Doctoral-Level Programs Prepare Nurses for Expanded Roles in Care and Research

For Kara Ventura, completing the doctor of nursing practice degree at Columbia University seemed the natural next step in her career. As an RN, MS-PNP, she was already caring for pediatric patients with liver and intestinal diseases as part of a multidisciplinary team at the Center for Liver Disease and Transplantation at Columbia University Medical Center in New York City. The training she received in the DrNP program prepared her to take on greater authority over her patients' care, whether they were in the outpatient clinic, the emergency department, or a hospital bed.

Ventura, who earned her DrNP in 2007, is part of a growing cadre of nurses who have received doctoral-level training in clinical practice. Columbia University created the first such clinical doctorate in nursing program in 1999; until then, PhD-level nursing programs prepared nurses for research or administrative careers. Now 92 such programs are enrolling students, with 102 more programs being planned, according to the American Association of Colleges of Nursing (AACN). From 2007 to 2008, the number of individuals enrolled in such programs nearly doubled, from 1874 to 3415.

The numbers of these highly trained clinicians will continue to grow, as the AACN is requiring all advanced practice nursing programs to shift from the master's degree level to the doctoral level by 2015. According to C. Fay Raines, PhD, RN, president of the AACN, as clinical care has become increasingly complex, colleges of nursing have responded by adding credits to existing programs to better prepare nurses. However, with such additions, master's degree programs have grown to have credit loads similar to those of doctoral programs. Rather than continue down this path, the AACN has established guidelines to help nursing schools upgrade these programs to the doctoral level (http://www.aacn.nche.edu/DNP/pdf/Essentials.pdf).

But the shift toward more advanced training for nurse practitioners has not been without controversy, as some professional medical organizations have expressed concern that patients may confuse DrNPs with physicians.

Mary Mundinger, RN, DrPH, the dean of Columbia University's School of Nursing, noted that nurses are learning more and doing more in practice. For example, many states have granted nurse practitioners the authority to prescribe medications.

“The authority of nurses and the level at which they’ve learned to practice far exceeds the core essentials of a master's degree,” Mundinger said.

The DrNP programs are typically 2 years long, including a 1-year residency, and accept individuals who have already earned a master's degree in nursing and have been licensed as a nurse practitioner. Eventually, programs will accept students with a baccalaureate nursing degree, but according to recommendations from AACN, these programs would take 3 to 4 years to complete.

The programs emphasize evidence-based practice, quality improvement, and systems-level thinking, said Raines. “We think people with the DrNP preparation will be particularly skilled at translating research into practice,” she said.

These advanced practice nurses also may be more prepared to be investigators themselves. Ventura was recently the first author on a paper she presented at the International Small Bowel Transplant Symposium in Bologna, Italy, in September. Ventura and her colleagues did a retrospective chart review of 78 infants treated at Columbia University Medical Center for intestinal failure–associated liver disease to assess outcomes of patients treated with an integrated medical, surgical (nontransplant), and transplant rehabilitation approach. She explained that there is a tremendous need for research in her specialty, and her DrNP training has given her the skills and the motivation to help build the evidence base.

“I’m not waiting for doctors to study something,” she said. “I’m initiating it, and then applying it to practice, and developing protocols for our center based on our findings and the findings of other practices,” she said.

Mundinger emphasized that another key difference between DrNP programs and master’s-level nursing programs is the emphasis on multisite care. She explained that master’s-level nurse practitioners are typically prepared to work at a single site—for example, a primary care practice. In that setting they are able to diagnose some patients' conditions, manage them, and, if necessary, refer to a primary or specialist physician's care. But a doctoral-level nurse with a primary care focus will have a more sophisticated base for differential diagnosis, more training in managing comorbid conditions, greater expertise in caring for patients with chronic conditions, and the skills necessary to coordinate care, she explained.

“It's a broader role,” she said.

Few data are available on the career trajectory of DrNPs, but Raines was optimistic about their job prospects. She noted that master’s-prepared nurse practitioners are already providing primary care in rural and underserved areas and that she expects many DrNP graduates will provide added value in primary care roles.

Karen Desjardins, RN, MPH, DrNP, who graduated in Columbia's first class of DrNPs, agreed about the great potential for doctoral-level nurses to help fill gaps in primary care, as more physicians choose specialty careers and as health reform increases the ranks of patients with access to primary care. “We're perfect for [primary care],” she said. “We're nurses, we know how to multitask, and we love that one-on-one relationship with our patients.”

