Shoring up the foundation

Not so long ago, I wrote a piece about the push to require a doctorate for nurse practitioners entering the field in the coming years.  I remain skeptical that a doctorate will add much to NPs clinical expertise, with which I am already sufficiently impressed to question the need for more training.  For those who want to pursue a more academic, research or administrative career, a doctorate probably confers a lot of benefit.  But I question the benefits of making it required for clinical practice.

Anyhow, as I mentioned in that piece, I work with three NPs.  All of them have extensive experience in clinical practice at some of the world-class medical centers in the area, and one of them teaches nursing students at a prestigious local college.  I have tremendous respect for all three, and was curious to know what they thought of the push to require a doctorate for clinical practice.

All expressed some degree of skepticism about requiring a doctorate to practice.  The one who has been with the practice the longest did express some interest in eventually pursuing a DNP, but primary for the purpose of advancing her career in a more academic direction.  Similarly, the one who teaches nursing students indicated that it might be something she’d consider in the future, but from what she understood of the DNP program at the college where she teaches, the curriculum is geared more toward theory than clinical practice.  As such, she had little interest in the degree at this time.  The third expressed little interest at all.  None seemed to think that there was a deficit in the master’s-level clinical training they’d received that would be corrected by getting a DNP.

What I found most interesting, however, is that two of them talked about the problem with training at the lower end of the nursing profession.  Rather than focusing on a push for doctorates in the upper echelons of nursing care, they expressed concern about the ongoing issue of what training is sufficient to call one’s self a “nurse,” and who gets to administer what kind of care.

At the lowest end of the training spectrum (excluding non-nurse personnel like medical assistants or nurse’s aides) is the licensed professional nurse (or, in some states, vocational nurse), or LPN.  While training programs vary, with different states having different requirements for licensure, most are about a year long.  A high school diploma (or GED) is usually required for enrollment, and graduates must pass the NCLEX exam in order to obtain a license.  Most LPN programs are offered by technical or vocational schools.

A step up from an LNP is a registered nurse, or RN.  Whenever I’ve worked in settings with both LPNs and RNs, the RNs have had greater clinical responsibility, which makes sense given their additional training.  What I didn’t know until I spoke with the NPs in our office is that an RN alone is an associate’s-level degree.  I had assumed (incorrectly) that an RN was additional training on top of a bachelor’s degree.  RNs must pass a different version of the NCLEX for licensure.  Many RNs do get a bachelor’s degree in nursing, which explains why they have “RN, BSN” on their name-tags.  (Insofar as I ever gave it any thought, I must have assumed the non-BSN RNs I’d worked with had gotten their bachelor’s degrees in something else, which seems pretty idiotic in retrospect.)

Both of the NPs who discussed the issue with me expressed frustration that someone who has only completed a one-year training program could (varying on the state) have similar clinical responsibilities to a person who has a bachelor’s degree, and that within the medical community there is no perceived difference between “nurses.”  An LPN who gives shots and collects vital signs is the same as a highly-trained nurse who administers chemotherapeutic agents into the central nervous system.  This wide disparity between levels of training and expertise leads to a lack of respect for the profession as a whole.  Both expressed the opinion that a bachelor’s degree should be required to call one’s self a nurse.

My only qualm is that I know there is a nation-wide nursing shortage.  On its merits, I agree that nurses should all have baccalaureate degrees.  Any good doctor (who isn’t an ass) will tell you that good nurses make all the difference in patient care.  In a crisis, give me a good nurse over a mediocre doctor any day.  But there is to be this requirement for entry into the profession, then there must also be policy to address the shortage.  Budgetary support for nursing training programs and faculty is vital (though good luck getting that increased funding in this economy).  In the end, however, I agree with my colleagues that giving all nurses the proper training is far more important than requiring a doctorate from medical providers who deliver great care without one.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.

One Comment

  1. Dr Saunders,
    Your conclusion makes me think this is why we need more Doctorate level nurses who can lead the PROFESSION of Nursing to a higher level and standard. We as nurses need to define our levels of practice in a more coherent manner. As you mentioned in your blog , there are many ways to educate a “nurse” . ..but what type of nurse are we talking about? My mother in law was a nurse and was “trained” in a hospital. I got my Bachelor’s Degree in Nursing, then got my Master’s Degree. Other nurses get Bachelor Degrees then return for their RN and other ‘s get Associates Degrees in nursing. They are all nurses. That is why I occasionally cringe when I am called a nurse even though I have been a Master’s Educated Nurse Practitioner for more than 20 years, before that I practiced nursing 7 years in a major academic center . There are too many “nurses” with different training and degrees. There needs to be a standard set for minimal education for each level. Each level should have its own name. The crazy thing is that even if I got my Doctorate, I would still be called “Nurse”….

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