Chronicle of Higher Education Article Regarding “Doctor Nurse” Degree
A New Degree and Exam Create ‘Doctor Nurses,’ Irking Physicians
By KATHERINE MANGAN
For years, advanced-practice nurses have struggled for greater autonomy from doctors while physician groups have fought back, trying to protect what they see as their turf. Now, a degree that is sweeping through nursing schools and a controversial new certification test are blurring those boundaries even further.
About 80 nursing schools offer “doctor of nursing practice” degrees, and by 2015, the number is expected to reach 200. Last year 1,874 students were enrolled in such programs nationwide, up from 862 students the year before, according to the American Association of Colleges of Nursing.
At the end of 2008, about 40 nurses with these doctorates sat for the first certification test for the degree, which was administered by the same board that licenses new physicians. The nursing test is based on the final section of the three-part licensing test that medical-school graduates must pass to practice.
The test, and the degree it certifies, has raised the hackles of some physicians while giving some nurses hope that they will finally get the respect they feel they deserve.
“If nurses can show they can pass the same test at the same level of competency, there’s no rational argument for reimbursing them at a lower rate or giving them less authority in caring for patients,” says Mary O’Neil Mundinger, dean of Columbia University School of Nursing, which began graduating students with the degree in 2005.
A nursing group called the Council for the Advancement of Comprehensive Care teamed up with the National Board of Medical Examiners to create the voluntary exam, which is based on a section of the medical-licensing test that measures how well people apply medical knowledge to patient scenarios.
The drive behind the degree and the test comes from demographics as well as trends in physician career choices. As the population ages and the number of medical students choosing to go into primary care continues to drop, what some proponents are calling “doctor nurses” could help fill the gap.
The practice doctorate, nursing educators say, is not designed to turn nurses into doctors. Already, nurse practitioners are able to diagnose and treat patients, as well as prescribe medication in most states. But they usually do this with some kind of review or supervision from a physician. Advocates say the doctoral degree will give advanced-practice nurses the extra clinical experience they need to independently treat patients with complex needs in a variety of settings.
Earning a practice doctorate and passing the certification test won’t automatically give nurses autonomy in states that require physician oversight; however, both the degree and the test could provide leverage to nurses seeking changes in “scope of practice” laws.
But some physician groups continue to vehemently oppose efforts to grant nurses such autonomy. They argue that even with a year of clinical experience and a doctorate, a nurse’s experience does not compare with the training of a physician who has completed seven years of study, including at least three clinical years.
Ted Epperly, president of the American Academy of Family Physicians, says the medical board “crossed the line” when it began offering the nursing certification test.
“This is not the National Board of Nursing Examiners; it’s the National Board of Medical Examiners,” says Mr. Epperly, a family physician in Boise, Idaho. The degree, he says, may confuse patients.
“If I go into an exam room and I’m talking with my patient, I don’t want them to wonder, ‘Are you a doctor doctor or are you a doctor nurse?’” he says.
The American Medical Association, in a 2006 resolution, warned that the “quality of care rendered by individuals with a nurse doctoral degree is not equivalent to that of a physician,” adding that “patients led to believe that they are receiving care from a ‘doctor’ who is not a physician … may put their health at risk.”
Defending the Test
The National Board of Medical Examiners, which administers medical-licensing exams, defended its decision to offer the nursing test in a lengthy paper posted on its Web site. “Current and future patients of these nurse clinicians deserve a system that assures them that the clinician providing services meets appropriate quality standards,” it says, adding that there is no evidence that these nurses provide substandard care.
Susan Doyle-Lindrud, a nurse practitioner since 1994, received a practice doctorate from Columbia in May and took the certification test in November. “At this point, there’s tons of research showing that there’s no difference in the outcomes of nurse practitioners and physicians, but we still struggle to get companies to put us on their provider panels and get legislation passed that respects our competencies,” she says.
Physicians she works with at the Cancer Institute of New Jersey respect the degree, she says.
“It doesn’t change the scope of practice,” she says, “but it does change the way physicians talk to me and makes it easier to develop a more collegial relationship with them.”
To be eligible for the exam, a candidate must be licensed as an advanced-practice nurse and have a nursing-practice doctorate. The multiple-choice test is based on questions that have appeared on previous versions of the licensing exam for physicians.
Not all nurses, however, agree that a medical licensing board should be certifying nurses.
“We already have accredited certifying bodies for nurses. It makes no sense to turn this over to a medical board,” says Jan Towers, director of health policy at the American Academy of Nurse Practitioners.
“There are so many other ways to demonstrate that we are on a par or even offer superior outcomes,” she says.
Nursing groups also point out that nursing isn’t the only health profession transitioning toward a doctoral degree. The growing complexity of patient care and concerns about patient safety are prompting other fields, including pharmacy and psychology, to do the same.
“Patients know whether they’re seeing their doctor or their dentist or their podiatrist — all of whom go by the title ‘doctor,’” says Ms. Mundinger, Columbia’s nursing dean. She believes physicians are feeling threatened because “all of a sudden, we look too much like them.”
According to a report released last year by the Center for the Health Professions at the University of California at San Francisco, 11 states allow nurse practitioners to diagnose and treat patients and prescribe medication without any physician involvement. Ten states mandate some sort of physician supervision, and the rest require collaboration with a physician. This sometimes means that a physician has to approve prescriptions or simply has to be available for consultation by telephone if needed.
So why the switch to a doctorate?
Most nurse practitioners, nurse midwives, and nurse anesthetists are trained in master’s-degree programs. By 2015 the American Association of Colleges of Nursing wants the doctoral degree to replace the master’s as the standard qualification for new advanced-practice nurses. (Until recently, most doctoral nursing degrees were oriented toward research and teaching rather than practice.)
A doctorate of nursing practice typically takes four years, following a bachelor-of-science degree. A student who already has a master’s degree in nursing can usually complete the doctorate in two additional years. In each case, the final year is a full-time clinical residency.
The nurses who took the medical board’s inaugural certification test will probably get their results this month.
http://chronicle.com
Section: The Faculty
Volume 55, Issue 19, Page A7
