1. Barry, Jean PhD, RN

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The original impetus for this article was based on a proposed resolution by the American Medical Association (AMA) to restrict the clinical use of the title doctor only to physicians, dentists, and podiatrists.1 The restriction also applied to the terms resident and residency. Needless to say, leaders from our national nursing organizations (the Nurse Practitioner Round Table [NPR], American Nurses Association, American Association of Colleges of Nurses [AACN]) responded clearly and succinctly that no one discipline has ownership over the title doctor.2-4


Ultimately, a less restrictive resolution was passed by the AMA in 2008. Resolution 232 A-08 called for AMA state-level organizations to develop legislation mandating that professionals using the title doctor in the clinical arena identify their qualifications and degrees to patients. The resolution also required development of legislative language stating that misrepresentation of oneself as a physician would constitute a felony.5


My first reaction when reading the original restrictive resolution was wonder at the chutzpah of declaring ownership of a word and uncertainty whether doctors and nurses would ever learn to just get along. Given the legislative ups and downs encountered by advanced practice nurses (APNs) in their quests for autonomy and recognition, I wondered how intense the conflict would be over this new issue.6,7 I assumed that the new resolution and its predecessors were at least partially based on a growing concern on the part of physicians about the national proliferation of doctorate in nursing practice (DNP) programs. These practice doctorates have also been called clinical doctorates or professional doctorates to differentiate them from research doctorates (PhD).


To better understand the dynamics surrounding the AMA resolutions and to check out my assumptions, I talked with some nursing administrators and physicians to hear their opinions about the AMA issue. I make no claims that the information I collected is generalizable in any sense of the word. The professionals I interviewed were individuals, currently practicing in acute care, whom I know or were referred to me by colleagues. Although they had many opinions and questions regarding the AMA resolutions, what predominated was the limited amount of knowledge they had about the DNP program and the rationale for its development. Since there is so much published about the DNP role, I expected that nursing administrators, at least, would be informed. In addition, these professionals were also unaware of the proposed AMA resolution before our meeting.


The new AMA resolution does not restrict the use of the title doctor by nonphysicians. However, as more and more nurses with DNPs are employed in a variety of healthcare settings, I believe that many nursing administrators will be confronted by this issue. To respond strategically and effectively, nursing administrators must be well informed about the purpose and design of DNP programs and how these programs can enhance the knowledge and skill sets of APNs and those professionals seeking a DNP in the area of nursing administration.


The DNP Movement

The demands of a rapidly changing and complex healthcare environment mandate that nurses in administrative and clinical specialty practices have in-depth scientific knowledge and practice expertise. Researchers have established a clear link between higher levels of nursing education and better patient outcomes.8,9 Most nurses are aware of the PhD, which prepares one for a career in research and academia. However, many are unaware of the national movement toward the DNP degree. Examples of current practice doctorates include medicine (doctor of medicine), law (juris doctor),dentistry (doctor of dental medicine), pharmacy (doctor of pharmacy), and physical therapy (doctor of physical therapy).10,11


The rapid proliferation of DNP programs in the United States has been influenced by a number of emerging factors in the healthcare industry. The rapidly expanding knowledge bases for practice combined with the increasing complexity of patients are 2 major issues. In addition, national concerns about the quality and safety of the care provided to patients, major shortages of doctorally prepared nursing faculty, and increasing educational expectations for the preparation of other health professionals (eg, doctor of pharmacy, doctor of physical therapy) contribute to this movement toward the DNP educational credential.10-13


Two major reports reinforce the need for changes in nursing graduate education; an IOM report called for major rethinking and revision of how health professionals are educated to meet the factors identified above.14 Exceptional competencies in the translation of research into practice, development, and implementation of evidence-based quality improvement programs to ensure excellence in patient-centered care and patient safety, interdisciplinary collaboration, and the utilization of technology and information systems to improve care and safety are the 5 IOM recommendations.14


The second report from the National Academy of Sciences called for nursing to develop a nonresearch clinical doctorate to prepare expert practitioners who could fully implement the emerging science and practice innovations developed by nurse researchers and to help in the amelioration of the major shortage of nursing faculty.15


Based on these driving forces, the ACCN in 2004 adopted the DNP as necessary preparation for advanced practice nurses10 by the year 2015. Advanced practice nurses who fall under this 2015 date include nurse practitioners, clinical nurse specialists, nurse midwives, and nurse anesthetists. Although not required as an educational credential, DNP is also highly relevant for nursing administrators practicing in a variety of settings.


