September 19, 2006, 8:34 pm

A Constipated Profession or A Visionary Movement?

mom

Nope, you’re eyes aren’t playing tricks on you!

This really is Milk of Magnesia Toothpaste!

Two tubes for thirty-three cents!

I guess back then you could get your teeth and your rectum squeaky clean!

Sort of a new perspective on the term “tightie whities”.

Today, we have Crest Whitestrips to brighten our smiles!

I wonder.

If you drink Milk of Magnesia do you get any teeth whitening benefits?

******************************

I think I am going to be sick.

Either that or I am going to bang my forehead into the wall until I’m committed as a 5150.

The reason?

I just finished reading the responses to a Medscape article entitled “Introducing the Doctor of Nursing Practice”.

Dear God.

Would someone pass the Zofran?

******************************

I am a nurse.

I am a member of a profession that can’t even decide on the appropriate entry level degree and even if they ever get around to it, they can’t produce nurses fast enough because they don’t have the instructors!

Now they want to add an additional degree level to become an Advance Practice Nurse!

And guess what that new APN would be called?

DOCTOR!

Excuse my language, but WTF????????????

******************************

Dear Nursing Leaders of America,

With all due respect,

First things first, okay?

  • Decide on what you want the entry level of nursing to be.
  • Pay the pants off anyone who even remotely verbalizes an interest in teaching so that they will teach!
  • Fill the profession in from the ground up.
  • Once you have eased the nursing shortage, make it easy for RNs to become Advanced Practice Nurses, be they Nurse Practitioners, Midwives, CRNAs – I don’t care what you call them.
  • Pay them comensurate with the amount of education already required to attain that status. Nurses will flock to it if you pay them what they are worth.
  • THEN, educate the public on exactly what an Advanced Practice Nurse does and does not do.

And after you have done all of the above, and taken care of the crises already existing in the nursing profession, then and only then will a Doctor of Nursing Practice be taken seriously by the rank and file.

You know. Us. The grunts in the trenches.

From your hallowed halls of academia we were given “nursing diagnoses”.

Now I don’t know if you are aware of this, but here in the real world, the majority of nurses consider nursing diagnoses absurd.

But…we jump through the academic hoops because we are a profession that can now diagnose.

Great.

Hmmmm…and now you want a doctorate degree as the entry level to advanced practice nursing?

Call it medical school and be done with it.

It sounds to me like our profession has a whopping case of doctor-envy.

And I’m sick of it.

******************************

So.

Do I focus on my bedside patient care and retire from this identity crisis ridden profession keeping my mouth shut?

No friggin’ way.

I’ve put too much of my life into this profession to let it get screwed up and over.

I’ve been quietly looking at an online RN-to-MSN program for Associate Degree and Diploma graduates.

I wasn’t sure if I was going to do it.

It’s a lot of money for no financial gain.

But….I thought it would be interesting to put my time and money where my mouth is and see if an advanced degree would really change my practice.

Well, this has made me so angry I’ve decided to do it.

******************************

What is going on in the heads of our leaders?

They are totally disconnected from the rest of us, that’s what.

And if there is going to be any change then it needs to come from inside the profession.

From advance practice nurses, or nurses with advanced degrees who can manage to stay focused on what this profession needs.

Right now what this profession needs is a good laxative and someone is going to have to be the enema.

******************************

And people wonder why we need an Office of the National Nurse.

Maybe the National Nurse would actually represent my profession.

Lord knows the leaders aren’t focused on the real work of nursing.

The real work of nursing is recruiting and retaining the best nurses we can.

Not inventing another hoop to jump through.

My nurse, the doctor.

Something is drastically wrong.

******************************

And so, in conclusion: the Doctor of Nursing Practice.

Sign of a constipated profession or visionary savior of the fold?

I’m pretty sure you know where I stand.

Any questions?

