This spring, the University of Rhode Island in Providence is starting the registration process for the state’s first Doctor of Nursing Practice (DNP) degree. Scheduled to commence in the fall, it will join the ranks of 153 other DNP programs presently operating in the United States; some 106 new ones are currently under development.
(Information courtesy of American Association of Colleges of Nursing, http://www.aacn.nche.edu/Media/pdf/Docprograms.pdf)
As this degree is gaining ground, it continues to stir intense debate and conflict within the health care community.
On one hand are the proponents, who argue that the doctoral-level degree focused on the clinical practice (as opposed to a PhD, which prepares nurse researchers/scientists), gives nurses enhanced knowledge and skills to treat patients, especially in places where there are no other primary care providers. On the other side are the critics, claiming that the “doctor” prefix confuses and misleads patients into believing they are being treated by a Doctor of Medicine (MD) or a Doctor of Osteopathy (DO), the two professional doctoral degrees for physicians in the US. Just as importantly, many medical organizations say, is the quality of patient care provided, since DNPs receive far less training than MDs and DOs do.
The Commission on Collegiate Nursing Education (CCNE), the leading accrediting agency for Bachelor’s and graduate degree nursing programs in the United States, began the process of accrediting DNP programs in 2008.
While leaving the specifics of the DNP curriculum up to individual academic institutions, the American Association of Colleges of Nursing (AACN) explains on its website that the degree’s focus is on “providing leadership for evidence-based practice.” Furthermore, AACN states, “It is believed that enhanced educational preparation will lead to degree parity with other health care professions and assist graduates to assume leadership roles in clinical practice, clinical teaching, and policy development.”
AACN, the voice for the country’s nursing education programs, notes in its position statement that more doctoral-level nurses are needed to meet the changing demands of the nation’s health care system. An estimated 32 million additional Americans will gain coverage as of 2014 under the recent health care law, so a larger number of health providers will be needed to care for these patients. For this reason, AACN has suggested moving the level of preparation necessary for advanced nursing practice from the master’s to the doctorate degree by 2015.
Butting Heads Over DNP’s Role
The idea is that DNPs would fill some of the gap left by the on-going shortage of primary care physicians needed to treat not only the newly insured, but also the growing aging population. If predictions are accurate, the demand for health services will outstrip the supply: The Association of American Medical Colleges says that, at current graduation and training rates, the U.S. could face a shortage of up to 150,000 physicians in the next 15 years.
These present and future trends and challenges have prompted the Institute of Medicine (IOM), the nonprofit arm of the National Academy of Sciences, to issue a report at the end of 2010 urging increased training and autonomy for nurses. The most contentious part of this report is a call for the so-called “scope of practice” – the authority nurses would have to order tests, prescribe drugs, as well as perform other medical services.
According to Kaiser Health News (KHN), an independent news organization providing coverage of health care policies and trends, the report “calls for states and the federal government to remove barriers that restrict what care advanced practice nurses provide and includes many examples of nurses taking on bigger responsibilities.”
Some states have already started this process, while others are on the way. KHN notes that Colorado “recently became the 16th state to allow nurse anesthetists to work without a doctor’s oversight. In Michigan, nurses are pushing for legislators there to allow advanced practice nurses to prescribe drugs. Other fights over scope of practice for registered nurses loom in Kentucky, North Carolina, Iowa and Minnesota.”
But as increasing numbers of DNPs are being trained and getting ready to assume more responsibility for patient care, many physician groups are concerned about the implications of these measures.
The Level of Training
One of the main arguments advanced by organizations such as the American Academy of Family Physicians (AAFP) and American Medical Association (AMA) against giving DNPs autonomy to care for patients is the lower level of education and clinical experience as compared to training MDs and DOs receive.
AAFP’s president Roland Goertz, MD, MBA, tells SDN that the educational requirements for DNPs “focus more on topics such as concepts in nursing, health policy, illness management, drug therapy, epidemiology, and health assessment. In general, the DNP does not have residency training, and the only clinical requirement is that candidates for this degree receive at least 1,000 hours of supervised clinical experience.”
By comparison, Goertz points out that family physicians spend nearly 6,000 hours in lectures, clinical study, lab and direct patient care as medical students. They then go on to three years of residency training, in which they complete an additional 9,000 to 10,000 hours of clinical training.
(Information courtesy of American Academy of Family Physicians, http://www.aafp.org/online/etc/medialib/aafp_org/documents/press/nurse-practicioners/educational-training.Par.0001.File.tmp/NP-Kit-FP-DNP-UPDATED.pdf)
The table clearly demonstrates that not all “doctors” are created equal, at least as far as the level of their training is concerned.
