Since the Affordable Care Act (ACA) first made headlines, a frequent topic in the media has been the shortage of primary care providers (PCPs) to accommodate the influx of newly insured patients. At the time of its implementation, it was estimated that there would be a shortfall of 45,000 to 60,000 PCPs to provide care for the millions of newly insured Americans (Rosenberg, 2012; "Survey reveals", 2012). The concerns continue. Recently USA Today cited that the demand for primary care providers cannot be met (Krasselt and O'Donnell, June 30, 2014).
While many of these articles note that NPs and PAs are qualified to serve as PCPs, a recent survey of Health Maintenance Organizations (HMOs) by the National Nursing Centers Consortium (NNCC) revealed that 25% of the HMOs do not credential NPs as PCPs. Compounding this problem, it was also revealed that many companies will credential the NPs but will not reimburse them directly or that the company will place restrictive stipulations in their contracts.Some will not list the NPs among their published list of credentialed PCPs for that HMO ("Survey reveals", 2012).
Health insurance without health care is of little value. The seemingly obvious answer is that the federal government can mandate that NPs (and PAs) must be empaneled as PCPs. Even if that occurred, the disparity between the scopes of practice of various states must be evened out. Currently, only 18 states allow independent practice by NPs while the remaining 32 states require physician oversight of diagnosis, treatment, and/or the prescription of medications (Cassidy, 2012). In order to fulfill their potential as PCPs, NPs must have some continuity of practice from state to state. While some of us may rue the entrance of the federal government into healthcare, that die has been cast. Federal intervention may be necessary to achieve the stated goals of the ACA.
There is, of course, opposition to the expansion of the role of NPs in primary care. The American Medical Association (AMA) has argued that the doctor shortage is not a reason to turn over primary care responsibilities to the NPs. They have contended that each NP should be supervised by a physician at all times (Mahar, 2010). The American Academy of Family Physicians (AAFP) suggests that NPs as independent practitioners creates a "two tier" system with the Physicians offering the highest level of care and the NPs representing the "less qualified" tier (Rosenberg, 2012). The implication is that the NP cannot be trusted to work alone.
Nurse practitioners stand trained and ready to offset the upcoming shortage of primary care providers that will result from the implementation of the PPACA. Facing an access to care debacle, it would be unwise to ignore the ready supply of providers trained in primary care and, in many cases, already employed in primary care offices.
This article was condensed from:
Reddish, W. (July 2014). Policy paper: NPs as PCPs. Unpublished Doctoral Paper for Maryville University.
Cassidy, A. (October 25, 2012). Nurse practitioners and primary care. Health Affairs. 31(11) Retrieved from http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_79.pdf
Krasselt, K. and O'Donnell, J. (June 30, 2014). Supply won't meet growing demand for primary care. Retrieved from http://www.usatoday.com/story/news/politics/2014/06/29/primary-care-shortage-health/11101265/
Mahar. M. (2010). The battle over letting nurse practitioners provide primary care. Retrieved from http://takingnote.tcf.org/2010/04/the-battle-over-letting-nurse-practitioners-provide-primary-care.html
Rosenberg, T. (October 24, 2012). The family doctor, minus the M.D. Opinionator, Exclusive Online Commentary from The Times. Retrieved from http://opinionator.blogs.nytimes.com?2012/10/24/the -family-doctor-minus-the-m-d/?nl=opinion&emc-edit-ty-20121024
Survey reveals that more health insurers recognize nurse practitioners as primary care providers. (2012, September 25). PHMC: A Non-profit Institute for Public Health. Retrieved from http://www.phmc.org/site/index.php?option=com_content&view=article&id=768:survey-reveals-that-more-health-insurers-recognize-nurse-practitioners-as-primary-care-providers&catid=67:2012&Itemid=1574
I had an interesting experience last week when a patient of mine that I referred to ENT within my clinic called to ask to be referred to another provider. Apparently, this patient - who thinks very highly of me and my work ethic - went to see the specialty provider, referenced me as Dr. Cash and the ENT proceeded to bash me instead of addressing the patient's main reason for being there. This turned the patient off, and she called and spoke with one of our patient advocates about the situation.
