My Nursing Mastery
My Nursing Mastery
Why the DNP is Here to Stay
Hello and welcome to nurse casts. I'm Joe Merida senior acquisitions editor for Springer publishing company. Today we'll be talking about the doctor of nursing practice. We're joined by Dr. Steven Ferrara associate dean for clinical affairs at Columbia University's School of Nursing. Last summer Steven wrote a great piece for daily nurse dot com on why the DNP is here to stay. That article attracted a lot of feedback from our audience. So we decided to invite Steven to our New York City office to talk about it.
Speaker 2:We wanted to learn more about the acceptance and evolution of the DNP degree within the health care community. Here's Dr. Stephen Fuller.
Speaker 3:Steven first of all could you just tell us a little about yourself in your experience.
Speaker 4:Sure. So I'm currently the Associate Dean of clinical affairs at Columbia University. This is Prak I oversee the clinical practice and our at our university we have three physical Primary Care locations as well as a house cost location. The other role I have is executive director of the Nurse Practitioner Association New York State. This is the professional association for nurse practitioners in New York and we are responsible for advocating for the profession reducing any barriers that persist and educating nurse practitioners in New York State.
Speaker 3:Okay great. So today we're here to talk about the doctor of nursing practice more commonly known as the DNP. Could you first of all just tell us about the DNP.
Speaker 4:Yeah. So the DNP was born quite a few years ago in concept and it's supposed to be known as the practice doctorate. It is the terminal degree in nursing practice.
Speaker 5:The other being the Ph.D. Ph.D. of course is the research side of things and what this was supposed to be was the equivalent of the Ph.D. But emphasis is on the practice side of things so we're not churning out neuroscientists we're churning out nurse practitioners professionals who can translate that evidence into practice and that's the hardest challenge today is that we have lots of research going on and we have lots of data but it takes on average 17 years to translate that into actual clinical practice. So with the DNP is supposed to do is give the nurse the advanced practice nurse the skill sets that they could take this knowledge and apply it to practice.
Speaker 3:And I believe the term is quality improvement is that right was that kind of the primary goal.
Speaker 5:Yeah there's a heavy emphasis on evidence based practice as well as quality improvement. And the idea is you can't just take a program that works well somewhere and just plop it down elsewhere and expect it to work. There are cultural differences in the environment that you're working with patients are different. So the idea is to have a process that implements a project and then you continually have this feedback and this is continuous loop of feedback so you can alter as you need to on the on the go and not wait till the end to make any changes.
Speaker 3:So from a bigger picture looking at the overall healthcare system in this country my understanding is that the AMA the American Medical Association has historically had some issues with the doctor of nursing practice and there's been some articles published about that. Could you just talk about that a little bit.
Speaker 5:Well I think one of the issues has been that the title doctor and nurse practitioners being able to use that term and those those nurses who have attained this degree certainly have the the right to use it and we try very hard to make sure that we as nurse practitioners and any provider or any professional that has turned the title doctor should have a qualifier as to say in what. So it's doctor of medicine it's Doctor of nurse of nursing practice it's a dental doctor so you know no one profession owns the title Doctor. Yes. In traditional settings anybody with the lab code is referred to as doctor. But today in the health care environment in which we live in and which we practice and there's many disciplines it's a multidisciplinary entity.
Speaker 4:Healthcare is today and we have to make sure that we're correctly identifying who we are the roles we play and really do some earnest patient education as to who we are and what we're doing. I think every every patient deserves that. We all patients deserve to know who's treating them and who's involved with their care are the doctors just trying to preserve their turf.
Speaker 3:Don do you think or go beyond that.
Speaker 5:I think it's it's it's a new innovation in healthcare and it's one that's not driven by medicine. And again in medicine and in healthcare today it is multidisciplinary so I think you know we're all trying to find solutions and we're all trying to move health care forward as as complex as it is. So you know I can't speak for them as to what their issues are per se but I know that this degree is supposed to enable the doctors well-prepared nurse to fulfil the challenges in healthcare today. And I think anybody who's fighting against that needs to look at it and I think we all need to be on the same page and tackle these issues together rather than trying to to to find things that divide us.
