes at the master's degree-required level. Increased education requirements will mean increased education costs that will ultimately be passed on to the consumer. Critics have reported that it remains uncertain whether DNP-educated advanced practice nurses will be affordable to employers.[57] Ultimately, from a cost standpoint, requiring the DNP will begin to defeat one of the intended purposes and desirable outcomes of the advanced nursing practice role. Moreover, the resultant costs associated with a DNP mandate are clearly distinguishable from increased education costs stemming from training more physicians. In the former, more will be required in terms of education and related costs from an existing provider type, ie, aspiring advanced practice nurses will incur more education expenses. However, in the latter, more education is not required of an existing provider type; rather, greater numbers of the existing provider type are trained to meet the current demand (ie, training an adequate number of physicians to meet the demand). Simple economics tells us that cost correlates directly with demand, thus meeting the demand will result in lowered costs.

Proponents may argue that the DNP is a necessary step in advanced practice nurses obtaining additional practice rights, such as privileges to admit. However, it is noteworthy that one class of advanced practice nurses, nurse midwives, a group who in the collective do not advocate requiring the DNP,[29] remains a strong proponent of seeking privileges to admit patients to hospitals.[63] Moreover, the call for such privileges predates the inception of the DNP concept.[64] If a need for such privileges exists, the case may be made on the basis of research in regard to cost and quality outcomes, not via a push for a practice doctorate.

Conclusion

Many questions remain with regard to the appropriateness of requiring advanced practice nurses to hold a DNP degree. Should advanced practice nurses be required to hold a clinical doctorate? Should the scope of practice of advanced practice nurses be further expanded, as is contemplated by several states at this time? Does mandating the DNP degree urge the expansion of the scope of practice? Are the increased education costs and time spent in school associated with the DNP degree justified? Will the DNP lead to patient confusion with respect to the identity of the individual rendering care? Should we be training more physicians rather than looking to other provider types to fill the gap? These are just a sampling of the many questions mandating the DNP degree raises.

The term “doctor,” applied in the medical setting, has always held a firm identity among patients, and the difference between doctor and nurse has been historically visible. Although the differences in function may not always have been clear to the public, the identity has been. Even if the divide has been somewhat bridged in recent years due to expanded roles for nurses, the title of doctor has remained an unmistakable identifier to patients. It's not to say that advanced practice nurses do not have their place in the American healthcare delivery system; they certainly do. These practitioners make important contributions in the provision of care. However, the title and the required degree for practice should not be that of doctor.

Requiring the DNP degree at this time risks fading the line between doctor and nurse, thus clouding an important distinction between providers. Moreover, the scope of advanced nursing practice should be cautiously approached to avoid creating confusion by patients, a decrease in quality, and conflict within the medical profession.

A true need for the DNP degree has not been demonstrated, and those in opposition have voiced some valid concerns. Simply stated, we should not be requiring advanced practice nurses to earn a clinical doctorate.

Where we once used the terms “doctor” and “nurse,” we may have to begin using the terms “physician” and “nonphysician doctor.” Is this really what is best in terms of achieving the goal of improving the overall quality of care at a reasonable cost while ensuring sufficient access, or will requiring the DNP simply cloud the identity of practitioners and invite conflict within the medical community?