24 Comments


  • Janet

    September 19, 2006 at 9:56 pm

    Iagree with you, Kim! I just read the same stuff.
    I think we need to re-emphasize bedside nursing. Advanced degrees are well and good and they have their place but more and more basic nursing is being delegated to nursing assistants and “care partners” who often do not have the experience or background to recognize when something is awry.

    I’m afraid the National Nurse will end up spouting the same old stuff we’ve been hearing. I hope I’m wrong.



  • Mother Jones RN

    September 19, 2006 at 10:58 pm

    Stop the insanity. Good grief! I’m a nurse, not a doctor. I agree with Janet, if you want respect for nurses, focus on bedside care. Nurses living in academic ivory towers make a laughingstock of the profession.

    Don’t worry, Janet. The Office of the National Nurse will welcome nurses from all educational levels to participate in the office’s activities.



  • DK

    September 19, 2006 at 11:07 pm

    Kim,

    I’ve read your blog for a long time but I’ve never commented. Now’s a good time to start I suppose.

    I’m a nursing student right now. So your recent posts about the state of nursing education kinda hit close to home with me. In the time I’ve been (back) in school I’ve seen this DNP thingy emerge. I didn’t read the medscape article, don’t have a login.

    Pharmacy schools went from a BS of Pharmacy to Doctor of Pharmacy a while back. Physical therapy degrees used to be at the BS level. A while back they went to MPT and recently to DPT. You see, nursing was left out due to the lack of a terminal professional degree.

    But seriously, there are people who belive that education is the magic bullet. Education is important but it’s quality, not quanity that makes a good practitioner of any sort. My biggest concern, as a student right now, is that academic nursing has something to prove. Well, I come from an engineering background. I can say for sure that there are lots of educated folks out there who can’t function in the real world.

    The old saying about clothes not making the man; well, that can be applied to education as well. A degree does not a smart person make. From my vantage point, nursing (today) needs to be more concerned with competence and consistency in practice than in the ivory towers of the educational institution.

    That’s my $0.02 worth!



  • Patrick

    September 19, 2006 at 11:50 pm

    The thing that makes nurses so vital to the medical system is that they are NURSES.
    It is a different job than doctor, though no less important, and to call it the same thing simply removes focus from the actual job.
    Without nurses our hospitals would not run, because of the direct bedside care they provide, that is what they do, no reason to dress it up.



  • Patrick

    September 20, 2006 at 12:28 am

    thank you for your suggestion. regarding the University of Minnesota med school. I’ll definately check ’em out.



  • tscd

    September 20, 2006 at 4:56 am

    Wow! Milk of magnesia toothpoaste – that’s like, ‘two for the price of one’!

    So this Advanced practice nurse, is that like a PhD or something in nursing?



  • Susan

    September 20, 2006 at 8:01 am

    I am so confused – how must the patients feel?

    One way or another, the nursing profession has to get its shit straight. This is ridiculous!

    I agree with having pay commensurate with education and experience. And I agree with different levels of expertise and specialty within the nursing profession. But I want some kind of clear delineation between each level, and the education required thereof.

    There is room for all of us certainly. We just need to have someone make a specific outline of each of our places within our profession.

    Kim, I nominate you!



  • marachne

    September 20, 2006 at 8:37 am

    I’ve been watching this change in AP nursing with close interest too. I agree, I think some of it has to do with the sense of inadequacy that the nursing profession/discipline has felt.

    The other thing that bothers me is one of access, both for the practitioners and the patients. In rural areas, much of the primary care is provided by nurses (here in Oregon, an NP-run clinic, which grew out of the nursing school, is the main primary provider in an eastern part of the state. If you ask for a higher level of education, it will put it that much further out of reach for people who are from rural areas — the people who, in the long run are the most likely willing to stay and practice in rural areas. And these higher-educated people will want more money, making them less accessible for the people who need them the most and can afford the least.

    And don’t get me started on the decision to phase out CNS.

