Journal Departments

Controversies in Nephrology Nursing

Is the Burden Worth the Benefit of the
Doctorate of Nursing (DNP) for NPs?
Christy Price Rabetoy, Department Editor

Doctor of Nursing Practice:
The Time is Now
David C. Smith, MS, RN, NP
Adult Nurse Practitioner (Nephrology)
Scottsdale Healthcare
Scottsdale, AZ
Member, ANNA’s Desert Vista Chapter

The American Association of Colleges of Nursing Calls for Requiring the DNP for Entry into Practice for Nurse Practitioners

I recently enrolled in Doctor of Nursing (DNP) program at the University of Arizona. During orientation, I learned that the amount of healthcare information doubles every 5 years. That fact gave me pause as it should anyone. We practice in a scholarly environment that is moving at a mind-numbing speed. The increasing complexity of healthcare demands the best possible preparation for licensed independent providers. Accordingly, the American Association of Colleges of Nursing (AACN) has proposed that the DNP be the terminal clinical degree offered in nursing (for the full report, see http://www.aacn.nche.edu/DNP/pdf/DNP.pdf). It is expected to be the requirement for entry into practice for nurse practitioners by 2015. The DNP is a clinical practice degree; it is neither a replacement nor a substitution for the PhD in nursing, which emphasizes development of nurse researchers. The focus of the DNP is to create expert nurse clinicians.

Doctoral Level Education is the Standard for Independent Healthcare Providers
The AACN is not alone in appreciating the need for doctoral level education for clinical practice. A clinical doctorate has become the standard for many healthcare professions that once required MS-level preparation such as pharmacy (PharmD), physical therapy (DPT), and audiology (AuD). The necessity of a doctorate has long been accepted in medicine, podiatry, and dentistry. There is no debate about the need for doctoral level education for physicians and dentists. Should the bar be any lower for nurse practitioners? The fact is that the call for doctoral level education for nurse practitioners is also arising from outside our profession. In a 2005 report entitled “Advancing the Nation’s Health Needs: NIH Research Training Programs,” the National Academy of Sciences endorsed the clinical doctorate in nursing stating, “the need for doctorally prepared practitioners and clinical faculty would be met if nursing could develop a new non-research clinical doctorate, similar to the MD and PharmD in medicine and dentistry” (National Research Council, 2005).

The DNP Will Prepare NPs for the Challenges of the 21st Century
As envisioned by the AACN, the DNP curriculum will require a global increase in the amount of scientific education and clinical training of nurse practitioner students. The proposed curriculum will provide advanced instruction in pathophysiology, pharmacology, informatics, statistics and research methodologies, genetics, evidence-based practice, diagnosis and management of illness, and preventive healthcare. There is also content in healthcare systems and health policy. In addition to preparing the NP to be a highly competent independent provider, the DNP will enable the NP to possess the skills necessary to be a thoughtful consumer of healthcare research, a vital skill for healthcare professionals. The ability to comprehend areas such as research, genetics, and informatics is now fundamental in the technology-driven world of 21st century healthcare.

Grandfathering for NPs Currently in Practice
Historically, licensure requirements for NPs have varied greatly from state to state. In many states, an ADN nurse could work as an NP. Over time, a consensus developed among most state boards of nursing requiring masters-level education and national certification. This evolution caused considerable anxiety and anger in many NPs. Boards of nursing grandfathered-in NPs who did not meet the new educational requirements. The move to require the DNP for entry into NP practice will follow this same pattern of grandfathering.

The DNP Has Arrived
The reality is that the DNP is here. Twenty universities are enrolling DNP students. Over 100 schools of nursing are developing DNP programs. This is the natural progression of NP education. This evolution is driven by the complexity of healthcare sciences, the increasing autonomy of NPs, and the move of NPs into more and more specialized roles. To remain relevant in healthcare, NPs must hold doctoral level training. The DNP should be embraced by the nursing community. It is what is best for us as a profession and what is best for those we serve, our patients.

Reference
National Research Council. (2005). Committee for Monitoring the Nation’s Changing Needs for Biomedical, Behavioral, and Clinical Personnel, Board of Higher Education and Workforce. Advancing the Nation’s Health Needs: NIH Research Training Programs. Washington, DC: The National Academies Press.

Implications of Doctorate in Nursing Practice - Still Many Unresolved Issues for Nurse Practitioners
Sara Otterness, RN, APRN-BC, CNN
Renal NP
Veterans Administration Medical Center
Minneapolis, MN
Immediate Past President of the Twin Cities Metro ANNA Chapter.