Speaker 3:OK great thank you. The American Association of Colleges of Nursing a senior producer a position statement on this practice doctor in 2004. So it's not that old. Actually. We're moving up on 13 years where they've been promoting the DNP. How do you think it's been going so far.
Speaker 4:I think there's been a little confusion. I think certainly with the number of DNP programs that are out there we've certainly seen exponential growth in the DNP. But this sort of evolved from what used to be known as the doctor of nursing science what was was out there at one point. And then there was the nursing doctorate at one point so these concepts have evolved over time and the ASEAN has has agreed that this should be the DNP and this is the pathway to the terminal degree for nursing practice. So so having said that I think we've seen an embracing of this concept in the number of programs that there are the number of graduates from DNP programs that exist today. And there was some confusion I think when the idea was AZN had put out the recommendation that by 2015 that all programs would transition to the TNP as the terminal degree. Well it's 2017 and that has not happened and these things take a lot of time and a lot of effort. So we're beginning to see this transition now. I would remember a lot of nursing students nurse practitioners students would ask me do I need to go back and get my DNP today because it's going to be mandated. And I would tell them you know that was a recommendation by a C and nobody is mandating anything at this point. And for all intents and purposes a lot of existing graduates would be grandfathered in or grandmother down into their roles where they wouldn't necessarily have to go back and get their DNP to maintain their position.
Speaker 6:This is really looking forward at the profession and saying OK as of this date all advanced practice nurses or all nurses would get their doctorate of nursing practice.
Speaker 3:OK. And I believe it's still the case today where the bulk of the nurse practitioners even who are getting their respective Schrinner degree these days are in a master's program. Is that still true.
Speaker 4:It is by far and large it is still masters and we're beginning to see programs that are entry to DNP. So you come in as as a non nurse and you transition through the program and end up with a terminal degree.
Speaker 3:You have a bachelor's degree when you come in. Is that right.
Speaker 4:Yes. And in some. And part of our challenge in nursing. It's a challenge but it's also a blessing is that there are so many pathways into into the profession of nursing. You know there's associate's degree there's a baccalaureate degree and we're not seeing so many of the associate's degree programs anymore. In fact a lot of the major hospitals will only hire a baccalaureate degree nurse. But we've also seen a proliferation of the second career nursing. These are individuals who had a bachelor's degree and another in another discipline and decided to cut back and to become a nurse or a nurse practitioner. So there's an entryway for that for those folks to get into the profession as well. So admittedly it is a little challenging to understand all of the pathways and it can be confusing to somebody not in the profession. But but the good thing is that there are plenty of opportunities to get into the profession and you know today there are three point three million nurses across the United States. You know we represent the largest part of the health care workforce.
Speaker 3:Eventually do you think all of the nurse practitioners are going to be trained at the DMP level.
Speaker 6:I do I believe that's the ultimate goal and it's not to say that there is a one is better than the other I think it's more of a robust skill set. And traditionally the number of hours that the masters prepared a nurse practitioner or nurse did was not far off from actually what a doctoral degree required. So we were sort of more than halfway there but just really the degree didn't exist beyond 2004. So it took some time to sort of understand OK this is what it is. And really the credit load is not all that much different from actually transitioning this to a doctorate degree from students and DNP programs often.
Speaker 3:Or are there experienced professionals some of them are already leaders. Is there a DMP job like when they when they graduate what does that they're doing. What's different about their responsibilities and what's kind of a normal job title if you can even answer that question.
Speaker 5:I think we're seeing not specific DNP titled jobs right now.