    One thing I do disagree with you on is that “you might as well send them to medical school and call them doctors.” The nursing model is not the medical model. It is a more wholisitic approach. It doesn’t try and just “fix” a problem, but looks at the whole context: physical, psycho-social, environmental, etc and tries to both help people with their crisis/illness and empower them to maintain the best possible health. You may not see that so much in the ED, but in a lot of nursing that’s the heart and soul of the practice. Doctors are great, and do wonderful things, but NP/APNs, whatever you want to call them are a different breed, and bring a different mindset to healthcare and healing.



  • medrecgal

    September 20, 2006 at 9:04 am

    Ouch…as if people aren’t already confused enough about the hierarchy in medicine! Personally I think the whole healthcare system needs a complete overhaul; calling advanced degree nurses “doctor” will not help the problems. It will just make practitioners and patients even more befuddled by a system that–as you suggested–needs to get itself back on the right track and recruiting more people into the (nursing) fold before trying to change the stakes and add another level of advanced degree practice.

    I agree with the person who commented above regarding the differences between the nursing model of care and the medical model…I can see those differences after several years as a patient in a medical practice that employs an NP. She doesn’t have the same mindset as a physician, and yet the care provided is just as thorough and competent. And she’ll actually take the time to answer any sort of questions you might have. It’s a different–and vital–perspective.



  • Candy

    September 20, 2006 at 9:13 am

    It’s the “a rose is a rose” problem all over again. LPNs and RNs are both nurses, but what do you call a person with a PharmD? A pharmacist. Not a doctor pharmacist. And a DPT? Still a physical therapist. There’s no confusion between that person and an MD who specializes in rehabilitation. If we can’t agree on what who we are, why should we expect our patients to know? When housekeeping comes into a patient’s room wearing the same scrubs that CNAs, LPNs and RNs wear, should we be surprised that the person in the bed doesn’t know who’s who? Even with color coding, how does the patient know on first glance? When a person enters a patient’s room wearing a white lab coat (even over scrubs) or in street clothes, patients think it’s a doctor, even when it could be the case manager.

    I think a lot of this discussion has to do with protecting turf, but I agree with Kim that we’re working it backwards. First, we have to determine where we need to start. Should we have tiered levels of practice, from the LPN to ADN to BSN, then up? Should we make it easier for anyone wanting to become a nurse to get into a program? Should there be a common curriculum and pathway for these practitioners to move from one level to another, to ensure that everyone is prepared in the same way? We already have a mish-mash of practice environments, depending on region, facility size and regulation. Wouldn’t it make sense to lay out a plan that allows for nurses to progress, including different advanced practice specialties? Earning an MSN does not necessarily mean you can be a CNS — but both have advanced degrees in nursing. We need to differentiate advanced “practice” from advanced “education,” and determine what level of education is necessary to make the practice part work. If I went through an NP program, for example, that took 4 years after my BSN (the same amount of time, incidentally, that a dentist attends graduate school), I’d want a doctorate degree.

    And here’s where I’ll put my foot in the boiling water — for the NPs who say they don’t want to be doctors, who maintain they are nurses with advanced degrees, I have an observation. If you are an NP working in a physician’s office, you are working as a doctor. You are, in most cases, seeing patients as a primary care provider (like a doctor), writing scipts for everyday meds (like a doctor) and interacting with patients to encourage and provide wellness and healthy living information (like a doctor AND a nurse). If it looks like a duck…is it something else?

    The confusion is hampering our ability as a profession to perform at our optimum level. The infighting is not good and only serves to keep people out, not pull them in. Who wants to get into a pissing match with someone who’s arguing semantics, not substance?

    It’s true a rose is a rose — and look at the wide variety of plants that fall under that name. Can’t we find a way to better define what “nurse” means that’s inclusive and not exclusive?



  • Bardiac

    September 20, 2006 at 10:34 am

    I’m not a nurse, but an academic, so I have more questions than not. In most fields (medicine being an exception), a doctorate is a research degree; originally the term “doctor” indicated that one was qualified to teach–and research–at the college/university level in one’s field. (Aren’t there already doctorates in nursing? How would this be different, if so?)