I don't feel that it is right for a provider to bash another provider in front of a patient, let alone a provider that they have never met or spoken to. I would never bash a colleague in front of a patient or a staff member - and I would hope that other providers would be respectful of my knowledge, credentials and the fact that my patients are very satisfied and well-cared for. This is not the first time that this has happened at the clinic where I work.
You see, this has happened with our compliance officer as well (who is an RN). She came out to my office for compliance week and then went on a tirade to the radiology tech about how I wasn't a real doctor and that she was going to make sure that she put an end to me calling myself doctor. Luckily, my radiology tech stood up for me, and said that they were referencing me as Dr. Cash because I had received previous approval by the board to do so. Of course this didn't make her happy and it showed all over her face during our encounter.
I found out the next day during my annual review that she sent an email about it to our clinic director (who is also an RN) who only briefly mentioned the incident to me without any detail. The phrase "nurses eat their young" is true. I thought that I had gotten past this, given years of experience. Apparently it still applies, because some are not accepting of the changing paradigms in healthcare, especially the role of the DNP and the title and credentials that come with it.
I guess I just expected more from my own. I mean, I expect it from the physicians, but the nurses too?
Evidence-based practice...we heard about it throughout nursing school and into our master's degrees; you hear the phrase in almost every health profession and in discussions regarding our current healthcare system. However, it wasn't until my DNP education that I truly understood the process of using the evidence to guide care and the importance of being a leader in this type of practice.
One of the most important acquisitions from my DNP education was the need for this evidence-based practice in today's healthcare environment. With the Affordable Care Act in full swing, there is a dire need for cost savings and improvement in patient outcomes to reflect on the cost spending. Just as changes have been made in the hospitals with the decreased reimbursement or even fining for services that are not supported by the evidence, the time will come when the same is true for primary care. The opportunity exists for leaders to guide care and support the healthcare system that is in need of evidence-based practice. This is exactly what our DNP education sought out to do: improve patient outcomes through research. Although a doctoral degree is not necessary to take part in evidence-based practice, the DNP education supports the leadership of this movement.
It is to this that I request those with a DNP to respond. The DNP degree was developed with the intention of improving clinical patient outcomes through research. Simply put, the focus is on improving the knowledge of clinicians in relation to clinical practice outcomes by using the research to provide higher quality of care. We must be leaders in this undertaking. Not only to improve patient outcomes, but also to provide a trickle effect on the entire healthcare system. As the parable of the fisherman teaches us, "Give a man a fish and he eats for a day; teach a man to fish and he eats for a lifetime."
We as doctoral-level trained nurses must be the teachers and leaders in our healthcare system through evidence-based practice as well as the guidance of using the evidence to support patient care. We must lead our peers - including nurses, physicians, legislators, etc. - in the practice of evidence-based care in order to not only improve the health of our patients, but also the well-being of our entire healthcare system.
In 2004, the American Association of the Colleges of Nursing (AACN) proposed that the Doctor of Nursing Practice (DNP) should be the entry level for Advanced Practice Nurses (APN). A year later, the Commission of Collegiate Nursing Education (CCNE) announced that the only doctoral practice degree that the CCNE would accredit would be the DNP (AACN, 2006). As a result of these actions, DNP programs have increased precipitously in the United States. While we can assume some regularity in these programs, can we also assume that all programs are the same?
One university in the Midwest offers the DNP degree online with no obligation to visit the campus during the program. The student must complete 33 credits, and the university advertises that the program can be completed in 18 months. There is no clinical requirement but the student must complete a capstone project with clinical application. While there is an epidemiology with biostatistics class, there are no true clinical courses (such as physical assessment or pathophysiology). The remainder of the curriculum is focused on leadership and scholarly writing and research. Like the remainder of the programs in the review, a Master of Science in Nursing (MSN) with national certification as an APN is a prerequisite.
A well-known university in the Northeast offers a 36-credit program with two-, three- and four-year plans for completion. This university makes no mention of online classes. Similar to the previous university, the courses are focused on evidence-based practice through research and its applications, as well as courses to develop leadership. A doctoral project is also required.
