Advanced Nurse Practitioner Education in the U.S.:

1. Advanced Nurse Practitioner Education in the U.S.: Historical Perspectives, Current Status, and Future Trends Oita University of Nursing and Health Sciences: October 30, 2008 Elizabeth Madigan, PhD, RN, FAAN Associate Professor

2. History of NPs in the U.S. In the 1960s, there were two simultaneous developments that promoted the role of the NP: • A shortage of physicians in primary care (increase in the number of specialist physicians), particularly in rural and poor areas • Development of payment systems for the poor and elderly

3. Confusion Regarding Titles • The development of the NP role was not federally managed leading to many certification bodies (11 at one time) and confusion over titles and educational credentials • At first NPs were educated in certificate programs (post-basic RN training) • In 1993, the American College of Nurse Practitioners was created and became a single, more unifying voice for NPs

4. Evidence on NP Outcomes • Much resistance by physician groups regarding development of the role—concern over NPs being “safe” and “effective” • Also prestigious nurses thought the NP role lost the “nursing” element: mini-doctors • Several important research studies published in prestigious journals (Journal of the American Medical Association and New England Journal of Medicine) with interdisciplinary researchers showed the patient outcomes of patients cared for by NPs were as good and sometimes better than patients cared for by physicians

5. Effective Lobbying • Many groups, led by the ACNP, effectively lobbied at the state and federal levels for recognition of independent provider status • Took > 20 years (from 1965 to early 1990s) for NPs to gain independent provider status • Still some areas where NPs cannot prescribe (i.e. home health care)

6. Continuous Lobbying • Continuous lobbying and policy work is necessary as there is continued physician pressure to reduce the role of the NP • Requires policy savvy NPs on federal boards, oversight committees, working with political leaders and other areas to continue the fight for NP independence

7. NPs in the US • As of 2007, there were 120,000 practicing NPs (excludes NPs whose primary role is education) • The US prepares ~6,000 new NPs each year from the 325 university programs • Two primary settings: primary care and acute care

8. Types of NPs • Acute care • Adult health • Family health • Gerontology • Neonatal • Oncology • Pediatric/child • Psychiatric/mental health • Women’s health

9. New Developments in NP Education • Increasing development of sub-specialty education for NPs where an NP obtains a more general specialization and then takes additional course work and clinical in a very specialized area • Example: Flight nursing NP—more general specialization is acute care nurse practitioner with additional education in flight nursing

10. Sub-Specialization • Example: Family nurse practitioners or adult nurse practitioners who take additional course work in dermatology • Practice is then care, prescribing and procedures in dermatology practice settings

11. Advantages of Sub-Specialization • Recognition of the specialized focus of much of US health care • Similar to physician sub-specialties • Increases job opportunities (joint practice with physician colleagues) • Increases NP recognition • Makes better use of physician expertise as NPs manage the routine cases

12. Forces Within the U.S. Health Care System Driving NP Demand • Increasing recognition that the biggest problems facing the US health care system are chronic diseases • Research demonstrates that the most effective chronic illness care is provided by teams of health care professionals • Policy is slowly changing to encourage this • Practice is also slowly changing

13. Summary • NPs have demonstrated their worth to the US health care system • The forces within the US health care system are changing and there is no guarantee that things will remain the same • Constant political action is necessary to maintain and increase NP status

14. Legal regulation for NPs • In the US, this took many years since our laws for nursing practice at any level occur within each state • Required effective health policy experts, both NPs and legal experts • Recommendation: Work through the JNA since it is a recognized group in Japan • Recommendation: Use the argument that NPs fill gaps for under-served groups (e.g. rural) • Be persistent—NPs are valuable to the health care system

15. Working with physician organizations • Difficult task as physicians offer see NPs as “competitors” even though NP/physician teams are very effective • The reimbursement system will be an important aspect so that physicians do not see their incomes fall as NPs enter the system • Recommendations: research on NP effectiveness will help as it is hard to argue with data

16. Working with physician organizations • If you can design your system so that there are incentives for physicians to work with NPs, many will see the benefits • May take some change in the culture of practice and this is difficult • Might consider working with the health care system leaders in addition to physician groups

