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DNP Answers

'Practice' or 'Clinical' Doctorate?

Published April 20, 2010 8:47 AM by Lisa Chism, NP

Here at the DNP Answers blog we take your questions about the DNP and answer them as best we can. This is our first DNP question:

Q: “If the DNP is a clinical doctorate degree, why are programs admitting students that have a Masters in education, forensics, etc.?” (from reader Melissa Prouty, who asked us on Facebook)

A: Melissa, what a great and pertinent question. The American Association of the Colleges of Nursing (AACN) has actually deemed that the Doctor of Nursing Practice (DNP) degree be described as a “practice” doctorate, not a “clinical” doctorate (AACN, 2004).

The reason for this stems from the AACN’s definition of nursing practice: "The term practice, specifically nursing practice, as conceptualized in this document refers to any form of nursing intervention that influences health care outcomes for individuals or populations, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations, and the development and implementation of health policy. Preparation at the practice doctorate level includes advanced preparation in nursing, based on nursing science, and is at the highest level of nursing practice."

It is helpful to understand that the definition of nursing practice is quite inclusive and that “practice” includes both direct and indirect interventions which impact patient care and healthcare delivery. So, while many programs admit students who are clinicians, many also admit students who are in indirect patient care and healthcare delivery roles, such as nurse educators or nurse executives. It does get somewhat confusing and in an effort to reduce confusion regarding advanced nursing practice, the AACN defines advanced nursing practice as including but not limited to the four current APN roles: clinical nurse specialist, nurse anesthetist, nurse midwife, and nurse practitioner. Also, it is important to remember that “practice” is not just direct patient care. Practice encompasses all aspects of care and healthcare delivery including direct care, policy development, leadership and implementation and evaluation of evidence-based practice. Therefore, the DNP is a “practice doctorate” which focuses on all areas of practice, both direct and indirect. I hope this gives you some clarity regarding your question.

Editor's note: Comment below to continue discussion on this topic, or, if you have another question, send it to jford@advanceweb.com.

posted by Lisa Chism, NP
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14 comments

As an outsider perspective, and a husband of an RN who was planning to pursue her masters for Nurse Practitioner.

As a long time strategist, I can tell you this plan will bomb. I can understand the desire to create a level that is more on par with MDs.  But does anyone really believe you're going to see MD level pay?  Nope...you'll have to expend as much $$$ on student loans as a doctor, but not recoup the investment at anywhere near the same rate.

Furthermore, you're going to halt the upward mobility of many nurses to the traditional nurse practioner role. My wife included. We have three kids. The thought of having to get her NP completed in such a short time is essentially an impossibility. That leaves needing to earn a PhD.  Well, there is no way she can do that in the time frame.

So what did the AACN in it's infinite wisdom (foolishness) achieve? The 100% opposite of their claimed intended goal.

Now please do not get me wrong. I do not think the DNP is a bad idea. I think it is in fact an EXCELLENT idea. I think the AACN's proposed implementation is blind and borders on insane. And it largely stems from the mandate of the PhD.

The correct solution, is to maintain the bachelor based RN, the nurse practioner role at the Master's level and the Doctor of Nursing Practice as the PhD.

It's quite evident as to why this should be.  To mandate PhD with zero benefit of earning a masters creates far too much of an investment without return on benefit.  This will essentially, place every advanced nurse in debt bondage.  (Talk to some doctors coming out of college now and struggling with huge loans. Now imagine the same but with less earning potential.)

There is a great advantage to allowing for a stepped level of role.  If one can earn a masters and increase their role and earnings while they pursue their PhD.

"To answer why not get your MD? Because Nurses and NP's have different philosophies of care. MD's are taught on a medical model which focus on treating illness. Nurses and NP's are taught to be wholistic, proactive, prevent illness, promote healthy lifestyles and to treat illness. While we are trained to treat illness too, we are first taught to investigate the cause and try to remove it instead of merely covering it up."

Seriously, you know what this sounds like to an outside. Lying to one's self. I do not mean to be rude.  But I am sure many doctors would take offense to being labelled trained to cover it up. Furthermore, I know many doctors who do pursue a more wholesome proactive approach.

So if that is the sole difference, that one paragraph. Than I have to conclude it'd make more sense for my wife to try to transition to an MD.  She'd probably only need to add an extra year and half of undergrad credits to be able to moving into an MD track that would be completed in the same time as DNP.

AACN needs to reconsider a stepped approach if they want the DNP program to succeed.