Speaker 4:I think with the evolution of healthcare and the chaotic environment in which we live we're seeing Duyen PS being able to fill certain role so it could be a CEO of a hospital could be executive director of of of of an association. I think this is where we see a lot of GNP but remember GNP is the practice doctorate so we're also seeing clinical leadership. So it could be leading teams within clinical environments that you know they're looking at certain patient outcomes and being able to tailor treatments to those patients. So we're not exactly seeing a lot in the job market that says okay. This requires a DNP versus versus a master's. So I think that's where we are today. I think you'll also see that in academia you know DNP is not a pathway to teach at the college level. It would require additional education for that practitioner or that to that nurse to be able to teach. But it puts you on that pathway. But the bottom line is to be able to always remember that it's about clinical practice it's about improving patient outcomes or improving systemic outcomes that is bringing into this healthcare system.
Speaker 3:I don't think we've talked about it but I know of minder's saying that a fundamental part of what the DPP learns in a DNP program are leadership skills which is kind of what you were talking about. I mean if implemented you know quality improvement those kinds of things if the lead staff are other kind of leadership skills. Could you talk about that.
Speaker 6:Yeah. Leadership is very much part of the DNP because as you said we're dealing with multi disciplines of of individuals and the skill set that's required is one to be able to rally the team gain stakeholder support and be able to make the case be able to handle any challenges along the way.
Speaker 7:And these are some of the skills that a student would get in a DNP program today.
Speaker 3:Do you think we'll see any changes to the DMP curriculum or kind of the goals of some of the national associations in the next five to 10 years or anything like that or is it pretty much set in where we are now.
Speaker 5:I think it's pretty much set you know the ACA has come out with their essentials. And this has been primarily the guideline that all school of nursing that offered GMP use. That's not to say there won't be some tweaks along the way but I think we're really focused on evidence based outcomes evidence based care. And then along with the other important parts which includes health policy and health economics and health informatics and all of the things that that make up our healthcare system today. So I think we'll continue to see that emphasis. I don't think we'll see all that much deviation over the next five to 10 years.
Speaker 8:Are you interested in sharing the latest evidence based nursing research with the DNP community or just want to stay up to date with the latest nursing research to advance your career. The Journal of doctoral nursing practice is a bi annual peer reviewed publication that showcases clinical excellence in the application of evidence based practice. The content is appropriate for nurses at the DNP level submit or read relevant articles on clinical practice patient care practice issues as well as innovative methods of teaching and evaluating advanced practice nursing including the use of case studies. Learn more today. Springer polka dot com slash JD and.
Speaker 3:So could you talk about the program at Columbia a little bit and how these you know the DNP programs is affected and what your goals are and your curriculum. Absolutely.
Speaker 4:So we actually just made the transition at Columbia to offer the DNP as the terminal degree. So there is no other way to become a nurse practitioner or advanced practice nurse at Columbia other than through the pathway of the DNP. So you have no master's programs and we have no master's programs for the advanced practice nurse Columbia's program is a little bit unique because we don't have that traditional undergraduate program. Our nursing students are coming in as that second career nurse. So they are coming in with that baccalaureate degree already and it really made sense from a few different perspectives. The recommendation is are right that we should be offering the terminal the grade. The second thing is we found that there's more financial aid available as a master's degree as I'm sorry as a as a DNP rather than as a baccalaureate and masters degree. So that helps our students. It helps the profession sort of move this along as as a DNP because what was happening before was students would get a second baccalaureate degree in nursing and then a masters degree in as an advanced practice nurse. So now that's that has been retired and our first class has begun where they enter as a non nurse and they make their way through and through the DMP and graduate with that with that degree and be eligible to become advanced practice nurse to that point.
Speaker 3:Right. So what kind of issues and obstacles do you face making that change from masters to DNP.
Speaker 4:GRAHAM I think it was mostly in conveying that to the students because not a lot of programs have made that switch yet. So it was convincing them why this is the way to go. There is an exit point. So remember these are not nursing individuals entering the school so they could actually they're eligible to take their are and test at the end of what we would traditionally be the masters portion. So there's a stop point there but it must. Most do choose to go on and continue seamlessly through and get their D and pay as an advanced practice nurse and Colombia has quite a few specialties for nurse practitioners and vans practice nurses. We have a c RNA that's a certified registered nurse anesthetist. There is the failing nurse practitioner or adult Jero nurse practitioner psychiatric mental health nurse practitioner. So these are all the acute care. So we have quite a few specialties for the advanced practice nurse which is somewhat unique in the landscape of of nursing education.