After a national consensus building process conducted by the AACN, 8 core essential competencies distinguishing the DNP and serving as a common framework were identified and approved by the AACN.16,17 These core essentials include the following:


* the scientific underpinnings of nursing practice that reflects the complexity of practice; DNP graduates will have the ability to translate scientific findings into practice;


* organizational and systems leadership for systems thinking and continuous improvement in quality;


* scholarship and analytic methods for evidence-based practice;


* use of technology and information systems to transform healthcare;


* health policy for advocacy in healthcare;


* interdisciplinary collaboration to improve healthcare practices and outcomes across patient populations;


* clinical prevention and population health improvement; and


* advanced practice theory and practice.



Although all graduates must demonstrate competencies in all 8 core essentials, further DNP preparation is divided into 2 general categories: roles that focus on direct expert care of individuals and roles that specialize in expert practice at the systems or organizational level. A major scholarly project serves as the capstone experience; these projects may take many different forms and should not be construed as the classic dissertation of original research required for attainment of a PhD.


Currently, there are more than 100 schools of nursing that offer a DNP program, with 50 additional schools in various stages of development.16 Programs vary in design, with some being post-master's degree as the starting point and others, post-BSN; additional programs allow students to start at either point.


The DNP is a terminal degree with a different focus than the PhD but very definitely equivalent in rigor and challenge. Graduates of DNP programs will have the highest level of nursing knowledge and expertise in the practice setting. These doctorally prepared nurses, in partnership with interdisciplinary team members, will be the vanguard for the transformation of local, state, national, and global healthcare systems.


Key Points

There are 3 important points to emphasize:


Point 1: requiring the DNP credential does not in anyway alter the current scope of practice for APNs. State nurse practice acts regulate the scope of practice, and these differ from state to state. In my conversation with physicians, this area was questioned and seemed to be a source of concern. Therefore, nursing administrators must be prepared to field questions about their state's current APN regulations. Also, they will need to have ongoing up-to-date information about any nursing or medical state organizational activities to alter these regulations.


Point 2: although the AMA did not pass a resolution restricting the use of the title doctor, this does not mean that it might not happen at the state level. Currently, there are 7 states (Georgia, Illinois, Maine, Missouri, Ohio, Oklahoma, and Oregon) that have laws prohibiting nonphysicians from using this title.18 The AMA resolution has no binding effect on state law; however, it does indicate a significant level of concern on the part of at least some of our medical colleagues. Nursing administrators will provide leadership by facilitating open dialogues among the medical and administrative staff, the DNP graduates, and others regarding the use of the title doctor and other important aspects related to the introduction of DNP-prepared APNs to the health system.


Point 3: physicians are not just being difficult and not just protecting their turf, although certainly this is a part of it. Physicians are struggling with concerns that the "prerogatives of (their) profession are being systematically destroyed."3,19 Low reimbursement rates and loss of autonomy are major morale issues and sources of career dissatisfaction. Physician shortages are predicted; some believe that it has already reached crisis proportions in some regions and in some specialties.20 It is understandable that physicians' perceptional filters might have them experience some degree of threat by the doctoral preparation of APNs and their clinical use of the title doctor.



With this level of insight and knowledge, it is critical that nursing administrators begin to work with their medical and administrative colleagues to prepare for this new breed of doctorally prepared APNs and administrators. Strategies to optimally use these nurses in the practice setting must be identified. Nursing leaders should introduce the fact that these DNP-prepared nurses will use the title doctor and identify what must be in place to ensure that patients and families always know who and what type of clinician is caring for them.


Nurses and physicians have a rich history of working together to provide outstanding care to patients. We also have a long-standing history of struggling with gender-based politics; rigid bureaucratic structures in which medical dominance is embedded; and nursing frustration, distress, and angst. We are again presented with what can be seen as a brilliant opportunity for honest dialogue about each discipline's concerns, mutual clarification of our separate and overlapping domains of practice, and our differing contributions to the health of individuals and populations, or it can just be more of the same with the continuation of nursing's meta-narratives about oppression by the medical profession, lack of appreciation of the contribution made by nurses, and the general lack of respect of the nursing profession by physicians and administrators.21,22


Perhaps it is time to stop wondering if nurses are appreciated and respected by our medical colleagues. Let us just stop engaging in these particular conversations. It just adds mass to beliefs that no longer are accurate. Let us stand together and declare that we are appreciated and we do have respect. Our contributions over the decades have been phenomenal and have made many great differences in the health of the citizens of this country.


There is an urgent need for leadership if we are going to redesign healthcare to meet the challenges of the 21st century. Let us just move forward, becoming leaders and followers, unconstrained by historically based beliefs, to tackle the major healthcare issues that we, as a nation, are facing. Nursing administrators are well positioned to provide the clinical context and the vision for the creation of optimally performing teams. Graduates of DNP programs will prove to be outstanding partners, having exceptional knowledge and skill sets to provide leadership to these teams whose focus is the continuous improvement of patient care in all settings.




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