In the Southeast, a school advertises that its 33-credit program can be completed in 15 months. Most of the classes are online, but the school does require two three-day sessions at the university. Unlike the previous schools, this institution requires 360 "self-directed" practicum hours in addition to a capstone project. The curriculum is similar to the other schools except that eight of the credits are for the clinical practicum. The practicum hours, however, can be filled by attending conferences, shadowing DNPs or doing other scholarly endeavors. A second school in the South advertises a 36-credit two-year program with similar classes. This university requires 1000 hours of clinical practicum but allows the student to apply their practicum hours from their MSN program. There appears to be a research course but not a true research project.
Obviously, this is not an extensive review of the nation's hundreds of DNP programs. Certainly for prospective students, a far more complete review of the programs available should be undertaken. My review does seem to show, however, that while the programs may vary in their curriculum, they are geared towards developing an evidence based practice and preparing the DNP for leadership in the healthcare community.
AACN. (2006). The essentials of doctoral education for advanced nursing practice.
Getting my DNP was challenging, but, unfortunately, my employer was not as supportive as I had hoped of my hard-earned achievement. When I received my doctorate I intended to introduce myself as Dr. Cash to patients and wanted staff to address me as such, as well. I found out this would be harder than I thought.
The organization I work for is highly physician-centered. Yes, they still reference NPs and PAs as midlevel providers and physician extenders. I despise these terms. I was told I could not address myself as Dr. Cash because I, in fact, was not a doctor. I promptly challenged this pointing out that I was not a physician, but I was a doctor. I thought it absurd to only allow physicians to call themselves doctor. The clinic clearly employed other non-physician doctorate-prepared professionals. What were they calling themselves? Were they okay with this? Had anyone ever challenged this before? I would be the first.
I was told by a higher up in the company that the clinic had never allowed and would never allow other non-physician providers to use the title doctor and in his words (not mine) said, "let's face it, PhD's are not real doctors!"
I about choked, thinking, Could he really be serious?
Did he even know the difference between a DNP and a PhD? I am not even sure he knew what a DNP was. Certainly didn't sound like it! Clearly this was a teaching moment. So began my quest to be ‘allowed' to call myself doctor and bring awareness to the DNP title with my current employer.
I was asked to write a letter to the board of directors and our credentialing committee as to why I should be allowed to introduce myself as "doctor." How absurd I thought, but I did it.
It took them six weeks to respond and it came in the form of a letter from the medical director (whom I still have NEVER met). Initially, they were not going to allow me the privilege, but realized it was not within their right to deny me. They also said they would not address me as Dr. Cash - only as Keischa Cash, DNP - in all clinic correspondence, publications, newsletters, emails, marketing materials and website mentions. I still don't know how I feel about this.
I challenge all DNPs to go for what you want. Fight for what you believe in. Because we (DNPs) are still so young in our existence, we MUST challenge the status quo. We are knowledgeable, highly educated and have a lot to offer employers that are willing to see beyond traditional nursing roles and titles.
Lastly, let me be clear, this is not about titles. It's about putting NPs and the profession I love in the forefront. This is about all of the DNPs that will follow me.
My quest to change existing paradigms has only just begun. Wish me luck.
After waking up from my nap, (yeah, I know, a nap!) I started thinking about going back to school next month. I have been spoiled this summer - even though I am working, I feel like I am on vacation. This summer followed the most difficult semester that I have ever been through. This past semester I took Pharmacology and Physical Assessment with a clinical component. Do I really want to go back to getting up at 5 a.m., staying up until 11 p.m., reading and studying for hours on end?
I can't help but get those pre-semester butterflies in my stomach when thinking about all of the new knowledge I will be gaining, and the challenges I will be facing during the learning process. But I also think about how that feeling goes away after the first few weeks with the long reading assignments, the writing assignments and the first test.
I remind myself that all of the work, sweat, worry, and sometimes tears are all for a greater cause, and that is becoming a DNP. Once I become a DNP, I will be able to see patients as the primary caregiver in the family care setting - that is my current most important career goal. It also means that I will have a better understanding of the society that I work in, the science of being a nurse practitioner and evidence-based medicine. I will also be able to eventually work in academia, which is an interest of mine, since I have held academic positions in the past.
So, the answer to my original question - do I really want to go back to school after a very relaxing summer - is yes! (But I have to admit I will have to find some time to get a nap in.)