The Doctorate in Nursing Practice (DNP) is a suggested practice degree to prepare nurse practitioners (NP) to assume full leadership roles in clinical practice, clinical teaching, and research applications, with the ability to deliver exceptional, high quality care and leadership in increasingly complex health care delivery systems. The DNP implies NPs will be provided parity with medical doctors, pharmacists, and dentists (Steefel, 2005). However, there is no indication from these professionals that this theory will materialize in everyday clinical practice.

Practice-focused doctoral degree programs in nursing were first offered in 1979. Since then, many programs have been developed to offer an alternative to the Doctor of Philosophy (PhD), which has historically been a research- focused degree. There currently exists programs for Doctor of Nursing (DN), Doctor of Nursing Science (DNS, DSN, or DNSc), and now a Doctor of Nursing Practice (DNP, DrNP). In October 2004, the American Association of Colleges of Nursing (AACN) voted to establish the DNP degree as the terminal degree for NPs by 2015 (Glazer, 2005). This shift has created many controversies and implications to the practice of advanced practice nursing. The most significant issues to NPs that the practice doctorate creates are the need for standardized education, which includes addressing the present status of NPs with masters degrees, standardized nomenclature and titling for NPs, definitive identification of practice guidelines, changes in billing and coding procedures, and the necessary education of the public and the healthcare industry.

Dr. Ann O’Sullivan, president of the National Organization of Nurse Practitioner Faculty (NONPF), maintains that the move to the practice doctorate is no longer in question for NPs of the future. The question is how to bring about the transition and the needed change in the educational system to facilitate this move (Glazer, 2005). The current curriculum for NPs is being changed and expanded on an ongoing basis. Many NP programs currently exceed the usual and required credit load and duration for a typical master’s degree, raising additional concerns that professional nurse graduates are not receiving the appropriate degree for a very complex and demanding academic experience (The Essentials of Doctoral Education for Advanced Nursing Practice, 2006). Formulating curricula to standardize the education provided to basic entry level nurses, entry level consideration of students who are not nurses, and graduate nurses with varying degrees and varying levels of experience and expertise is an enormous challenge to the individuals establishing curricula and to the nurse educators. An additional challenge is the fact that the nursing faculty shortage is limiting college enrollment. NPs who practice in specialty care areas and may decide to return for doctorate preparation also have the issue of finding appropriate preceptors for residency programs and preceptorships.

It has been recommended by AACN to standardize terminology and titling to include research doctorate (PhD) and practice doctorate (DNP) for doctorate prepared nurses (AACN, 2004). There is no recommendation for practitioners who carry prior licensure as NPs which will lead to significant confusion with the presence of multiple titles and levels of education.

The contribution to health care systems of educationally prepared individuals with DNPs is not established. Regulations in many states require collaboration with a physician to practice as an NP. The expectation of DNP- prepared nurses is that they practice as autonomous health care providers, therefore current restrictions will lead to licensing and practice conflicts with the DNP. To better support the graduates of DNP programs, there should have been a survey of the clinical needs, clinical agencies, consumers, employers and current NPs to clarify the desired outcomes and competencies needed of these graduates.

The DNP is a degree that is suggested to have a high level of functionality in the health care systems. The path to establishing this degree in the current nursing environment has many implications and concerns to current NPs. There has been significant exploration into position statements, standardization of education, practice implications and uniformity in credentialing and titling in the recent past. There is continued need for further standardization of basic nursing entry level education requirements, uniformity of practice and billing standards, research on the effectiveness of doctorate prepared clinical providers, and evaluation of acceptance by the health care environment and the consumers. More data should have been gathered prior to nursing recommending a change in the status quo. The idea of the DNP may be popular with some nurses, but it may foster and promote yet another controversial issue for nurses to debate and other health care providers to criticize.

References
American Association of Colleges of Nursing (AACN). (2004). AACN position statement on the practice doctorate in nursing. Washington, DC: Author.

Executive Summary of National Forum on the Practice Doctorate, co-hosted by NONPF and AACN, December 8, 2003, Washington, D.C.

Glazer, G. (2005). Overview and summary: The doctor of nursing practice (DNP): Need for more dialogue. Journal of Issues in Nursing Online, September 30, 2005.

Steefel, L. (2005). New doctoral degree aims to advance nursing practice. Nevada Rnformation.
The Essentials of Doctoral Education for Advanced Nursing Practice. (2006).

The Controversies in Nephrology Nursing department focuses on exploring ethical and clinical issues within the nephrology clinic practice in a point/counterpoint format. Address correspondence to: Christy Price Rabetoy, Department Editor, through the ANNA National Office; East Holly Avenue/Box 56; Pitman, NJ 08071-0056; (856) 256-2320; or by emailing her at christycpr@comcast.net. You may also log onto this column at www.nephrologynursingjournal.net (clink on Department link) and email your comments to the Editor (see Discussion Area). The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses' Association.