I just read an article regarding nurses calling themselves “doctor.” It appears that physicians are upset about the whole DNP situation, and are about to put up a fight. After reading the article I had more questions and frustrations than ever! I think this directly relates to the (awesome) discussion that was started two posts ago, regarding the Future of Nursing report by the IOM.
My first question: why are physicians more involved in the fate of nursing than nurses? I have tried not to let this get under my skin, but now it’s starting to itch!!
My second question: were these challenges anticipated when the powers that be decided to create the DNP and then make it mandatory as of 2015?
My third question: why have we still not found a solution to the entry-level-of-practice-for-nurses question?
Unfortunately I was left with far more questions than ideas after reading an article by a Chicago law firm for medical malfeasance, or the lawsuit info about Xarelto and what troubles can appear if any kind of maplractice taking place, but one thing I thought of is, couldn’t physicians be called “physicians” and nurse practitioners be called “nurse practitioners” and PAs be called “physician assistants,” etc.? If someone introduces themself as “Dr. So and So” that would reflect their educational background/degree, and then they would immediately clarify their role. I, for one, prefer to be called “Jane” by my patients, but I always let them know that I am a nurse and certified diabetes educator. I’m not sure what outcome(s) we’ll see from this physician-led legislation, regarding who can be called “Doctor,” but it seems that if someone earned a doctorate and wants to be called that, it’s their prerogative. There are a lot more doctors out there than just physicians, after all.
Thoughts?
NurseManifest 
Jane,
Thanks so much for your timely post! I read the article too, which was on the front page of today’s NY Times. Here’s the link for those of you who haven’t seen it yet:
I thought, wow, what a silly fight to pick, for all of the reasons you pointed out. Then I thought, what is the real issue here? Turf? Money? Why the front page of the NY Times today?
Then I searched the term Doctors, Inc. to see what I would find…the first three Google hits were “Best doctors, it’s your health, be absolutely sure…” this turned out to be a site called http://www.bestdoctors.com.
The reality is it’s time to share and work in partnership with all health professionals to optimize care. I hope we nurse providers can speak up more about what we do and how/why it is of value to medical providers. We really can all live symbiotically in this crazy, complex universe.
Wendy (hoping to also have the title Dr. (of Nursing Science) someday soon)
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Hi Jane and Wendy, This topic definitely is getting attention, well over 300 comments on the NY Times article story from their readers and friends from high school that are now MDs are in on the Facebook conversation. The new director of RAND (Arthur Kellermann, MD) gave a lecture at Penn last week to a room full of physicians and talked about the need to utilize APRNs to their full extent to meet the primary care needs of the nation. He also avoided answering a question about whether nurses should train with physicians, emphasizing their distinct disciplinary approach that is more holistic and suited to primary care. At one point he pointed out the over qualification of a board certified emergency physician providing acute care for the 4 most common acute complaints of an upper respiratory infection, urinary infection, skin rash and asthma. Pennsylvania only recently changed the practice laws allowing APRNs to prescribe medication so it’s interesting to see the more narrow-minded comments on-line coming from Philadelphia area patients and providers.
My clinical area is community and public health nursing – when I am practicing in the clinical setting, I am under the RN (registered nurse) scope of practice laws for my state – which means I am an autonomous health care provider who is able and obligated to assess a patient/family/community, make nursing (not medical) diagnoses and work with a patient/family/community to improve their health and wealth being. RNs can also carry out a plan of treatment precribed by a physician or nurse practitioner, but we are not working under their license, we work under our own, and carry our own malpractice insurance. If we “correctly” give an unsafe dose of medication prescribed by a physician, dispensed by a pharmacist, it’s still our fault and we are liable. This is why registered nurses have a reputation for knowing nearly as much as doctors, we don’t – but we can often spot a careless error and know what the standard of care is for the common conditions that our patients live with chronically or at risk for developing. Nurses are responsible for teaching patients about their medications, and monitoring for side effects and the patients response to new medications. See where the overlap in roles happens?
