Philosophy vs. Practice

Last week I had a discussion with one of my students that made me realize there are a lot of new BSNs anxious to start their advanced practice education before 2015 and be grandfathered in rather than have to get a doctorate. After launching a discussion concerning the potential issues with competition in the job market, reimbursement, and practice scope down the road, I finally got to the real reason this and several other students have been saying "no" to the DNP - "I don't like all that research and dissertation stuff."

Translated - "Homework? Yuck!"

I explained the DNP was a practice doctorate, much as the MD is, that incorporates philosophy of science, but with the emphasis on the area of clinical specialty in the field rather than academic research in the library. And for those students for whom autonomy is a priority (aka "I don't like to be told"), it provides true professional parity with the other advanced level health care practitioners. On paper.

I admit I am bothered that there are a lot of young nurses who would rather sneak in under the wire than see their advanced education through to the end. It reminds me several competent LPNs I know who are convinced they cannot be an RN because of the statistics requirement. Moreover, I am disappointed that there are many bright, driven individuals capable of representing the nursing profession well who are intimidated by the work involved with a PhD. Advanced practice is not for every nurse, but why put in the effort to reach the middle when the top is just a few tests and papers away?

In a down economy, I understand folks want to get out and start earning revenue and that this is only a transitional hiccup. As universities scramble to change their 2-year MSN to a 3-year DNP, I feel it is part of my role as an educator to foster awareness to the different advance practice options available to BSN students so they do not find themselves at 30 years old pushed out of the marketplace unless they go back to school. I have a number of students interested in becoming educators, and I strongly advocate the PhD or EdD routes as the most appropriate for that track.

I can envision folks opting to do the DNP as an "easy out" to becoming a "doctor" without having to do the deep research of a PhD that is essential to certain aspects of advanced practice, however the PhD across all disciplines opens doors that practice doctorates do not. Many MDs who want to engage in research and education move forward with the PhD and I believe universities will continue to prefer or require the PhD credential for didactic-focused tenure.

I found this comparison chart from the Duke University School of Nursing that really clarifies the matter (it is somewhat program specific):

	Doctor of Nursing Practice	PhD in Nursing
Focus	Nursing Practice	Nursing Research
Degree Objectives	To create nursing leaders in interdisciplinary health care teams by providing students with the tools and skills necessary to translate evidence gained through nursing research into practice, improve systems of care, and measure outcomes of patient groups, populations and communities.	To prepare nurse scientists to develop new knowledge for the science and practice of nursing. Graduates will lead interdisciplinary research teams, design, and conduct research studies, and disseminate knowledge for nursing and related disciplines, particularly addressing trajectories of chronic illness and care systems.
Curriculum Focus	Translation of evidence to practice, Transformation of health care, Health care leadership, and Advanced Specialty Practice	Trajectories of Chronic Illness and Care Systems
Core Courses	Evidence Based Practice and Applied Statistics Data Driven Health Care Improvement Financial Management and Budget Planning Effective Leadership Health Systems Transformation	Philosophy of Science & Theory Development Advanced Research Methods Statistics & Data Analysis Longitudinal & Qualitative Research Methods Chronic Illness & Care Systems
Mentored Teaching Experience	optional	Minimum of 140 hours
Clinical Hours	400 minimum within capstone project	None
Capstone Project	Yes	No
Dissertation	No	Yes
Distance Learning/Online Option	Yes	No
Part-time study	Yes. Program designed for working nurses	No
Point of entry	BSN or master's in advanced nursing practice	BSN or MSN (or related master's degree)
Program Length	5 semesters for MSN entry, varies for BSN entry*	four to five years
Credits Required	34 to 94*	57
Employment Opportunities Post Graduation	Health care administration, clinical nurse faculty	Nurse scientist, nursing faculty
GRE Required	Not for students who have an earned master's	Not for students who have an earned PhD
Tuition Waiver **	N/A	Full tuition, fees, and health insurance paid by School of Nursing
Stipend	N/A	Stipend for five years with expectation that students participate in gaining external sponsored support
* Program length and required credits depend on advanced practice specialty selected, 73-94 credits for BSN entry. For MSN entry, 34-41
**All applicants are encouraged to discuss financial aid options with the School of Nursing Financial Aid Office.

I also liked this editorial about the concern over the role of the PhD. I do not agree the terminal role for all advanced practice nursing should be the PhD, but there are several point for contemplation as we look to define the future of our profession.