Although a 10th grade history teacher
sparked my interest in history through asking provocative questions, that
interest remained dormant for many years. Other than occasionally surfing the
History Channel, I didn’t know what a history enthusiast was… That all changed
when I married my husband. My husband arrived with many book shelves full of
history literature, many of them primary
sources, which – depending on your perspective – are either quite dry or very
This year we saw the 70th anniversary of
D-day (June 6, 1944). In August, we will see the 100th anniversary
of the start of World War I… Both of which are truly historic, world-changing
anniversaries. My 98-year-old next door neighbor – who eats healthfully, walks every
day, and goes to the senior center for socializing and dancing (all things we
as APNs celebrate in our patients) – recounts a world very different than the
one today. He saw a world in the midst of dramatic change, as democracy
triumphed over fascism and Stalinism, women joined the workforce, and national
interests and alignments were reshaped.
And it reminds me that time marches on. For children
born today, World War I will be nearly as remote as the Civil War was to those
of us born in my era. And for high schoolers, the Vietnam War will seem as
distant as World War II seemed to us. This year, family members from two
generations passed on and a new little one joined our family. As I walked
through a cemetery with family members dating back to my great-great-great
grandparents, it got me thinking...
Next year we will celebrate the 50th
anniversary of the nurse practitioner – a truly revolutionizing history full of
changing innovation… not only in nursing, which it was, but also in health
care. It was an innovation that pushed boundaries and changed alignments. And
this year we will also celebrate the 10th anniversary of the AACN
publishing their paper on the DNP, which started another revolution in
healthcare, bringing more APNs to the forefront in leading the change.
As APNs, I believe we are just at the tipping point of the maturing of our profession. Correct me if I’m wrong, but I believe there are now 18 states, plus the District of
Columbia, with plenary authority practice environments. We are finally beginning to experience the setting in which we can thrive (and thus our patients too)! All but one state now allows NPs to prescribe controlled substances. And more states are updating their laws every year. In recent years, we’ve also begun to see people who do what we do in media explaining to others what we do! It seems we might see the day when the general public no longer confuses us with the licensed practical nurse. We even have our (unified) professional organization meeting with our nation’s president, the Secretary of Health, and others to influence policy and bring about more holistic and inclusive healthcare frameworks.
I envision a world in which the general public not only trusts nurses, but knows what we do, and finds us to be the provider of choice for their families. A world where APNs are not only employees, but owners and managers of healthcare organizations; a world where APNs have a reserved spot on every significant healthcare committee and board, ensuring that there is an inclusive, well-trained provider pool and optimal health coordination for our patients; a world where every nurse has access to a quality (paid) residency program; a world where the personalized holistic care we provide is part of the integral MODEL for healthcare; a world where APNs consultations will become the norm; a world where nurse researchers’ data is as valuable as any other discipline, moving the ball forward. State nursing action coalitions have already begun this important work.
What is your vision for the coming era of advanced nursing practice?
Dr. Ruth, Dr. Phil, your dentist, your therapist, your veterinarian, your attorney, your pharmacist, your professor, and yes, your nurse practitioner are all potentially doctors of something... but why has the American Medical Association and the American Osteopathic Association stated that only MDs and DOs can identify themselves as doctors without explanation? A multitude of professions exist that call themselves doctors, but due to the already-established "turf war" between physicians and nurse practitioners, NPs are reluctant to be called "doctor" in the clinical arena without an explanation behind the, "Hi, I'm Dr. Schreiner".
I am a Family Nurse Practitioner in primary care and successfully completed my Doctor of Nursing Practice. Prior to my graduation, the office manager of the practice said, "Congratulations, Dr. Schreiner" with my collaborative physician overhearing. In response, he jokingly stated, "Careful how you use that term around here." I smiled in return and stated, "I never claimed myself to be a Doctor of Medicine, but I am a Doctor of Nursing."
This is the battle that NPs with their doctorates face. After extensive hard work on this degree, they are told to be careful on how they use the term "doctor". Why is there such a battle over the term "doctor," specifically in the clinical arena? There is a widely accepted theory that patients might get confused and think the NP is a physician. This theory of confusion has become such an issue by physician counterparts that some states are going so far as to ban nurses as well as other professions with their doctorates from using the term "doctor". But if patients are getting quality care, having ailments addressed, having sicknesses cured, and therefore able to continue their life without restriction, does confusion of your provider's title really matter?