I sat for the RN licensing exam after completing a 4-year Bachelor of Science in Nursing program of study that included 2 semesters of chemistry, 2 semesters of biology, 2 semesters of anatomy and physiology, microbiology, nutrition, pharmacology, statistics, research (focused on being able to critically read the research journals and “evidence” for best practice), plus all the humanities, social sciences and nursing courses. The coursework really is 5 years of full-time study if you take anything extra or don’t have AP credit for the first Biology, Psychology, English, Foregin Langauage course, etc., and this is one argument for nurses having their first degree be at the graduate level.
Back to my path, while working as a home care or visiting nurse, I completed an additional 1 year graduate certificate program in public health nursing (from the University of Colorado). Another 1 year graduate certificate in nursing education helped prepare me to be an effective teacher at the university level. My PhD (Doctor of Philosophy) is in Nursing – a research focused degree was completed after a total of 8 years of graduate studies including a dissertation. I am now in the middle of 2 years of postdoctoral training in advanced research methods, that is the minimum needed before I can reasonably expect to have my research considered for federal funding, or a university consider hiring me for a tenure-track position (meaning I will a chance at a semi-permanent position if I can get federal research grants, publish lots of papers and please my students during 5 year probationary period).
Apart from the research track (PhD or DNSc) there is a clinical doctorate that the article referred to called a DNP (doctor of nursing practice) which has been a pathway for experienced, master’s prepared APRNs to focus on how they can apply their clinical expertise to improve the health of patient populations, either through focusing in health policy (like Yale’s program) or clinical research (like UConn’s program). What is important to realize is the people going through these 1-2 year programs have already completed a 4-year BS in Nursing, worked as an RN often for 2 or more years before being permitted to enroll in a MS (APRN or CNS) program, and has often worked for 5-10 years as a nurse practitioner before starting a doctoral program. These phenomenal nurses are often already in a leadership position where they are employed, and gaining skills and credentials to make them more effective in advocating for system-wide changes that would improve patient care.
Regarding titles… I haven’t worked in the clinical setting since completing my PhD. I always introduce myself by first (or first and last name, and if appropriate that I’m a nurse or postdoc). Unless you introduce me as a student or address me as Miss. Jaron or Yarin it doesn’t really matter. What would really be an honor is to be called Professor, maybe in another 10-15 years I’ll earn that one.
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Dear Olga,
Thanks for your post! You have clearly identifiied the many years of academic and continuing education that is required for a nurse to obtain a doctorate degree and clearly nurses are entitled to be called Dr.. Medical doctors do not have, and are not likely to win a restricted covenant on the title Dr. For example, my local newspaper announced “….Physical therapy group welcomes two new doctors!…of physical therapy” the photos were of two young women, who looked to be in their twenties…
The idea of a practice doctorate with a preestablished timeline is something we can thank our MD friends for, after all it is somewhat based on their model of education ie: 4 years undergrad, then the doctoral program and residency (we nurses call it clinical)… But they are more trained in the disease model and we are trained in the holistic health model…we do have a role and you have outlined it well in your post. In reality we drag it out, we place years of clinical, educational and leadership experience into our real world training…maybe that is why patients/clients trust us so much? What is the value of how most of us nurses get educated? Why do we make it so hard? Does it have to be? I think we can learn from our colleagues. I for one truly respect the amount of work you are putting into you career and believe you deserve the title Dr. Jarrin!
Best, Wendy
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And cudos to all the medical doctors who are supportive and appreciative of nurses as respected colleagues!
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In fact for most physicians, the title of Dr is an honorific one as most do not have PhD’s at all. The title of Dr is primarily for those who have an earned doctorate and it is not the sole preserve of physicians. They need to get over it!
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I remember this subject of conversation from “way back” when I was getting my MSN degree in 1999. The idea was the same; the medical doctors felt that only they should be called “doctor”, but the reality of folks being honored to be called “doctor” for many years of study and development of knowledge, expertise, and (I would add) development of philosophy in a specific are supersedes the physicians desire to be the only “doctors” by a few thousand years. I would say that the MDs issue here is mostly fear-based or ego-based.