Jason Epperson July 30, 2012 4:24 PM
PA

I was a huge skeptic of the DNP when I first learned of it. It has taken much time and research for me to educate myself and understand how the DNP will improve nursing overall.

Just for a point of clarification-non-nurses cannot get a MSN or a DNP. You must have a bachelor degree and be an RN. Most programs require that you have a BSN. RN's that are Not-NP's can go for MSN and DNP degrees although. Perhaps you are thinking of PA's who do have to receive a bachelor's degree, but not in nursing.

Master prepared NP's are grandfathered in and do not have to complete their DNP. It is optional. Many, many years ago, a bachelor degree was entry level. Much of the push is to get doctoral prepared faculty in. The length of time and energy to get a Ph.D turns many off and thus faculty is scare. Not to mention the money is not nearly as good as a practicing clinician. A DNP is a "practice doctorate" just like a MD or DO.

To answer why not get your MD? Because Nurses and NP's have different philosophies of care. MD's are taught on a medical model which focus on treating illness. Nurses and NP's are taught to be wholistic, proactive, prevent illness, promote healthy lifestyles and to treat illness. While we are trained to treat illness too, we are first taught to investigate the cause and try to remove it instead of merely covering it up. When people ask me why I didn't get my MD, I answer because I beleive in the philosophy of care that the profession of nursing provides.

The DNP focus is knowledge translation and best practice. In other words, taking all those research findings done by the PhD's and putting them into practice in the form of protocols, proceduces and guidelines. Yes, we are already proven expert clinicians but some of us want an avenue to take it to the next level and still be a clinician (not a researcher). If you like to teach (especially in doctoral programs) you will need a DNP or PhD.

Also, many ask if DNP's will want to be called Dr's? Technically physician's have been using the word doctor like kleenex. The word doctor refers to those holding doctorate degrees. Much of the public associates doctor with physician though. With so many professions changing to doctorates as the terminal degree. I think this will change. In the meantime-we all should refer to professionals by what they are...physician, NP, PT, OT, pharmacist, etc.  As always, nurses are at the front line to educate.

Nurses-lets be cohesive and address the issues of too many degrees and titles by meeting with our professional organizations and legislators. We cannot be a strong profession if we do not work together!

Denise Cooper, NP March 18, 2011 12:59 PM

Sorry, that is AND they have 2 tracks.

Denise Cooper, NP January 14, 2011 10:37 AM

The addition of the DNP degree has certainly been confusing and a lot of misinformation is out there. I teach in a DNP program and am completing my DNP currently. First, the DNP degree is only for either RN's or APN (CNM, NP, CRNA, CS). Most schools that have transformed their MSN programs to DNP have 2 tracks. One is for Bachelor prepared RN's (some allow ADN or diploma RN's with a bachelor in another field) and is a 4-5 year program (full-time). The other is a post master's program and is a 2-3 year program (full-time). For the post master's you can have a Master's degree in another field (eg. education) and NOT be an APN. This is for RN's that are interested in a practice doctorate but do not desire to be a NP (like DON's). Some of the programs out there have this option and others require that you be an NP. So some of the confusion is coming from the different programs. I agree that Nursing degrees and titles are so confusing even to those in the profession. We need more consistent titles and degrees. We are working on that slowly! I personally believe that the DNP should ONLY be for APN's and that other practice doctorates (not named DNP) be available for RN's who desire a doctorate. When someone says that they have a DNP, that does not necessarily mean that they are an APN, it does mean that they are an RN with a practice doctorate in nursing. I don't know of many programs out there putting out NON-APN DNP's but I disagree with the idea. As a practicing NP although I agree that a DNP for APN's is essential. The current Master's programs require schooling BEYOND a traditional Master's to prepare us. A doctorate is just giving us the degree that is more in line with the amount of time invested (the additional post-master's work is not that bad).

As stated earlier, MD/DO's are specializing. They don't want to be primary care providers, because they can make more money specializing. I believe that NP's will be the primary care providers of the future. Although I know that NP's have been shown to provide safe and cost-effective care equivalent if not better than MD/DO's, we need public trust. I truly believe that a DNP is taking us down that road. Nurses need to remain strong as one, educate themselves, and educate the community. Hopefully that helps clear some things up :-)