By the time MDs and DOs start family practice, they have completed about 11 years of rigorous training – both academic and residency, clocking in between 20,000 and just over 21,000 hours dedicated to the study and practice of medicine. By comparison, DNPs education lasts, on average, between 7.5 and 9 years over 3,500 to 6,000 hours. In other words, physicians routinely receive 15,000 to 17,000 more training hours than DNPs.
The curricula for both degrees also vary. Just as an example, medical students learn anatomy, biochemistry, physiology, pharmacology, psychology, microbiology, and pathology, among numerous other courses focusing on treatment and prevention of a wide array of diseases.
Some of the courses offered by various DNP programs (determined by each educational institution) include Evidence-Based Practice and Nursing Systems, Health Policy Development & Implementation, Ethics and Public Policy in Healthcare Delivery, and Global Health & Social Justice.
An important consideration when assessing the DNP curricula, AMA Board Member Rebecca Patchin, MD tells SDN, is that “there appears to be little consistency among educational programs across states awarding the DNP degree.”
She notes that some programs offer DNP degrees that focus on administration, some offer the degree online, and others “have little or no clinical content.”
“The first issue is ensuring that patients understand that a new term for their advanced practice nurse doesn’t necessarily mean additional education and clinical training,” Goertz says. “DNP advocates want the degree to become the minimum educational requirement for advance practice nurses. It is, in essence, the ‘new’ master’s degree and thus doesn’t necessarily reflect clinical expertise beyond today’s master’s degree-trained advanced practice nurses.”
However, AACN’s spokesman Robert Rosseter points out to SDN that doctoral-level nurses play an important part in the evolving health care environment.
“Preparing a more highly educated nursing workforce is in the best interest of patients and serves the public good,” he says. “Nurses and physicians both have essential roles to play in the provision of primary care.”
He notes that while some doctors’ groups have voiced concerns about the DNPs’ role, “many physicians realize the obvious benefits to enhancing health care access and meeting the needs of the patient population.”
As an example, he cites Jeff Susman, MD, Editor-in-Chief of Journal of Family Practice, who wrote in the publication’s December 2010 issue that “joining forces with APRNs to develop innovative models of team care will lead to the best health outcomes.”
Is There a Doctor in the House?
Another bone of contention between physicians and nurses is the confusion surrounding the use of the “Dr” title. Organizations like AMA and AAFP claim that the proliferation of doctoral medical degrees is confusing to the lay public and therefore only board-certified physicians should identify themselves as “doctors” to their patients.
AACN spokesman Rosseter responds that the title is “common to many disciplines and is not the domain of any one group of health professionals.”
“Many Advanced Practice Registered Nurses (APRNs) currently hold doctoral degrees and are addressed as ‘doctors,’” he says, adding that other expert practitioners such as clinical psychologists, dentists, and podiatrists, also use this title.
However, AMA’s Patchin points out that her organization’s data “consistently shows that patients are confused about the qualifications of the different types of health care professionals.”
For example, a survey conducted by AMA in 2010 found that 35 percent of Americans thought a DNP was a physician, and another 19 percent were not sure whether a DNP was a physician.
“For DNPs to introduce themselves to a patient as ‘doctor,’ can set up false expectations and possibly hinder the patient’s ability to receive the most appropriate care,” Patchin notes.
AAFP’s Goertz agrees that if the “doctor” title is used without clarification, it can be misunderstood by the patients. “A significant number of Americans assume a doctor of nursing has the same clinical training and expertise as a medical doctor or doctor of osteopathy,” he says. “This can be detrimental to patient care”
The same AMA survey also demonstrates that 83 percent of respondents prefer a physician to have primary responsibility of the diagnosis and management of their health care.
“All patients have a right to know who is providing them care and what training they have,” Goertz adds. “Transparency in who is delivering care should be a priority.”
AACN’s Rosseter explains that, to avoid misrepresentation and confusion, “DNP graduates will be expected to clearly display and explain their credentials to insure that patients understand their preparation as a provider, just as current APRNs do.”
The resolution to this controversial issue may very well lie in the proposed federal legislation called the Healthcare Truth and Transparency Act, a bipartisan bill introduced in May 2010. Supported by AMA, AAFP, and several other physician organizations, including the American Osteopathic Association and the American Society of Anesthesiologists, it would require that health care professionals be truthful about their credentials and qualifications when advertising services.
Additionally, the state chapters of the physician organizations are pushing for state laws requiring accurate advertising and information about the licenses of health care professionals. Illinois, Oklahoma and Pennsylvania have recently passed such legislation.
As patients navigate the increasingly complex health care system, “consumer education is the most important way to ensure that they understand the clinical expertise of the person who is providing their health care,” Goertz concludes.