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This topic also makes me itchy. As a Nurse and PhD student, I sense the intrinsic questions and threads of power, oppression, and historical construction in this debate. We, as nurses, and as ‘doctors’, cannot continue to let physicians and dominant discourse define us.
It is my understanding that physicians first started using ‘doctor’ to appear more worthy of respect, as was given to PhDs. The common use of ‘doctor’ to describe medical practice is not worldwide. In Canada, and I believe in the USA, medical education is not a graduate credential.
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Sorry – hit reply too soon. Please add this to my original reply
I will watch this ongoing debate closely. It is my hope that it becomes a platform for nurses to raise their voices and power in the public arena.
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Thanks for contributing to the conversation, Mindy!
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Make no mistake, fellow nurses. This is not about diagnostic accuracy, patient safety, or even the risk of confusing patients. It’s about territory, which is about money. And about the dominance that physicians have long enjoyed in health care. Personally, I’m rather delighted that some physicians (far from all) are threatened by us – that shows what power nurses have! We’ve changed health care, and we’re going to change it even more in the future.
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Teresa,
I’m glad you think nurses have power, because sometimes I don’t feel that way. I like your attitude that nurses will continue to change healthcare – only for the better, I hope!
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I’m late to this discussion, but I have a few perspectives to add as a retired dean who was present when AACN voted on the DNP route. The vote was taken by secret ballot since the debate was fierce. Afaf Meleis was eloquent is articulating the problems and unanticipated consequences of this decision. I echo her points and add a few:
1.) the DNP will draw students from PhD programs because it will seem “easier” if one doesn’t have to complete a research dissertation. This has happened; I hear this reasoning from nurses.
2.) Many DNP graduates will be in, or gravitate, to faculty roles in universities. There, the DNP will not qualify the individual for tenure track appointments nor to meet tenure criteria. Our campus colleagues will continue to view the nursing faculty as unqualified. This is happening.
3.) the rigor of DNP programs can be challenged as new programs were quickly added across the country. I do not see rigor.
4) physicians’ complaints about the title are ludicrous. In university culture, it is presumed everyone has the requisite PhD for assistant professor appointment, Once the right to use the PhD/Dr credential is earned (the “union card”), it is no longer a big deal. “Professor” is the currency. Yes, physicians should get over their pique. Some years ago at the U of Cincinnati Medical Center, a policy was adopted that only physicians could the title “doctor.” This was quite an insult to the PhD faculty in the Med Center who were often much better educated. (An aside, in England the title professor, once earned, is for life and is not tied to a particular university, Hmm.)
Since retirement I’ve been focused on the ONE thing I might be able to accomplish that would have lasting value for the profession and the public….raising the educational preparation of the nursing workforce. We’ve been working In Ohio since 2009 toward BSN in Ten legislation. The chief opponent here, incredibly, is the hospital association whose member hospitals benefit from the financial outcomes of better educated nursing staffs. Read the literature; do the math. The Leapfrog Group used Magnet Hospital status for the first time this year in selecting its “best hospital” list. Magnet hospitals set goals for BSNs and have better outcomes than non Magnet hospitals.
Curiously, here in Ohio, the state medical association has thus far ignored the BSN in Ten. No one has replied to my calls or emails. I think they’re focused on advanced practice.
Working on the BSN in Ten has been the most difficult task I ever attempted. It’s a compromise position that exempts current nurses. ??? Are others working on BSN in Ten initiatives? What’s your experience?
A chance reconnection with Peggy Chinn brought me to this blog. I’ll look in again.
Best wishes for change in the new year, wherever it’s needed.
DE
Dr. Doris Edwards RN
Dean of Nursing Emerita
Capital University
Columbus, OH
dedwards@capital.edu
dorisedwards@columbus.rr.com
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Doris,
Thanks for contributing to the discussion. It is sad and disheartening to hear your perspectives, and at the same time I am thankful that you are so dedicated to helping our profession. I look forward to hearing more – Happy New Year!