PhD vs DNP, Research vs Clinical: The Battle Begins . . . Again

National NP Week: Positive Press

Do you know why NPs need to hire a PR firm? Because I am an NP and I had no freakin' clue that this was the official "NP Week!" Here is a selection of excellent advocacy and information articles in celebration:

A Closer Look At Nurse Practitioners

How nurse practitioners benefit patients

The “nurse” in nurse practitioner is always evident in the way NPs focus on health promotion, health education and attention to the patients’ overall health needs. NPs demonstrate the science of curing along with the art of caring, regardless of their specialties. With a growing need for quality care and an expected shortage of doctors in the coming years, NPs will become increasingly part of the solution.

Nurses' Role in Primary Care Access Critical, But Constrained

What nurses with advanced training and certification want to deliver, and what patients in rural areas need, is greater access to primary care.

But don't take their word for it (or mine). Look at the findings of the Institute of Medicine after it examined how nurses can help attain the objectives of the 2010 Affordable Care Act. The two-year study culminated in the report, The Future of Nursing: Leading Change, Advancing Health.

One of the IHI's key recommendations:Nurses should be full partners with physicians and other healthcare professionals in redesigning healthcare in the United States.

The Primary Care Turf War

According to a study published in 2000 by the Journal of the American Medical Association, care given by nurse practitioners is just as good as care given by physicians. That's a study a lot of nurse practitioners refer to when they say they can help fill the impending doctor shortage.

Ah, the impending doctor shortage, or rather, the shortage of adult primary care physicians. You might not feel it now, but with an aging population and 32 million newly-insured Americans entering the system, you'll probably feel it soon. Only 7% of fourth-year med school students are planning careers in adult primary care - a supply problem that's been described by none other than NPR's "All Things Considered" as a potential crisis.

What It Is, and Where Its At!

Here it is, the big, bad, position statement that has caused a lot of nurses to be very, well "nursey." The gist is, the psych CNSs and NPs competencies are nearly identical. Even though the CNS is 30 years older, the "NP" designation is the most publicly and professionally understood (using "understood" pretty loosely here). While the ANCC backs APRN as the single advanced practice nursing psych credential of the future, the APNA wants to ensure the CNSs who do not go back for their APRNs maintain their scope of practice and level of reimbursement.

APNA Position Statement: Psychiatric Mental Health Advanced Practice Nurses

The burgeoning mental health needs of the population demand access to highly qualified providers. Psychiatric Mental Health Advanced Practice Nurses (PMH-APRN) include both the Clinical Nurse Specialist and Nurse Practitioner. Both are prepared at the graduate level in research, systems, and direct patient care to provide psychiatric evaluations and treatment, including psychopharmacological interventions and individual, family and group therapy, as well as primary, secondary and tertiary levels of prevention across the lifespan. They are a vital part of the workforce required to meet increasing population mental health needs.


The PMH-CNS certification began in 1974. The introduction of the Psychiatric Nurse Practitioner certification examinations in the early 2000s created confusion regarding the scope of practice of the Psychiatric CNS and NP. This further became confounded with variances in state licensure and titles.


The position of the American Psychiatric Nurses Association is "psychiatric advanced practice nurses, whether they practice under the title of CNS or NP, share the same core competencies of clinical and professional practice. While the individual APRN-PMH may actually implement portions of the full scope and practice based on their role, position, description, and practice setting, it is importantly, the full breadth of their knowledge base that informs their practice." (Psychiatric-Mental Health Nursing: Scope and Standards of Practice (ANA, APNA, ISPN, 2007).


The following data lend further support to this position:

• The Essentials of Master's Education for advanced practice nursing requires the same core courses for both titles (AACN, 1995).
• The American Nurses Credentialing Center and the American Psychiatric Nurses Association conducted a Logical Job Analysis of the PMH-CNS and PMH-NP in 2005. Analysis of the existing role delineation studies of the PMH APRN revealed 99% of the identified competencies were shared between the two titles (Rice, Moller et. al., 2007, p.157).
• The ability of Psychiatric Mental Health Clinical Nurse Specialists to have title rights, prescriptive authority and direct care billing of CPT codes began in 1978 in the Pacific Northwest and has extended to 37 states and the District of Columbia.
• Medicare continues to reimburse ANCC certified Psychiatric Clinical Nurse Specialists for any CPT codes related to evaluation and treatment. Certified Psychiatric Nurse Practitioners were added in 2007.