Ultimately, this battle is one that will only get in the way of our patient care. As a DNP I am more qualified to and capable of providing quality care to my patients than I did with my masters. While the focus of my masters degree was on clinical care, pharmacology and patient assessment, my doctorate was one on improving patient care outcomes, assessing the quality of interventions, keeping up to date on improving practice through research evidence, and finally, improving the state of our healthcare system. This education offers not only benefits to our injured health system but also to my small practice setting. It is to this that I speak to when combating why I should be called "doctor". With the toolset provided by my DNP education, I have the potential to save the practice money, improve patient outcomes, and ultimately improve the patient care being provided. By limiting how we come up against physicians in regards to the DNP, and formulating a more educative stance on what the DNP can do for them- our patients and the healthcare system- we have the potential to limit this war on the term. This will allow more of a collaborative union of healthcare professionals with one goal in mind: providing the best care for the people that drove us to go into these professions - our patients. I could not have put it better than an NP who stated, "Collaboration and dialogue will advance the healthcare system of citizens of the US faster than engaging in turf wars and belittling." 1
No, I will never claim myself to be a Doctor of Medicine, but I am proud to be Doctor of Nursing. I will continue to break down the walls of the term "doctor" by educating and collaborating with those around me, including physicians, on why I should be called "Doctor" and how we can work together as "doctors" to improve the care of our patients.
1 One physician confides, "My primary care doc is a nurse". Mahar M. Posted April 3, 2013. http://www.healthbeatblog.com/2013/04/a-doctor-confides-my-primary-doc-is-a-nurse/
In May 2012, I entered an online Doctor of Nursing Practice (DNP) program. I had chosen to pursue the DNP because I viewed myself as a clinician and I had no interest in becoming a white coat researcher. After a great deal of investigation, I chose the school that most closely conformed to my tightly controlled schedule. I could go online and complete assignments at any time that I chose and there were no obligatory meetings where the student must sign in at a certain time. The program promised the possibility of completion in 18 months (admittedly the strongest incentive to choose that program) with a commitment of about 17 hours per week. Divided into 16 week semesters, the student was expected to take six credits per semester to remain with the original cohort. My original cohort had 20 students from various backgrounds and scattered through four time zones.
It didn't take long for the reality of the situation to sink in. It soon became apparent that 17 hours per week would not begin to cover the time needed for the completion of the readings and writings that were assigned to us (in fairness, we were the first cohort so it was purely a guesstimate). In reality, the time commitment was often in excess of 30 hours per week and there were hard deadlines to be met. Many of the students could not meet the time requirements and their social and occupational obligations suffered greatly. Our 20 dwindled to 10 and in December 2013, six of us graduated in the 18-month window. The other four graduated at 24 months. Surprisingly to me, the online program brought me closer to the faculty and my classmates than I ever felt in any brick and mortar school. We talked or chatted daily, sometimes several times a day. We worked in groups and completed projects together. By the time we attending hooding and graduation on campus we felt as though we had been friends for years.
There were other surprises. We were all surprised at the spotlight on research and the lack of clinical courses. I'm not sure what we expected but we all expected some clinical component in the program. Other than a course on epidemiology, it could be argued that all of the courses were focused on writing, research, and leadership. This is not to say that we conducted research on the scale of the PhD nursing students, but research was a big part of what we did, and the completion of that capstone research project was the stumbling block to graduation for several of the students.
So is this blog an attempt to discourage potential DNP students from pursuing that terminal degree? It absolutely is not. It was a fantastic experience and I would recommend it to anyone who can commit the time that the program demands. Rather, this is an opportunity to encourage the potential student to look closely at the curriculum and to have a realistic understanding of what it will require to add DNP to the signature block. The focus is to prepare us as nursing leaders and the DNP accomplishes that goal.