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Slipping back a few comments, Doris and Jane, have you seen the Dec. 30 Huffington Post article on the BSN in 10 legislation in NY? It came to my attention because it cites a 2003 study published in JAMA by my mentor, Linda Aiken, reporting on the association between higher proportions of nurses with a bachelor’s degree and lower rates of death after surgery. The “value” of nurses with a BSN, lower staffing ratios, the work environment and Magnet status is the focus of the Center for Health Outcomes and Policy Research at the U of Pennsylvania School of Nursing where I am a research fellow. I am happy to share references related to our research (and others working in this area) which may be the “evidence” needed to get the attention of policy makers and hospital administrators.
http://www.huffingtonpost.com/2011/12/30/ny-bill-would-require-bac_n_1176475.html?ref=college
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How wonderful to hear from you on this topic, Doris! You are raising such interesting concerns, and I would love for others to contribute to this discussion as well — particularly others who are working with DNP programs and curricula. This degree is here to stay — too many programs jumped no the bandwagon, in part, I think, because of long histories of resistance from male-dominated academic settings that just could not bring themselves to approve a PhD program for nurses. But that aside, given the fact that it has proliferated so rapidly, I would like to know about ideas to address the issues that you raise here — particularly the quality, and ways to assure that nurses who earn these degrees do indeed make a difference in practice. It is true that we need doctorally prepared nurses in academia – perhaps we will see the day soon when the qualification for clinical supervision of students is the DNP (not the masters) — or is this a good idea????
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Adeline, Olga and Peggy
I, too, believe nurses should be outraged when their education does not receive the same recognition other disciplines take for granted. Peggy, Jo Ann Ashley, Marge Stanton, and Gert Torres would likely explain this phenomenon by the double misogyny that is directed at women in general and nurses in particular in the health care system. Remember, we were born in the church and raised in the army. Obey, forgive
Olga, we in Ohio have based our BSN in Ten case statement on the “collected works” of Aiken and her outstanding colleagues, Estabrooks, Tourangeau and a number of other scholars. The evidence is robust. If anyone wants a copy of the white paper or bib, I can send by email. I wrote the case to make several points for several audiences…that BSNs are needed and that Ohio has capacity to to deliver BSN completion education so I provide a lot of detail in several sections. I’ve been ” a scholar in action” for about a year now and haven’t updated the bib so you may have new sources for me. I’d appreciate any new material you have. I am in contact with colleagues in NY- cheers for them.
We do know, unfortunately, that politics often trump evidence.
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Doris,
Can you post a link to the white paper here?
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Hello Jane
Our work is on the Ohio Nurses Association website. The white paper link is on the Yellow Team page at http://nursing2015.files.wordpress.com/2011/10/upload-2-yellow-team-research-on-bsn-access-3-23-201115.pdf
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Thank you Doris, I’ll share your white paper at work and send you any new references we have. I love how simply you expressed the issue as obey and forgive. Kathryn Fiandt and others here have written about this using the language of Graves’ Spiral Dynamics (color-coded core value stages or worldviews that permeate a culture). To complete a BSN and work with others who also have a BSN almost ensures that the individual and work group values will not be centered in obey/forgive (red-blue) but rather in achievement/pluralism (orange-green). I am not surprised that the resistence to BSN in Ten comes from medical associations – as Fiandt put it, nurses functioning from the blue meme “are fundamental to the smooth functioning of the institution.” This brings to mind the achievements of nurses in California, and makes me think about the nurses striking at Kaiser Permanente late last spring, another controversial issue that is hard to avoid in this conversation. I have long admired the California “Public Health Nurse” title requiring a baccalaureate degree in nursing, or a baccalaureate degree in another subject plus “completion of a specialized public health nursing program associated with a baccalaureate school of nursing accredited by NLN.” Maybe evidence needed is that hospitals and other health care facilities with highly educated nurses can not only have better patient outcomes, but still run at a profit margin, despite higher salary costs. Makes me want to go back in time and chat with Lydia Hall about the Loeb Center in the Bronx, NY.
