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Letter to the Editor

Reply by Jan Fulton and Brenda Lyon on "The Need for Some Sense..."

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March 27, 2006
reply by authors in response to letter by Lori L. Ellis on The Need for Some Sense Making: Doctor of Nursing Practice by Janet S. Fulton, PhD, RN; Brenda L. Lyon, DNS, RN (September 30, 2005)

Thank you for the note responding to our article "The Need for Some Sense Making." We wrote the article in the spirit of provoking more universal discussion and debate within the profession. The existence of programs carrying the same DNP title yet with very different purposes, foci and student outcomes presents a confusing picture within and outside the profession. Additionally the existence of DrNP programs, vocalized the same as DNP - "Doctor of Nursing Practice," that greatly differ in purpose, focus and outcomes not only from the DNP but also between DrNP programs, is also confusing. There is no internal consistency in DNP or DrNP programs. Schools jumped on the bandwagon for the DNP without a consistent purpose and set of expected student outcomes and without data to support a public need for the degree.

As for the rationale for the DNP in your response, we are concerned that some fundamentals involving the education and regulation of nurses are not well understood, creating problems with the logic supporting the DNP. One such fundamental involves the notion of independent practice. It is fairly common that the notion of "independent" practice is not well understood. Within the regulatory arena a license to practice – in any profession or trade – is by nature a license for an independent scope of practice – that is "self-directed." The scope of nursing that an RN may independently provide is defined in state statute and varies only slightly from state to state. Although all statutory scopes of RN practice include a delegated scope of practice (thus dependent on physician) for RNs to implement regimens prescribed by physicians, all RN practice acts contain a broad independent scope of practice including assessment, diagnosis, and nursing therapeutics/interventions (wording varies slightly from state to state). All holders of an RN license are legally responsible and accountable as independent providers of nursing care. In noting that there is an advantage of the DNP over the PhD for NPs in independent practice, your response confuses an academic degree (DNP) with state laws authorizing a scope of practice. Obtaining a DNP will not change scope of practice for the holder of that academic degree – an NP with a DNP will be held to the same legal scope as an RN and an NP if the state provides an for a separate scope of practice for NPs.

Your response notes that the DNP will assist NPs in receiving reimbursement from managed care. Reimbursement for what? For the delivery of the same service that physicians provide? Physician scope of practice includes the diagnosis and treatment of disease. Are you seeking to have nurses scope of practice be similar to physician’s scope of practice? If the DNP is the degree that will move nursing education closer to the physician’s scope of practice, does the focus of the DNP then become education in the practice of medicine?

Within the nursing profession there are groups that are diligently working to codify nursing practice into standardized language for the purposes of reimbursement of nursing care. While you may have "no aspirations to be a nurse researcher" it is not logical to assume that preparation with a nursing PhD is inappropriate for practice. It is, for example, the skills of the researchers that are driving the codification of nursing care for reimbursement – an agenda that will make nursing’s independent scope of practice visible as well as legitimize payment for nursing care both within health care institutions as well as in private practice settings. Given the misunderstanding of the notion of "independent practice" and because the DNP is being developed without data to support either the need for this academic degree or the curriculum for the degree, or the contributions of the graduates to the development of nursing (beyond extending into the scope of practice of medicine), it is difficult to project the outcomes that persons prepared with a DNP will have on nursing practice and the cost-benefit for DNP graduates relative to a career trajectory. Students in DNP programs may not be aware of the misgivings about this degree within the profession and may be making career decisions that do not hold the long term promise that was advertised.

Jan Fulton and Brenda Lyon

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