According to the American Association of Colleges of Nursing (AACN, 2008), 34 states and the District of Columbia currently offer doctor of nursing practice (DNP) programs in the United States. Presently, states with the highest enrollments are Florida, Minnesota, New York, Pennsylvania, and Texas. Ninety DNP programs were available at nursing colleges and universities in 2008; only 53 programs were up and running in 2007. More than 3,400 students were enrolled in DNP programs in 2008. This reflects an 82% increase in DNP enrollment in the previous year, 2007. The number of graduates tripled from 122 in 2007 to 361 in 2008 (AACN, 2008). Several DNP programs are in the planning stages and more than 200 nursing schools nationwide may offer the DNP degree by 2015 (AACN, 2009).
Recently, the National Board of Medical Examiners (NBME), an independent, not-for-profit organization that provides examinations for various healthcare professions (since 1915), developed a voluntary DNP certification examination for one group of advanced practice candidates-NPs. The examination is based on the same test that physicians take to qualify for a medical license. The intent of the NBME was to establish a national standard for DNP-NPs.
The NBME began administering this NP examination in the fall of 2008. The DNP examination is based in part on Step 3 of the U.S. Medical Licensing Examination. Step 3 is the final phase of physician testing. The Council for the Advancement of Comprehensive Care, a nonprofit nursing group, contracted with the NBME to develop the examination. Fifty percent of the DNP-NP candidates who decided to take the inaugural certification examination received passing scores (American Medical News, 2009).
There are some proponents in the nursing community. In an article titled "Making Room for 'Dr. Nurse,'" dated April 2, 2008, in the Wall Street Journal, Mary Mundinger, Dean of Columbia University's School of Nursing in New York, stated that DNPs were being educated to have more in-depth training than physicians in patient care coordination and in many primary and specialty areas in which the Institute of Medicine had concerns for disparity and access to care. Columbia's 2-year DNP program currently includes a 1-year residency and prepares nurses with more knowledge, training, and skills than the current NP master's degree programs, according to Mundinger. Dr. Mundinger supports this voluntary DNP examination for NPs.
Part of the confusion is that the DNP is an academic degree. The DNP is not a "clinical" option. The DNP is therefore available to nurse practitioners, nursing administrators, nurse midwives, nurse anesthetists, clinical nurse specialists, and others. DNP programs will be eligible for accreditation by the Commission on Collegiate Nursing Education. The Commission on Collegiate Nursing Education also collaborates with specialty-accrediting agencies through the Alliance for Nursing Accreditation.
OPPOSITION TO THE DNP-NP EXAMINATION
Several advanced practice groups immediately responded in opposition to the volunteer DNP examination. These organizations included the American Academy of Nurse Practitioners (AANP), the American College of Nurse Practitioners (ACNP), and some specialty groups with the American Medical Association (AMA). In testimony at the AMA reference committee, several doctors argued that there is an appearance of equivalency between DNPs and physicians. One AMA member stated that the NBME went back on its promise to clarify that the DNP examination is not equivalent to the process involved in physician certification.
In 2008, the AANP wrote a response to the Wall Street Journal article delineating several reasons for not supporting the NBME certification examination for DNPs. First, there are currently psychometrically sound NP national certification examinations. Second, these examinations are based on "comprehensive assessments of NP practice and will be adapted to reflect future practice of the certificants" (AANP, 2008). Third, the AANP is also not supportive of plans to add another layer of certification for DNPs because it is a barrier to practice. Fourth, the AANP does not support the NBME's credentialing or regulation of a nursing role-NPs. "The DNP presents a normal evolution of our discipline and is based on the reality that master's-level NP programs have already expanded to incorporate all of the necessary clinical content to the point that they are more equivalent to a doctorate than a master's degree" (AANP, 2008, p. 1).
The ACNP echoed similar sentiments in its response to the Wall Street Journal article dated April 9, 2008, stating that NPs are not physician practitioners. The ACNP also remarked that the NBME is medicine-based and therefore is not the group to measure "nursing professional expertise" (ACNP, 2008). NPs should be evaluated by existing national board certification examinations.
In June 2009, at the AMA House of Delegates Meeting, several groups were in direction opposition to the DNP equivalency examination. These groups included the American Society of Anesthesiologists, the American College of Emergency Physicians, the American Society of Plastic Surgeons, the College of American Pathologists, and the Indiana delegation of the AMA (AMA, 2009, Resolution 301).
OUR OPINION
Nursing doctoral programs are not new. One of the first practice-focused doctoral-degree programs was the doctor of nursing degree at the Case Western Reserve University. This program was established 30 years ago, in 1979, and program offered an entry-level nursing degree. No "equivalency examination" was necessary then and none is necessary now.
According to AACN (2004), "it is reasonable to endorse a plan that will permit practice-focused programs to focus on any area of advanced nursing practice that influences health care outcomes for individuals or populations, while adhering to a consistent set of standards regarding areas of core content, supporting resources, student qualifications, and faculty expectations" (AACN, 2004, p.~1). An equivalency examination is, therefore, irrelevant.
Educational standards and indicators of quality for the DNP are being developed, competencies for the clinical educator and faculty roles are being identified, and the AACN is addressing the migration of preparatory programs from bachelor of science in nursing to DNP and the implications regarding certification and licensure. Finally, an interprofessional work group has been formed to examine the potential outcomes resulting from employment of DNP graduates in healthcare arenas including cost-effectiveness, impact on processes and outcomes of care, and priority areas for utilization.
In sum, the DNP is a degree for ANPs. The NBME DNP examination is therefore unrelated, extraneous, and immaterial to advanced nursing practice. NPs do not need another examination. Moreover, an examination for the NP would add yet another layer of certification, resulting in a barrier to clinical practice. For these reasons, advanced practice nurses do not support credentialing or regulation of the ANP profession by the NBME.
K. Sue Hoyt, RN, PhD, FNP-BC, CEN, FAEN, FAANP
Jean A. Proehl, RN, MN, CEN, CPEN, CCRN, FAEN
Emergency Nurse Practitioner St. Mary Medical Center, Long Beach, CA (Hoyt)
Emergency Clinical Nurse Specialist Dartmouth-Hitchcock Medical Center Lebanon, NH (Proehl)
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