Angelite Nurses

Physicians are concerned that the move will lead to scope-of-practice expansions.

Starting this fall, doctor of nursing practice graduates will be able to take a certification test that proponents say will set a national standard for DNPs and add to the profession's credibility.

The voluntary test, being created by the National Board of Medical Examiners, is based on the medical licensing exam. It will be offered at a time of growing momentum in the DNP movement: About 200 nursing schools are expected to offer the two-year DNP degree by 2015 -- more than double the programs available today.

Test proponents said the DNPs, called "doctor nurses" by some in the nursing profession, are comparable with primary care physicians in their diagnostic and disease-management skills.

But physicians expressed concerns that DNPs will use the test as leverage to seek scope-of-practice expansions that cross into medical practice.

"Why would they get a DNP unless they want to do things that are currently not in the nursing scope of practice in most states?" asked AMA Board of Trustees Secretary William A. Hazel Jr., MD. "It makes sense they will want to change their scope."

The AMA and the American Academy of Family Physicians said they support advances in nursing education but emphasized that nurses should operate as part of a health care team under physician supervision. Dr. Hazel said there are important distinctions between DNPs and physicians that the public should understand.

"I do not want to be construed as attacking nurses, but there are concerns," Dr. Hazel said. "There's a difference in training that should not be overlooked."

In April, the nonprofit Council for the Advancement of Comprehensive Care contracted with the NBME to create the exam, which is expected to be offered in November.

Mary Mundinger, DrPH, speaking for the council, said the goal is for a national standard that distinguishes DNPs who have an advanced clinical knowledge from those who have an emphasis in research, administration or systems management.

"While a primary care physician went to medical school and did residency, a nurse practitioner with a DNP has achieved many of the same competencies but through nursing education," said Mundinger, who also is dean of Columbia University School of Nursing in New York City. "They have the same skills in identifying a disease state and treating it, but it's a different hybrid of care."

Using a similar test

Richard Hawkins, MD, NBME vice president for assessment programs, said the test will be based on Step 3 of the U.S. Medical Licensing Exam, the last level in the test series.

"We're a testing organization, and this fit our mission," said Dr. Hawkins. The NMBE develops assessments for health care professionals in general, not just for physicians.

Mundinger said about 75 graduates qualify to take the DNP certification test. Once nursing schools finish their program expansions, she expects there will be at least 2,000 DNPs graduating each year. Candidates must first complete a master's-level nurse practitioner degree before they begin a DNP program.

Though DNPs have a year of residency as part of their two-year program, Dr. Hazel said, it is important to recognize the difference between physicians' and nurses' residencies.

Residency, DNP style

DNPs' residency year entails 1,000 hours, Dr. Hazel said. Medical residents work 80 hours a week, racking up about 4,000 hours their first year and approximately 12,000 hours over three years, he added. In addition, patients could easily confuse these nurses with a licensed physician.

"Let's make sure they make the distinction between a doctor of nursing and medical doctor," Dr. Hazel said.

At press time in early June, the AMA House of Delegates was expected to consider a resolution to endorse policy that the title "doctor" be used only by licensed physicians, dentists and podiatrists in a medical setting. The resolution also sought to have the title "resident" apply only to individuals enrolled in a medical, dental or podiatry training program.

Another resolution sought to oppose the NBME's development of the certification test and to urge the Association to adopt policy that DNPs practice under physician supervision.

AAFP President James King, MD, said that although these nurses pass a test similar to the one for medical school graduates, that does not make them physicians.

"I don't think they can replace family physicians," Dr. King said.

"If they are sincere in saying they are going to contribute to easing the physician work force shortage, they'll work as part of a team, not leading that team," he said.

Mundinger said the nursing degree and test do not alter existing scope-of-practice rules, but as DNPs demonstrate their expertise, she expects that scope to change.

"The more nurses prove they can do certain things, the more likely it is legislation will follow, but there is no direct link between certification and what nurses [legally] can do," Mundinger said.

Working with physicians

Richard Mulder, MD, is a family physician in Ivanhoe, Minn., who has worked with Dawn Bucher, DNP, since she was a registered nurse and then a nurse practitioner. He said her level of expertise as a DNP has eased his workload.

On days she works, he feels free to do hospital rounds or take a coveted day off.

He is confident that patients will be well taken care of by Bucher. He and his partner set her prescribing formulary and have given her unrestricted prescribing authority.

Bucher said the biggest impact her DNP degree has had is how she thinks about patient care. She looks for ways to better meet patients' needs and coordinate their care.

"We're all about patient care," she said.

Bucher does not introduce herself as doctor. When the voluntary DNP certification test is available, she plans to take it.