Denise Cooper, ANP-BC

Denise Cooper, NP January 14, 2011 10:12 AM

I am very confused on who sets all the criteria for these programs because state to state the criteria is not consistant. I have received DNP info from states other then Ohio that have an entrance to DNP slated at 3.0 or greater.  In OHIO An MSN passing requirement is a GPA of 3.0 or greater (as in other states) but the difference in Ohio is the a DNP entrance GPA is slated higher then their MSN graduate requirement. Ohio's DNP starts at 3.2 and some at 3.5. Ohio will allowyou to graduate with an MSN at 3.0, but not allow you to enter their MANDATORY DNP programs unless you have a 3.2 or higher. How can anyone make a mandatory DNP entrance GPA higher then what is required to pass their MSN program??? In the same state??? No wonder there is so much animosity toward the DNP when our own peers make it difficult to enter a DNP program. If one can pass the MSN why isn't that enough to go on and continue to the DNP? This is mandatory not an option so in my opinion the MSN to DNP is an oxy- moron in OHIO!!! This is typically a continuation of what nurses do to nurses, Physicians nurture their young nurses try to "eat them" as the saying goes; lets continue to set nurses up to fail!!! I'll take art courses and retire with my MSN at this point because an MSN with a 3.0 GPA means NOTHING in OHIO!!!!! Having DNP after your name represents initials only, not the professional representing that title. There are many book smart people practicing that I would not let take care of me or my family and that includes Dr.'s as well as NPs and PAs. Either raise the GPA for the MSN or decrease the GPA 0.2 for the DNP and come back down to the "practicing world" of reality.

Very passionate on this subject

Susan, FNP - CNP , SNF/express clinic December 26, 2010 1:17 PM
mentor OH

I really wonder why the push is on for the DNP---isn't one of our problems in nursing now the fact that there aren't enough MSN's choosing to go into academia because of the PhD requirement and then too the whack in pay that academia takes compared to a practicing NP. And if we want the public and the world of medicine to recognize us for what we can do and do well why muddy the waters with a DNP for gosh sakes. After 40yrs in nsg I find it incredible that there is/never has been consensus--ie: LPN, RN, RN AD, RN BSN/BAN, RN MSN and now DNP--go figure.

Kathy, Pulmonology - FNP, Wissota Vent Unit July 29, 2010 4:27 PM
Chippewa Falls WI

Could not agree more, Dorothy. We see in one of the other posts a recitation of what seems to be a major element of the "party line" espoused by AACN and other DNP supporters:

"Importantly, the DNP degree also benefits the nursing profession in that we now have a practice doctorate reflective of our practice profession. Our colleagues in pharmacy and physical therapy have adopted doctoral preparation for entry into practice and others such as audiology and occupational therapy now offer practice doctorates. The Institute of Medicine has proposed that all healthcare professionals be prepared at the doctoal [sic] level to improve healthcare delivery and reduce medical errors."

These remarks raise two very useful questions:

(1) Is the "Institute of Medicine" aware that MSN-prepared APNs have already been shown in multiple studies to be providing safe, effective patient care comparable to that of a GP physician, and have been doing so for many, many years? Why, then, has it suddenly become so crucially important that APNs be required to earn a DNP if they are clearly doing so well in their roles as things stand?  

(2) Does it ever occur to those who use "colleagues in pharmacy and physical therapy [etc.]" as examples of why all APNs should be required to earn a DNP that pharmacy, PT, OT, audiology, et al are fields that bear little to no resemblance to nursing in practice? Would it not be far more appropriate to look at the field that is, in general terms, closest in practice to what most APNs do -- physician assistant -- when attempting to draw comparisons of this type...and in so doing, take note of the fact that PAs are still prepared at the MASTER'S level?

It strikes me as telling that, to the best of my knowledge, not once has any mandatory-DNP advocate ever effectively addressed the questions I raise above, never mind made a truly compelling case as to why making the DNP mandatory for all APNs is so very important. In my experience, the only sort of response to such questions from the pro-DNP forces is more and more of the usual talking points that take some form of the above-referenced remarks, as though constant repetition of said points will carry the day in spite of any contradictory logic or evidence.

Until and unless the mandatory-DNP advocates can address these questions/concerns effectively, their position will continue to appear to be motivated by either the same sort of misguided mindset that says nurses will get more pay, respect, etc. (and never mind the weight of evidence to the contrary) if they simply add more letters to their names, or the cynical desire of certain academic interests to milk still more education dollars out of nurses.

