Paging Dr. Nurse

Nursing Degree Program Raises Red Flag With Physicians

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Medical Education Feature - June 2006  

By  Ken Ortolon
Senior Editor

Could the next "doctor" one of your patients sees in the hospital, urgent care clinic, or even in your own office be a nurse? Yes.

The Texas Higher Education Coordinating Board approved a new doctor of nursing practice (DNP) degree program in April. The University of Texas Health Science Center at Houston School of Nursing plans to offer what UT officials say is a "higher intensity level of training" than the current master's degree program to help increase academic nursing faculty. But UT-Houston's description of the program says the new doctor nurses would be prepared to diagnose and care for patients with complex health problems.

Physicians are worried the program will train nurses to perform procedures and services not allowed by state law.

DNP graduates could leave "quite the wrong impression," particularly if they routinely identify themselves as "doctor," said Harris County Medical Society President Diana L. Fite, MD. Physicians already are concerned patients frequently believe physician assistants or advanced practice nurses (APNs) are physicians, she adds.

Texas Medical Association and Harris County Medical Society officials also say the DNP program would harm efforts to reverse a severe shortage of bedside nurses, dilute scarce resources needed to train physicians and other specialized health care personnel whose need is well documented, and weaken the future of academic nursing research.

Even the nursing profession itself and some Texas nursing schools question the need for the program. 

Setting the Curriculum

UT-Houston expects to enroll 10 new full-time equivalent students in the program in each of the first five years, starting next fall. Graduates must complete 46 semester credit hours, including 18 hours of foundation courses, 18 clinical hours, and 10 hours of "capstone practicum" courses to provide practical experience applying what they've learned.

Students will take courses in practice theory, ethics, practice science, informatics, research methods and design, diagnostic and clinical management, interdisciplinary collaboration, and systems analysis. They also must complete 1,260 clinical practice hours and build a portfolio of 15 case studies. A dissertation is not required.

While doctoral degree programs in nursing are not new, most are geared toward teaching or clinical research, not clinical practice. There are only 11 DNP programs in the country. The first was launched in 1979 at Case Western Reserve University in Cleveland.

Since then, the programs have been slow to catch on, but at least 40 more are being developed. Coordinating Board officials say an informal survey of nursing deans indicates at least six other Texas nursing programs are interested in the DNP degree.

Driving this trend was a 2004 decision by the American Association of Colleges of Nursing (AACN) to raise the level of preparation for advanced nursing practice from the master's to the doctoral level by 2015. That would require all nurse practitioners, clinical nurse specialists, nurse midwives, and nurse anesthetists to obtain the DNP degree.

AACN says DNP programs would help develop needed advanced competencies for increasingly complex clinical, faculty, and leadership roles; improve nursing practice and patient outcomes; enhance leadership skills to strengthen health care delivery; achieve parity with other health professions; better attract individuals to nursing; increase faculty for clinical instruction; and improve nursing's image. 

A House Divided

While AACN and some nursing programs are prepared to go full steam ahead, there is plenty of concern in the nursing profession over whether the positives of the DNP degree outweigh the negatives.

In April 2005, the National Association of Clinical Nurse Specialists (NACNS) said the DNP "potentially creates a divisive change in a profession that has a long history of a lack of professional cohesion."

The group also said there is no consensus on how the DNP would complement the nursing profession, there are no studies showing advanced practice nurses with doctorates have better outcomes than those with master's degrees, and it is unclear how DNPs would improve patient safety.

"Decisions to initiate this major paradigm shift were not derived from an extensive nursing practice analysis, but from one group of advanced practice professionals," NACNS said.

The Texas Nurses Association (TNA) also is lukewarm toward the DNP program. Executive Director Clair Jordan, MSN, RN, says TNA has endorsed neither the DNP degree nor the report of a special committee made up of TNA, college deans, and other groups supporting the degree program.

An article in TNA's magazine last year raised several concerns, including whether existing master's degree programs would be eliminated, whether current master's-level APNs would be grandfathered under the new AACN requirements or prevented from doing advanced practice, and whether DNP programs would lead to a loss of nursing faculty.

Chris Fowler, program director for pharmacy and nursing at the Coordinating Board, says not all nursing schools are on the bandwagon.

Officials at the UT-Austin School of Nursing and several community college and associate degree nursing programs have expressed outright opposition or "qualified concerns" about the new degree, she says. The community colleges, where the majority of nursing faculty hold master's degrees, could have difficulty recruiting doctorate level faculty, Ms. Fowler says.

Kenneth I. Shine, MD, executive vice chancellor for health affairs for the UT System, supports the new degree program as a way to boost the number of nurses being trained by increasing the number of qualified nursing professors. He also says it will help UT nursing programs compete with programs around the country.

"One of the ways to do that [train more nurses] is to recruit faculty who have doctoral degrees relevant to nursing education. And since this degree has become very widely available in the United States, we want to be able to recruit the best and the brightest to be able to obtain a DNP with the idea that they will stay on as faculty members to teach people in terms of nursing activity."

Coordinating Board and TMA Alliance member Nancy Neal agrees the DNP program could be a positive step to solving current nursing shortages. She voted to approve the proposal.

"If I was persuaded that this was an infringement on scope of practice on the physicians, I would be struggling with it," she said. "At this point, I'm not persuaded that it is." 

Taking a Stand

But TMA officials say DNP programs and AACN's policy are aimed at producing clinicians as well as academic faculty and researchers.

In April, Dr. Fite, then-TMA President Robert T. Gunby Jr., MD, and Lawrence M. Hanrahan, MD, chair of TMA's Physician Distribution and Health-Care Access Committee, urged the Coordinating Board to examine APNs' defined scope of practice closely before approving the DNP program.

"State law authorizes only physicians to formulate a medical diagnosis," they said in a letter to the board. "A publicly funded training program in Texas should produce practitioners with skills allowed by state law. Otherwise, graduates would be forced to leave the state for employment, and the state would realize no benefit from the investment of public dollars in their education."

UT officials say they do not intend to train advanced practice nurses to do anything beyond their current scope of practice. But some DNP supporters clearly intend them to practice without physician supervision. The first item on a draft DNP entry-level competencies list developed by a National Panel for NP Practice Competencies says DNPs would practice "independently by assessing, diagnosing and treating undifferentiated patients within scope of practice."

Dr. Fite says APNs can be trained and supervised by physicians to perform some medical procedures. But she cautions against giving too much independent authority to practitioners who lack insight into the "whole disease mechanism" because of the risk of complications.

"We think medicine is best practiced by physicians with the appropriate training and credentials," she said.

Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at  Ken Ortolon.  

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