The most recent 2014 legislative session was one of excitement and of woes. We saw states like Connecticut, New York and Minnesota get full practice authority legislation signed into law. With the exception of Nebraska's law that was passed unanimously then vetoed by the governor, the 2014 session saw a lot of progress made toward achieving more autonomy for our nation's NPs. I for one was happy to see that Florida (where I reside) actually introduced a bill that included language to grant full practice authority after 2-3 years of being supervised by a physician or NP. This bill came about after the healthcare workforce and innovation sub-committee of the house was designated the task of examining the impact that nurse practitioners, among other professionals, could have on care delivery models in the Sunshine State. Unfortunately, neither HB 7113 nor SB 1352 came to fruition.
After listening tirelessly to hours of testimony by experts on both sides, it seemed undeniable that the solution to the problem of lack of access to quality, affordable care for the citizens of Florida was utilizing the talents of the state's NPs. But yet, despite the overwhelming evidence presented on PowerPoint after PowerPoint and hours of questioning of the panel by legislators, there was still opposition to the idea of allowing NPs in Florida to prescribe controlled substances and having full practice authority. I don't get it! Why have an entire committee dedicated to finding solutions when no one is listening to the facts?
Fact: NPs deliver care equal to or better than that of a physician.
Fact: NPs give safe care.
Fact: NPs are unfairly burdened by laws that prevent them from practicing to their full scope of licensure.
So why, when presented with irrefutable evidence of the quality and safety of NP care documented over the last 60 years, is there still debate? I can only come to one conclusion: some legislators are just motivated by doing what's best for their personal and social affiliations and less about what is for the greater good. Clearly, there is more than meets the eye when it comes to the situation here in Florida between NPs and the medical community at large, and they will go to great lengths to thwart the NP movement here.
I am appalled at some of the comments made by legislators regarding their views on NPs level of education as inferior to physicians and their apparent lack of knowledge of our educational and experiential requirements for practice was evident. Hopefully, this is where the DNP fits in as we move toward advocacy for doctoral education and preparation of our NP colleagues to create some sort of parity with other health professions and end all of this inter-professional discontent which detracts from our purpose (safe, quality, affordable health care). It seems that despite a society that enjoys facts and truth telling in elections, we lose sight of this importance when it comes to things that hit closer to home. I feel that I have been sent to an alternate universe where decades of evidence and recommendations from the highest medical institute in the country is simply just not good enough for Florida legislators to get a hint. I don't get it. Maybe next year.
As you may have noticed from my bio, I am a DNP student. I already have my master's as a clinical nurse specialist in critical care, but I am working toward the DNP degree and the right to sit for the CRNP exam. My goal is to become a family nurse practitioner, which is a long way from the patients I used to take care of in the cardiothoracic SICU. I remember when I first started my job as a Heart Transplant Coordinator and didn't even know what most of the medications were because they were oral, not parenteral, medications.
This past semester has been my most challenging yet because I had Pharmacology for the Advance Practitioner and Physical Assessment. Although it was the most challenging semester in my nursing education, it taught me a valuable lesson: what I was learning was much more important than the grade that I would earn for the course.
I think as nurses we look to others for their approval and that is why the "grade" is so important to us. Maybe I should have learned this lesson while I was pursuing my undergraduate or graduate degrees, but, alas, I did not. Studying to become a CRNP, to me, is a whole different thing. When you are a CRNP you really are making independent decisions that you usually don't make as an RN. That is why making the grade is important, but learning the material is critical.
For a long time I thought they should have just "grandfathered" the CNSs into the CRNP role. I'm not totally convinced that I couldn't have performed well as an Acute Care Adult CRNP, but I can see some of the reasons why that never happened.
I am not taking any courses this summer, but it does not mean I have the summer off. Of course, I still have to work, so I can pay for my tuition, but I am also continuing to study Pharmacology and Physical Assessment because I don't want to lose what I have learned. I also feel like I did not have the time to learn all of the things I felt were important to learn. Why didn't I have the time to learn all of the things that I felt were important to learn during the semester? Because there are only so many hours in a day and because I was just trying to make the grade.
Work calls attended to. Check. Three-and-a-half-year-old down for his nap. Check. Casserole in the oven for dinner. Check. Let's see... oh yes, time for blogging.
I'm new to blogging, but not quite as new at being a DNP. Back in 2003 when I investigated universities with an interest in pursuing my practice doctorate, there were very few in the nation, and most of them went under the ND (nursing doctorate) nomenclature, now long since forgotten. (The ND now clearly understood by most as the naturopathic degree.) I didn't want to be a researcher, although I've since realized what an exciting option that is for nursing, and if I had another lifetime would unquestionably add that to my educational plan. But I did want to make a difference.