Speaker 3:So if you compare a masters level family nurse practitioner program to a DMP level program what's the difference.
Speaker 5:Well part of it is the additional hours that you would get in the DNP. And I think you're getting a more robust understanding of what health care is today. So you know what we've seen in the last few years is you know heavy emphasis on evidence based practice. Now we're seeing that at the Masters level where that you to only appear at the doctoral level. Now we're getting at the master's level so it's it's all of that plus. So it's being able to systematically look at evidence and journal articles and critically appraise information and say Is this something that we can apply to our patient or to our population of patients. That's the other big parties population health. So it's all about taking care of populations of health and understanding you know cultural competency today. We know that all patients are different and have unique needs and wants and this degree is supposed to give you the skills to be able to bring that all together and the name of the game is in improving patient outcomes and that's why we do this improve patient outcomes reduce hospitalizations reduce anything that we may be able that could have checked earlier and didn't. And that's why we do this.
Speaker 3:So I'm curious are you a DNP. I am. I am. Are you. What could you tell me about your educational pathway.
Speaker 4:Well mine is somewhat non-traditional. They all they all are. So I was I was a bachelors of science biology major at one point. Finish graduate school didn't really know what I wanted to do. My aunt who was a nurse had always been sort of urging me to look into nursing and I did not until I had this epiphany one day and I said okay let me look into this. So I did go back to school. I became a medical assistant and became an EMT volunteer on the ambulance a little bit and then I did one of these programs where I was able to get my accelerated baccalaureate degree. I had all the science prerequisites and from there I went seamless through to the master's degree became a nurse practitioner and I practiced for about seven years before I decided to go back and get the DNP. There wasn't a wide range at the time of DNP program so I waited I waited for the programs that were important to me. What was important to me was to not find a program that just did Strictly more clinical hours because I was in the field I was treating patients with diabetes. I was treating patients with asthma. I didn't necessarily need to know how to do that better. What I needed to do I needed the skills to sort of bring that to populations of health and critically look at evidence and data and apply that in a meaningful way. So I didn't the DNP program and graduated in 2011 and I've been fortunate to have roles that have really meshed very well with the DNP. So one as as executive the nurse practitioner Association which is really important to help advance the the nurse practitioners by reducing arbitrary barriers which many still persist. I'm also on the board of the American Association of Nurse Practitioners which is the National Association of Nurse Practitioners in their region to director which covers New Jersey New York and Puerto Rico. And then my job at Columbia which has been just fantastic and able to apply what I've learned in school directly to clinical practice. I mean it's very unique that we have a faculty nurse practitioner practice that offers primary care three locations and also House calls that we just started to. So unfortunately I'm very fortunate. And it's just been I couldn't have written it better. I will say this is not how I planned it. I really didn't have a plan but I found things that have really I found passion in and I've been able to sort of.
Speaker 7:Find positions that mesh very well with that.
Speaker 3:And it sounds like you believe in the DNP and it's been a good for you and you think it's good for nursing. I do.
Speaker 5:I certainly do because I think there's a lot we don't know in healthcare.
Speaker 4:And you know you would think that's not the case in 2017. But when you start delving through the data and you start looking at things you could say well we really don't have good information on this intervention and it really hasn't been studied in earnest. So I am a proponent of the DNP. I know sometimes it's still a hard sell for some people especially the nurse practitioner who has been practicing for 25 years. They say well what's in it for me. Why would I go back at the expense. And you know they have to look at their portfolio right they have to say is this going to make a difference for me. Nobody's mandate anybody to go back. But if you're looking to attain a different skill set that's going to broaden your horizons give you opportunities that may not otherwise be there that I think the DNP is a really really good choice. It's expensive. You know I think that's that's that's a big problem. But I think we're seeing lots of institutions lots of hospitals are subsidizing it partially. You know there's all types of programs to help defer the costs. I am still paying to my DMV but you know that's available. And I would not be where I am today had it not been for that that degree and that decision for me to go back. So I'm a believer in and and I I appreciate where I am.