Mundinger also sees a role for DrNP-trained nurses in specialty care, an area where she said clinician shortages are less well recognized. She noted that many of the DrNP faculty at Columbia work with physician transplant specialists, essentially providing primary care to transplant patients by helping to assess them before transplant, caring for them in the recovery room and intensive care unit, and continuing to provide them with ongoing care after discharge. She explained that having DrNPs in specialist practices can allow physician specialists to focus on what they do best.

Raines said some DrNPs may also choose to pursue careers in leadership positions, for example, as executives at health care organizations or directors of clinical programs.

But some elements of the shift to doctoral-level clinical training for nurse practitioners have generated controversy. In particular, professional medical organizations have expressed concern that the DrNP degree blurs the line between a physician and an advanced practice nurse.

Ted Epperly, MD, president of the American Academy of Family Physicians, said the academy values nurse practitioners and supports their role in helping to fill primary care shortages. However, the association is concerned that addressing advanced practice nurses with the title “Dr” will confuse patients.

“We value nurse practitioners, but let's not confuse the public about each of our roles,” he said.

Raines noted that many other health care professions have already shifted away from master’s-level training toward doctoral-level preparation for practitioners.

For example, physical therapists, audiologists, pharmacists, and occupational therapists are now trained through doctoral-level programs. However, in the clinical setting they are not typically referred to as “Dr.”

The need for such a shift in nursing was acknowledged in a 2005 report by the Institute of Medicine, Advancing the Nation's Health Needs: NIH Research Training Programs (http://www.nap.edu/catalog.php?record_id=11275). The report focused on the need to grow the ranks of health care researchers, and paid special attention to nursing, among other areas. It also noted that the emphasis on gaining clinical experience in nursing often leads nurses to enter PhD-level research-focused training programs later in life, leaving them fewer productive years for research. Additionally, such individuals' research time may be limited by the need to teach, because educators for doctoral-trained nurses are in short supply. But the report said that creating a clinically focused doctoral track would boost the number of teaching faculty, as well as helping to meet practice needs.

Raines also emphasized that these highly trained nurses are not taking on a physician's role. “The scope of nursing practice for an advanced practice nurse will not change, but nurses in those positions will be prepared in a different way to meet the demands of the health care system,” she said.

One element of this shift toward higher education that has proved especially controversial was the creation of a comprehensive care certification examination for graduates of DrNP programs by the National Board of Medical Examiners (NBME) in partnership with the Council for the Advancement of Comprehensive Care (CACC) in 2008. The CACC was launched in 2000 to promote standards for the multiplying DrNP programs across the country. Mundinger, who is also CACC president, explained that creating the degree was one step, but that the certification examination provided a way to ensure that graduates from different programs could demonstrate certain core competencies in clinical care. The NBME-CACC examination tests some of the competencies tested in Step 3 of the US Medical Licensing Examination, which tests whether physicians have obtained adequate cognitive medical skill to practice unsupervised and draws from questions that have been retired from use in the Step 3 examination.

Epperly explained that he is concerned that board certification for nurses will further confuse patients, and questioned why the NBME is getting involved in a nursing examination. He noted the nursing certification examination is only 4 hours long compared with the Step 3 licensing examination, which takes place over 2 days. He also emphasized that in addition to earning their medical degree, physicians complete 10 000 clinical hours in residency compared with between 500 and 900 clinical hours that DrNP graduates complete.

“The two are not equivalent,” he said.

But the NBME issued a statement defending its role in the certification examination (http://www.nbme.org/PDF/NBME-Development-of-DNP-Cert-Exam.PDF), noting that the organization first assisted in the assessment of advanced practice nurses and physician assistants more than 30 years ago.

“Current and future patients of these nurse clinicians deserve a system that assures them that the clinician providing services meets appropriate quality standards,” the statement said. “Our support for the DrNP assessment process helps provide that assurance.”

Raines clarified the AACN's position on this certification examination, noting that it is one option for graduates of DrNP programs who wish to specialize in comprehensive care, but that individuals who choose this option must first obtain certification through a national nurse certifying body and state licensure.

“Historically, nursing has been seen as an adjunct to medicine more than as an independent profession, so it has taken longer to establish independence,” Mundinger said. But she maintained that DrNPs will not supplant physicians, but rather work in a complementary role. She noted that many of Columbia's specialty practices include both physicians and DrNPs.

“The partnerships are rich, and they're not conflicting,” she said.