I was in our university's first graduating class of DNPs in 2005. So what does a DNP do? I think the answer is as varied as the degree's essentials, encompassing practice, systems, populations, policy, etc. Among our graduating class, there is a chief wellness officer of a university (the first of its kind), a nurse anesthetist program director (also published author, and in a prior life a VA director), a psychiatric nurse practitioner who helps direct her state's NP organization, a Mayo nursing director, at least two professors, and a college health nurse practitioner. Most of us have published or been part of the sea of change in nursing. We are not an idle bunch. We are about changing things up.
I'm the entrepreneur among us. Prior to my DNP, I had visions of starting a practice that somehow met the needs of the underserved in the community (at a reasonable cost), while also being financially stable and not dependent upon grants. I had seen too many good-hearted nonprofits spend all their time fundraising and grant-writing (I LOVE grant writers, I'm just not one), only to be open for a mere 4 to 8 hours a week, which in my mind made it impossible to provide the kind of continuity of care patients need. I had seen too many for-profit NPs with the heart of a nonprofit find themselves in a distressing state of dissolution after a few years, as Medicaid payments or lack thereof kept them from keeping their doors open long term. Yet I continued to see so many uninsured or underinsured patients fail to get the care they needed, and end up in the ER with a much worse prognosis than if they'd had routine primary care.
I had a lot of ideas about how a hybrid clinic (which would meet the needs of the uninsured, low-income patient AND see insured patients or possibly cash services to stay stable) might work. But it wasn't until I took the time to pursue a DNP that I was able to: 1) evaluate the factors that caused local NP clinics to fail; 2) evaluate the financials and payer mix; 3) look at new models of care; 4) look at consumer perspectives on NP practices; and 5) be a change agent. Gradually it all came together: a unique model of care to meet a local population's need. About 3 years later, as the economy tanked, I went out and opened a little clinic.
And it was the best thing that ever happened to me. I hope it was also a boon to our community. A clinic where people get the kind of care they want and need (you know what I'm talking about if you're an APN: relationship-centered care, use of new technologies, time for evaluating each concern thoroughly, and time for education). And you know what? Even in 2014, ACA or not, there are people (insured or not) looking for a new-fangled, old-fashioned practice like mine.
My professional life consists of clinical practice, managing a business, involvement in professional groups, involvement in political action, publications, education, mentoring ... and yet I still have the control to be able to carve out plenty of play time during the week with the little guy. Now that's a benefit I didn't think of when completing my DNP.
Q: What are your feelings on the DNP? Is the degree really worth it?
A: The DNP movement has gained wide
acceptance. The numbers of DNP programs,
enrollees, and graduates have increased exponentially over the last ten years. There were 20 DNP programs in 2006, and in
2011 there were 182 programs in operation, with another 101 programs in the
planning stages. The number of enrollees
and graduates also grew from 862 persons enrolled in 2006 to 8973 in 2011; and
the number of graduates increased from 74 in 2006 to 1581 in 2011.
Over the same period, PhD programs grew, but
at a slower pace. There were 103
programs in 2006 and 126 in 2011. 3927 PhD students enrolled in 2006, compared
to 4907 in 2011. Such programs graduated a total of 601 students with a PhD
degree in 2011.
Initially, there was ambiguity about
the purpose of the DNP degree (that it was designed for clinical roles only), a
perception shared even by nurse educators.
However, as the DNP movement evolved and is overwhelmingly adopted, the
DNP degree is transforming not only how nurses are educated to take on advanced
practice clinical roles, but also to prepare nurses as administrators,
educators, and leaders.
As per the National
Organization of Nurse Practitioner Faculties (NONPF, 2005), "DNP programs
prepare leaders who will improve the quality of care, patient outcomes, and
health policy that expands their impact on the health of society," (page 1, para.
3. Available at http://www.nonpf.com/associations/10789/files/DNP-NPCurricTemplates0907.pdf).
note: At the DNP Answers blog, nurse practitioners with a DNP answer
your questions about the degree. This question is answered by blogger
Mai Kung, NP, DNP. Comment below to discuss this topic, or send new
questions to firstname.lastname@example.org.