Ironically, our much-maligned federal government has taken its first halting steps toward trying to grease the skids for more NPs to enter practice, having seen that they will be badly needed in the coming years as fewer MDs choose to become GPs. It is truly a shame that, whatever their motivations, those in charge of nursing education and credentialing are not similarly foresighted; indeed, if anything, they are actively working to discourage more would-be NPs and other APNs from pursuing such training by effectively doubling the already considerable burden of time, effort, and money required to do so at a time when the need for the services of APNs is forecast to increase dramatically in the near future.

Does that sound like a thoughtful approach to anyone else? It certainly doesn't strike me as such!  

Richard Snowden July 9, 2010 7:41 PM

Bravo, Dorothy!!  AMEN!!

Melody May 8, 2010 1:19 PM

I can guarantee you that practicing NP's if surveyed would not support the DNP. Why not just become an MD if you are going to spend that much time preparing to practice.WE have built a great profession with the APN, masters prepared. Now we have non-nursing individuals getting their msn/NP and they are probably the ones not comfortable in practicing when they complete their program. ARe we getting DNP's just so we can call ourselves Doctors. Why doesn't academia focus on getting the same entry level for RN's ...associate degree, bachelors degree, diploma degree.., LPN to RN completion, focus on an area with problems, not on something that is working well. And don't tell me it won't impact me..if I don't get my DNP I'll be limited in where I practice, the state I'm in and all other things will change, cost of liscensure, confusion and re-education of the public. Who dreams these things up. Hey lets just agree on what to call ourselves, APN,CNP, APRN,APRN,BC...why don't we address these issues first!!!

dorothy gariety, occupationalhealth/ family practice - CNP, WMH May 7, 2010 1:10 PM
sidney OH

I read that 50 something people took the controversial first national DNP certification exam in Oct. 2008 and only half of them passed the exam.  I understand that the exam drew clinical questions from the medical licensing exam.  This would indicate to me that the DNP does not advance our knowledge of advanced clinical nursing practice. I now understand that the DNP is a "practice" doctorate, not a "clinical" doctorate.  As I have stated before, the curricula of DNP programs appears to put a heavy emphasis on populations and social issues as opposed to direct patient care.  I would be extremely interested to know if data was collected as to which DNP programs the examinees of this first exam graduated from, particularly if any one university program had the highest pass rate.  I know this is a small sample size to draw any conclusions, but, I would think that those who passed the exam had more in depth preparation for clinical practice.  Would Advance for NPs publish this data if it is available?

Alice May 4, 2010 2:02 PM

Lets talk about Diplomates of Comprehensive Care Certification. %0d%0a%0d%0aAre clinicians who practice in states providing NP autonomy with the above desination and accomplishments still considered "Mid-Level Providers?"

Steve Carver, Family - NP, Dept. Of Health May 1, 2010 2:05 PM
Minneapolis MN

Vicki, I understand your concern. The DNP is not an advanced practice degree as a post master's degree and folks entering at that level will already be prepared as APNs, educators, or nursing administrators. As a post bachelor's degree, the DNP will include a specialty track to prepare folks as APNs followed by doctoral level content outlined by AACN in the Essentials of Doctoral Education for Advanced Practice Nurses.  The benefit of earning a DNP is often difficult to perceive. You certainly are already an expert clinician so why pursue a DNP? It is a very individual choice at this time and not required for practice. However, the benefits are global in that practice means more than the direct care given to the patient. As expert clinicians, additional skills in information technology, interprofessional collaboration, evidence-based practice and healthcare policy will enable nursing to better meet the needs of a changing, complex healthcare population. Importantly, the DNP degree also benefits the nursing profession in that we now have a practice doctorate reflective of our practice profession. Our colleagues in pharmacy and physical therapy have adopted doctoral preparation for entry into practice and others such as audiology and occupational therapy now offer practice doctorates. The Institute of Medicine has proposed that all healthcare professionals be prepared at the doctoal level to improve healthcare delivery and reduce medical errors. Hope this information helps you as you consider the DNP.

Lisa Astalos, Breast Care - Nurse Practitioner, Karmanos May 1, 2010 7:35 AM
Detroit MI

I find this information very interesting. My initial understanding was that DNP was an advanced practice degree. Considering the information provided, I don't understand the benefit for someone such as myself to pursue a DNP.

Vicki Miller, Psychiatry - CRNP, ISL Ltd. April 29, 2010 10:27 AM
Stroudsburg PA

I find this information very interesting. My initial understanding was that DNP was an advanced practice degree. Considering the information provided, I don't understand the benefit for someone such as myself to pursue a DNP.

Vicki Miller, Psychiatry - CRNP, ISL Ltd. April 29, 2010 10:27 AM
Stroudsburg PA

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