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Olga, so affirmed to read your comments set in conceptual frameworks. Seems to me, in the hospital culture, power & authority vie with facts & effectiveness. Indeed hospitals can improve the bottom line through a better educated nursing workforce that brings down mortality/morbidity rates in a reimbursement environment that increasingly refuses to pay for preventable mistakes and complications. Would really appreciate any insights from your shop. Lydia Hall approves!
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I am so interested in how this debate is surfacing in the U.S. You may know that in Canada, we not yet have the DNP, although there has been some debate about it in nursing education circles. But the issue of using the title “doctor” arose here 20 years ago when new regulatory legislation was passed in Ontario, restricting the use of the title in the provision of health care to: medical doctors, chiropractors, dentists, psychologists, and optometrists. It is section 33 if anyone is interested in looking at it
http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_91r18_e.htm#BK30
There are a few caveats for naturopathy and Chinese medicine. When this legislation was being proposed, I was part of a lobby to have this changed – there were other egregious restrictions proposed, such as removing health promotion from the nursing scope of practice statement and prohibiting nurses’ use of the term diagnosis, which we were successful in having removed. However, the restriction of the use of the title “doctor” remains through several revisions of the Act. It has always surprised me that nurses seem to have simply accepted it and are not outraged about it!
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This article showed up on my daily news feed for diabetes and I just had to share it here:
http://well.blogs.nytimes.com/2011/12/29/the-provider-will-see-you-now/?ref=health
As always, so much room for education.
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Jane, I read what you posted with interest. I had a eureka moment in the early 1990s when I realized that the turf issues between nurses and physicians were nothing compared to Wall Street’s discovery that there were huge profits to be made in the health care industry-on the backs of those who “care.” Twenty years later, the health industry is bankrupting the country while millions receive no care. The horse has been out of the barn for a long time. Is it too late?
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Yes, the DNP should be able to use the doctor title in the medical setting. The nurse that wants to get their DNP must go to school for 2 years of college to complete basic nursing prerequisites before being able to apply to a generic nursing program. After being accepted that person must then complete another 2 years to get their RN. After that, another 2 years of education to get nurse practioner. And yet, after that another 2 years to achieve DNP. Guess what, that’s 8 years + or – 1 depending upon your entry level and the school you select.
To all those MD out there, and to those who don’t know better, there are plenty of ways to get your MD in 6 years. A lot of MDs completed their degree in just 6 years outside of the United States. After they finish school they come to the United States to sit for USMLE3 and become licensed physicians.
And guess what “Graduates of foreign medical schools now make up a quarter of all the practicing doctors” (http://www.nytimes.com/2010/08/03/health/03doctors.html)
So that means in as many as 25% of MDs, a nurse practioner who is a DNP could have more education than a medical doctor by 2 years.
Oh and another thing, medical doctors are highly specialized after residency.
So, for the ophthalmologist and psychiatrist who cares. Compare the psychiatrist of 10 years to the family nurse practioner of 10 years and see who knows more about treating medical conditions.
Also, some medical doctors would use the argument that medical school is a much more rigorous education process than nurse practioner school. However, they omit what is required to become a nurse practioner. You must be a registered nurse with a BSN. Which takes 4 years, a lot like the unnecessary 2-4 years of prerequisites before being able to apply to medical school (in the united states). In some foreign medical schools it is possible to go into medical school straight out of high school, and then practice in the united states.
Something else I would like to say is, you can’t claim you own a word (doctor) and it can be earned by several fields. Those who have earned the title, are entitled to the title.
DNPs are doctors of nursing, and they do a damn good job at it.
In many cases, better than a medical doctor who may have just went to school 6 years, straight of high school. The real issue here is not the doctor title, nor is it the patients confusion, it is pride and money. MDs and DOs just don’t want competition.
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