    If a doctorate of advanced nursing degree is imagined as a research degree, then the person would be qualified to research nursing (marachne did a nice job explaining a way of seeing nursing as different from medicine above; is his/her distinction acceptible? If so, does that make doing nursing research make sense separate from medical research?). Does that mean that the push for the doctoral degree is coming from nursing faculty at colleges/universities where the administration values or demands a terminal degree (and, perhaps, pays accordingly?)?

    At my school, nursing is one of the few programs where faculty don’t necessarily have something that looks like a terminal degree to folks outside nursing. (We also have more students who want to be nurses than we can educate and stuff, which stems from state funding choices, ultimately. The state isn’t willing to educate enough nurses.)

    I’m trying to understand how different this is from people who get a social work degree (BA, BS, MA, MS) and go do good social work but who don’t go through a doctoral program (which is supposed to teach them to research and qualify them to teach–though many fine college/university teachers have masters degrees, competition makes that less and less likely these days).



  • marachne

    September 20, 2006 at 11:05 am

    Well I can answer this one — I am currently in a doctoral program in nursing, and yes, the focus is research and teaching (although, until recently the teaching part was given pretty short shrift, but that’s true of most doctoral programs in many disciplines — which is pretty lousy for the students who have these professors). PhD’s in nursing are relatively new — maybe 20 years or so. It’s partly a reflection of the history of nursing education: originally there were only diploma programs connected to hospitals, only later did programs become associated with academic settings. It’s true of the medical profession in general though, as until the late 19th century in the country medical schools would take anyone who could pony up the money. We’re talking apprentice model which has its good and bad points.

    The other difference, until recently was that nurses didn’t go straight through to advanced degrees but went out and practiced before becoming advanced practice nurses — one of the other controversies is the new direct-entry AP programs: if you have a bachelor’s in something else, you can do a compressed BSN program and go directly into some AP programs. Members of the community were concerned that without that practical, hands-on practice people would be providing healthcare, prescribing, often unsupervised with very little experience.

    So, the new DNP would be an advanced practice degree, much like, as was stated above: Dentistry (DDS), Pharmacy (PharmD), Psychology (PsyD), Occupational Therapy (OTD), Physical Therapy (PTD) and Audiology (AudD) offer practice doctorates. There are other advanced practice degrees out there CNS or clinical nurse specialists who tend to do a lot of education, but within the hospital setting, admin focused degrees, Masters of Public Health/Community Health Nursing (the MPH part is not strictly a nursing degree, but it has a fair number of nurses in the field). These folks look a lot at health on a systems/community/ epidemiological level.

    According to the AACN (American Association of Colleges of Nursing): “Some of the many factors which are emerging to build momentum for the move to the DNP include the rapid expansion of knowledge underlying practice; increased complexity of patient care; national concerns about the quality of care and patient safety; shortages of nursing personnel which demands a higher level of preparation for leaders who can design and assess care; shortages of doctorally prepared nursing faculty, and increasing educational expectations for the preparation of other health professionals.”

    The new DNP will have a higher requirement of supervised practice hours then the current AP nurses – over 1,000 hours. Also, while there are specialty NPs now (peds, gero, family, adult, mental health, midwifery, anesthesiology), there will be the potential for higher levels of specialization. Sorry for going on so long. As I said, I have very mixed feelings about this decision, but it looks like it’s going forward despite turf wars (both the AMA and the National Council of State Boards of Nursing have thrown in their two cents), and other disagreements.

    If you really are interested in some of this stuff, you can check out http://www.aacn.nche.edu/dnp/



  • marachne

    September 20, 2006 at 11:11 am

    Oh, and in reference to the his/her. I’m a girl.