Speaker 3:We didn't even talk about that. So how long were most of the DNP programs.
Speaker 6:There is some variability because there's part time options and there's full time options. They average from one and a half to three years depending on if its full time part time. A lot of the programs in existence are designed for those working nurse practitioners or advanced practice nurses already. So it affords some some flexibility. The program I went to was sort of had that executive style where it was intensive you know one day a month. There were there was it was a hybrid program where there was online content as well lots of reading lots of research. But I was able to do it working full time as well. And I believe most of these programs are designed for that.
Speaker 3:So when these programs they go through their coursework but I know at the end they have to produce a DMP project. You talk about the DNP project and what that entails.
Speaker 5:Sure.
Speaker 6:So typically it's it's a project that is identifying a problem and doing the research to see if it's been solved previously and if it is if it has been solved what is the the data on it and could that be applied into practice. You know I won't forget one of my professors said to me unlike the Ph.D. This is not your life's work. This is not what you are which is very similar to that Ph.D. You know somebody who's a neuroscientist who's doing their Ph.D. They tend to spend the rest of their careers on whatever they studied where did their dissertation on what's really different here. It's the skill set. And I can't emphasize that enough. We're able to look at problems that exist in and in healthcare systems and analyze it appraise the evidence and put in a solution and re-evaluate that process. So that's really where where where the project comes in. The nurse the nurse advanced practice nurses are given the skills to be able to look at any problem that persists whether it's patients with diabetes and you know having problems adjusting their hemoglobin day one sees which is the indicator of how well controlled their diabetes is or looking at patients with asthma. And why are they having these excessive exacerbations of asthma. So that's the key difference. And I'll tell you and my experience has been typical of what most TNP projects are so we identified a problem. The problem we identified was patients with type 2 diabetes had very high hemoglobin agencies. And despite many interventions their agencies remained high. So we had a clinical agency that we worked at we did lots of assessment of the environment that that was there. We found that a successful program was there prenatal classes so their prenatal classes they did with groups of people and groups of you know pregnant women and their their their partners and they said you know this was very effective. This was very effective because they had high engagement and and good outcomes. So we said well why can't we do this for patients with diabetes. So we actually looked at the concept of group medical visits for patients with type 2 diabetes where it was a multidisciplinary visit. So there was a nurse practitioner. There was a health educator. There was a nutritionist and there was a whole host of an intense two three hour of visits with seven to eight patients. And what we found over that course was this group medical visit actually decreased hemoglobin A1 sees by 1 percentage point in the patients that went through the program. I mean this is this is fantastic because this is a non pharmacological way of reducing a very pervasive problem for patients with diabetes. So we were able to do that. We wrote about it and we implemented it. So that was the project in a nutshell. And then from there we sort of individually spun off on that into an individual manuscript and a lot of other requirements for the DNP programs is to submit for publication which is great when you know there are publications that exist now.
Speaker 7:I'm going to give a plug for the Journal doctoral nursing practice in which the editor of. And I think this is a perfect venue for those TNP projects. But one thing I would I would say to all those students out there is not just to slap your cover page on our on your manuscript and submit it to our journal. We really are asking you to look at the author guidelines. Look at the types of articles and types of things we're looking at and tailor it to our journal. And you know we're trying to make sure that the knowledge that is gained in this DNP programs is disseminated and disseminated widely because what good is it if you do it in a vacuum and it's not seen by everywhere heard by everybody. So that's where this really comes full circle. And I'm appreciative of the opportunity to be involved with the journal doctoral in nursing practice and I think it's a great venue and I think where we've in a year and a half or so since I've been the editor we've been seeing many many more submissions and I think we'll continue seeing that as more people are aware and you know look at what's been published there and say OK this is this is some good information that everybody needs to hear about.
Speaker 3:Stephen thank you so much for all of the information that you shared with us. We look forward to learning more about the DNP and best of luck with the journal and everything else. Joe thank you I appreciate it.
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