17. Admission criteria to NP programs • In the US, we require: • A high grade point average (3.5 out of 4.0) • Graduate Record Exam (standardized test taken before admission to many graduate programs: verbal, quantitative, analytical) • Recommendations from two or three professionals • Interview

18. Critical thinking • NP practice requires high levels of critical thinking and diagnostic reasoning • Memorization approaches are of little use beyond the basic material • More important to use case studies and actual cases to teach the complexities of independent practice and diagnostic reasoning

19. Integration of classroom and clinical • To help the students integrate the classroom material, it is important that they do clinical hours at the same time • They can use the clinical experiences for part of their classroom case studies • Helps them to integrate and apply the classroom information to the clinical setting

20. Predictors of success on NP exams • Generally most NP programs have found that success on NP certification exams are highly correlated with advanced physiology courses • Likely related to the complexity of the material and the critical thinking it takes to pass the physiology exam • Recommendation: advanced physiology should be early in the curriculum • Recommendation: allow one re-take of the course

21. The Doctor of Nursing Practice (DNP)

22. Introduction “Unless we are making progress in our nursing every year, every month, every week, take my word for it—we are going back.” Florence Nightingale, 1914

23. Case’s Practice Doctorate in Nursing • Case’s Nursing Doctorate (ND), established in 1979, was the first in the country • Gone through a number of changes; became the DNP in 2005 • Levels of DNP students: • Graduate Entry (for students with non-nursing bachelor’s degrees) • Post-licensure / MSN • Post-MSN

24. History of the Nursing Doctorate • Two DNP tracks created at Case: • Educational Leadership Track: prepares doctoral-level nursing educators for clinical and academic settings • Clinical Leadership Track: prepares doctoral-level clinicians or practitioners in research and health policy

25. DNP and PhD Differences

26. Strengths of the Nursing Doctorate • Emphasizes the leadership role • Nursing practice extends beyond direct patient care • Need to look at care processes for collectives of patients (e.g., public health leadership) • Enhances status and privilege in the discipline • Expands the social definition of a doctorate as autonomous, hospital privileges, licensure (Pharm D, PsyD, DPT)

27. Strengths of the Nursing Doctorate • Strengthens translational research skills and research utilization • Provides research background for evidence-based practice • Applies research evidence to practice • Augments the science base of faculty • Bolsters the ranks of qualified nurse educators

28. Challenges of the Nursing Doctorate • Differences between DNP and PhD are not well understood • To advance the nursing profession, greater focus and emphasis are needed • Converting ND to DNP helps to clarify the nursing degree’s equivalence to dentistry’s DDM or medicine’s MD • More DNP-trained faculty needed to demonstrate parallel with MD, since both involve the same number of years of education

29. The Need for DNP-Prepared Faculty • Shortage of nurse educators who are: • Doctorally prepared • Expert clinicians • In 2001, less than ½ of nursing • faculty were doctorally prepared • Many nursing faculty set to retire within 25 years • Other doctoral programs: • Focus on preparation of researchers or clinicians • Do not have content or experience in clinical leadership development or educational methods

30. Educational Leadership Track Clinical Leadership Track FPB’s DNP Core Curriculum Core Program Leadership Track DNP Project or Thesis Advanced Nursing Research Health Care Planning & Policy and Information Management Systems Nursing Theory Statistics for Health Sciences

31. Impact: Case ND/DNP Graduates (N=129) • 33: Academic positions • Assistant Dean, Program Director, AD, BSN, MSN & DNP faculty • 31: Independent practice APNs (most CNM or NP) • 31: Offices based with collaborative providers • 29: Clinical/community & leadership positions • Example: VP for Nursing, city hospitals, community health agencies • 3: Researchers • 2: Army/Navy

32. DNP Graduates • See list of DNP Alums for selected names and positions

33. ND/DNP Alumni Profile Scott R. Ziehm, RN, ND ’87 Assistant Dean, Masters Entry Program in Nursing and Clinical Professor of Psychiatric Nursing Department of Community Health Systems at University of California, San Francisco DNP Alum??