  • PaedsRN

    September 20, 2006 at 2:12 pm

    Bardiac: there are already a number of doctoral programs available to nurses. Some are research-oriented, some clinically-focused. I think the issue here is _requiring_ doctoral level preparation for certain streams of what the AACN, in rather snooty tones, likes to refer to as “Advanced Practice Nursing”.

    Doctorates in nursing are problematic, because there is little recognition of them in terms of financial compensation or scope of practice. As you can see from some of the comments on this post, there is also significant resistance to higher education for nurses to be endured from colleagues!

    I don’t have any problem at all with doctorates in nursing science, clinical practice, research, or any combination thereof. I rather think I might do one myself at some point, if the right program and in particular the right supervisors were available. However, to attempt to mandate this concocted DNP qualification is nonsensical and completely unnecessary. I like the way these folks put it:

    “Finally, we have two graduate degrees that are well understood by our public and that have thrived – the MS and the PhD. Both of these degrees are based on science and driven by practice. Why are we creating yet another degree that requires certification and accreditation? We have the educational programs that create equal partners in the scientific arena. Let’s make these programs stronger and our science more influential.”

    (from The Case Against the DNP: History, Timing, Substance and Marginalization, http://www.medscape.com/viewarticle/514544_1 )

    Kim, y’know I love ya, but I have to take issue with you on one point: I don’t think the idea is to make it easy for RN’s to transition into what the AACN would like to think is ‘advanced practice’. I don’t want to be an NP! To me, advanced nursing practice is about looking deeper, understanding more fully the forces that affect patient care, and being able to carry awareness of them into my work. Making better decisions. Coming to the right conclusion faster. Recognising the qualities of my team and working with them more effectively.

    My message, I think, is basically the same as yours: the function of nursing leadership should be to acknowledge what you have now, then work to make it stronger. I don’t think they have ‘doctor-envy’, but I agree about the enema. Phosphate ok with you? 😉



  • FRECTIS

    September 20, 2006 at 6:00 pm

    BRAVO! I have an absolutely useless associate’s degree in midwifery that allowed me to get licensed as a direct-entry midwife. I have decided to head toward nursing school and hope to come out on the other end a MSN nurse-midwife to expand my scope and facility options (right now I’m home birth only which I enjoy very much). Now I’m in this community college where the ADN waitlist is now taking the students who are in the #500 range. A woman I met today is in the #1300 range. She expects to have her name called in THREE YEARS. I have two years of prereqs and then a three year wait plus a bridge ADN to MSN-CNM program of three years (quickest option) or BSN-MSN-CNM.

    I’m wondering if I’m not better off heading to a biology degree and heading to med school. I’d finish within the same time frame without waiting around! Sheesh. Or maybe I’ll work at the Gap.



  • jen

    September 20, 2006 at 7:52 pm

    crest whitestrips rock!

    Bravo on deciding to go further! Laura Gasparis says that anger is what makes it happen!!

    I just want to be a bedside RN, but I want more money to do it………I can make as much money travel nursing as an NP makes in a year without anything out of pocket. this frustrates me ALOT.

    This is an excellent post! I agree to fix things first, before jumping into a whole new ball game.



  • Melissa

    September 20, 2006 at 8:39 pm

    Great post. Thanks for the laughs.



  • Candy

    September 21, 2006 at 7:17 am

    Frectis, don’t work at the Gap! Your mother will have to pay your rent (oh, wait, that’s me and my daughter).

    Depending on where you live, if you want to continue to be a midwife and the ADN wait is too long, get your degree in biology, then apply to an accelerated entry level master’s program. That will get you your RN after the 1st year of the program, and your MS and midwife specialty 2 years later — and you’ll be able to continue working as a midwife while you’re going to school.



  • Sid Schwab

    September 21, 2006 at 8:45 am

    Eventually, as the weirdness builds up all around, the time comes when you just have to put your head down and do your work and ignore all the stupidity. He says. It only worked for me for a while, after which I couldn’t take it any more…

    On the other hand, if everyone used the MOM toothpaste, it’s be less often that you’d have to tell someone “Hey, you have some sh@t between your teeth.”