Return to blogs homepage. Return to ADVANCE for NPs & PAs homepage.
Q: From the Administrative Advanced Practice role and the DNP's perspective, I would be interested to know how many of you fall into this category and what kind of feedback you have been receiving related to the DNP degree versus a PhD or EdD. From my fairly limited current informal survey, many are viewing the degree as belonging solely to the directly clinical advanced practice role.
A: The Doctor of Education (EdD) can be a
research or a practice-oriented degree in education that prepares students for
clinical, administrative, academic or research positions. A Doctor of
Philosophy (PhD) degree is focused on research and a Doctor of Nursing Practice
(DNP) degree is an academic degree that is focused on practice in Nursing.
DNP programs also prepare nurses for
clinical, administrative, and academic roles.
Nurses who are interested in advanced clinical practice can choose to
become a nurse practitioner, nurse anesthetist, nurse midwife or a clinical
nurse specialist. Those who are interested in leadership and administrative
roles can choose to concentrate in health system leadership, administration or
health policy. Those who are interested in academia may choose nursing
education as an area of focus.
Dr. David O'Dell, DNP, a Founder and
Director of the DNP LLC, Inc., presented at the 5th DNP Conference
in September on "The State of the DNP Degree:
Analysis of Three Years of National Survey Data." According to these national survey data,
between 25 and 35 percent of the respondents named Leadership or Policy as
their DNP program concentration. This
presentation is available at: http://www.doctorsofnursingpractice.org/DNPConfArchives.htm.
At this meeting, I
also had the pleasure of meeting Dr. Launette Woolforde, an RN with a DNP
degree. She is corporate director for
nursing education at the North Shore Long Island Jewish Health System. She
works alongside other health systems leaders and oversees related activities
for 15 hospitals and over 12,000 nurses. Dr. Woolforde feels the DNP degree has
helped prepare her for administrative and leadership roles to improve
healthcare quality and safety.
Q: Please describe the DNP role in your NP specialty.
A: I will step up on my DNP soapbox once again to say that completing
your DNP serves to open up a new way of thinking, a way to approach
your practice. It is not an avenue for developing a new position or
making more money.
The DNP provides you with the tools and resources to understand how
to find and evaluate the evidence for best practice, to look at your own
practice setting, and to develop the skills to bring best practice to
your environment. It allows you to grow!
The DNP helps you to take all those problems in the system that leave
you with a burning feeling in the pit of your stomach, and figure out
how to bring about solutions. It helps to alleviate those situations
when you’ve looked at a great new idea in the literature and tried it
out, but you are left scratching your head and saying, ”Why didn’t that
Most DNP programs include courses on graduate level statistics,
translation of evidence, leadership, and advocacy in the advanced
practice role. The capstone is completed at the culmination of many
programs, which allows students to incorporate their learning into one
project of meaning in their current practice.
In my emergency department practice, I use my DNP knowledge to prompt
me to develop a clinical question- how we might change processes, or if
we are delivering best practice. Is there a guideline that could be
applied to a subpopulation within our department?
My current interest lies in differentiating patients who come to the
ED because their chronic pain is inadequately managed. These patients
may be on a pain contract, or they may be “doctor shopping” to get
relief. We often stigmatize them or categorize them as “drug seekers,”
while they are experiencing true pain in a system that is not addressing
the problem adequately.
How do we assess patients presenting for chronic pain in the ED? How
do we differentiate them from persons seeking opioid therapy for
diversion or addiction? Are there tools that we can use to accomplish
this? And are they appropriate in this population? How can we think
outside of the box, other than providing a Motrin and a Percocet, to
address their needs within the ED setting?
I’ll let you know when I get my answers.
note: The DNP Answers blog addresses your questions about the DNP. This
post is contributed by blogger Meg Carman, DNP, ACNP-BC, CEN, who
serves on faculty in the ABSN program at the Duke University School of
Nursing in Durham, N.C. She also practices with Wake Emergency
Physicians in Raleigh. Comment below to discuss this topic, or send new
questions to email@example.com.
Return to blogs homepage. Return to ADVANCE for NPs & PAs homepage.