  • FRECTIS

    September 21, 2006 at 6:00 pm

    Candy– thanks for the new pathway idea (like I need another one to keep me up at night, LOL!). I live in an backassward state that won’t allow me by statute to be a nurse AND a midwife without being a nurse-midwife. Gah. I’d have to surrender the midwifery license in favor of the nursing license while working on the grad specialty. I have a while to go before arriving at that crossroads decision so I will plug away. Wow, what a great idea. Now I will never sleep. LOL……… btw, I’d never make it at the Gap: I don’t care what you want to wear 🙂



  • Bardiac

    September 21, 2006 at 6:46 pm

    Thanks for the explanations; I’m beginning to understand my confusion, and the complexity. WOW.



  • NPs Save Lives

    September 22, 2006 at 6:56 pm

    Kim, Congrats for deciding to further your degree. As you know, I am currently in a Family Nurse Practitioner program right now. I have been on the fence about the DNP degree for a while. I do think that the degree should be available but not required as the entry level. All of the replies are very well thought out and I will have to sit down and compile a response on my site when I have the time. Great post!!



  • sandy

    October 7, 2006 at 8:07 pm

    I have just retired after 34 years of bedside nursing.
    When I get to be a patient, which may be any time now, thanks to the 34 years of bedside nursing,
    I hope the nurse responsible for my care has had the benefit of several years of “hands on” experience.
    I don’t think NURSING needs more PHD’S/DNP’S .
    It needs more people who simply CARE about the individuals they are responsible for and have average intelligence. I know this is a heretical statement but an advanced degree in nursing by no means guarantees better patient care or outcomes. If I should , at some point , be under the care of a NP, I hope it will be one who at least had several years (NOT 1000 HRS) of direct/bedside patient care. Anyone who simply collects CAPITOL LETTERS after their name may be academically qualified to do the job, but I sure don’t want them anywhere near me as a patient.



  • Timbo

    October 14, 2006 at 2:16 pm

    I was just at a open house at the my nursing school. I am currently in an ANP MS program that takes 2 years full-time or 3 years part-time. I went to sessions to hear more about the PhD and the DNP programs. I can’t understand what is going through their heads, but I think it’s realted to insecurity. First they tell us, in the MS program, that we complete so many credits it is equivalent to a Doctorate in other fields (e.g. PT) and then they tell us they want to eliminate the MS program and institute the DNP program that will take 4.5 years of full-time study to complete!!! Most of the people pursuing the NP program are 27 or older and have a family and a house payment. There is not way in hell I could justify going to school for 8.5 years, 4 years for BS plus 4.5 years for DNP, to work as an NP. I have to save to retire some day, and I need to provide benefits for my family. Since the DNP will not in any way increase the scope of practice of an NP employers have absolutely no reason to pay DNP nurse practitioners more than MS preparted NP’s. I don’t know how the people who thought this thing up expect adults to take 4.5 years out of their lives for no reward. But their answer is people don’t go into nursing to make money, and it will “make you feel more confident in your abilities” if you have a DNP behind your name. I’m sorry but 2.5 more years spent in school is 2.5 years of lost income, and probably 2.5 years of additional work before retirement. Apparently all of the people dreaming this stuff up have spouses who take care of all the bills and would do their jobs for free if they had to, since money doesn’t mean anything to them. If I was going to invest 2.5 more years in school I better get some reward for it or I might as well get a law degree, which only takes 3 years, and be an agency nurse on weekends for fun.
    I predict that once this program goes into effect enrollment in NP programs will drop off by 50% because the educational time requirements will have become so ridiculously long. This will lead to even fewer nurses qualified to teach and make the entry level nursing shortage even worse. These academics are really out of touch.
    To suggest that people go to graduate school without the thought of increasing their earning potential is naive and laughable to me.
    The only people I know who go to school without the thought of increasing their earning potential are either trust fund babies or people who are already retired


About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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