Presentations: Setting Context
Welcome
Justine Strand and Cindy Lord: Good evening I'm Justine and I'm Cindy and we welcome you to Atlanta. Than you for taking the time to be here and for bringing your expertise and your open mind to this important conversation. It's monumental to be here and I feel honored to be here as well. This is an emotional topic and I feel very proud that we are handling it in this way.
We feel this is moving forward in the right way. We're very appreciative of you taking the time to be here. We're very excited and we have open minds. We appreciate the great group of folks and the different perspectives that are here as well.
Let's move on.
Timi Agar Barwick: I'm the Executive Director of PAEA. This evening we'll be hearing from two speakers. These speakers represent two important perspectives on this issue. The first speaker is Polly Bednash. Her group spearheaded the discussion for the nursing community. Then we will hear from one of the physician groups in the military that moved to a doctorate program.
Nursing: Polly Bednash
Good evening everyone. Thank you for being here and inviting me. I understand the journey you are going through and we've gone through it. I want to say I appreciate the opportunity to work with Timi. She's an important colleague and we work together to provide the best care for people in this country.
Timi asked me to talk about why we decided to get into something called a doctorate of nursing. We have this confused array of people that call themselves nurses. We have consistency in what we call advanced practice. That has been at the Masters Degree level. There are still some people with an associate degree out there.
We copied our colleagues in medicine and developed essentials documents for baccalaureate programs.
We also prepared for research programs. That part of our work has evolved and in the last iteration of the standards for research programs we said there are things that are missing. We saw that there were people experimenting with programs that looked like doctoral programs. At the same time we started to look at the Masters programs and saw that these masters programs were getting bigger and bigger. A traditional Masters degree is like 30 credits and these nurses were getting about 80 credits. We weren't giving people the kind of credit they were deserving.
Were they getting bigger because faculty wanted to make things measurable? The issue was the changing world of practice. For instance they didn't know about gathering aggregate data to make the link to practice based evidence and then transfer that to the sciences. The system dynamics weren't there.
We appointed a task force to look at these things. That task force struggled with these things. They recommended if people were going to prepare people for the highest level of learning in nursing they should get a doctorate.
If they wanted a doctoral degree we needed to design programs that allowed them to move on and do that quickly. We set a timeline for 2015 to get these things to occur throughout nursing.
Concurrent to this something came from the National Academy of Sciences. They did a chapter on nursing and how we prepare people for research careers. There was this idea that you can't learn anything until you work in the field. With that you have nurses going out and working, having a baby, etc. and then they come back about 7 to 10 years later for a Masters Degree. Then they practice and come back in their late 40s for their doctorate.
Their report said, you need to stop using the practice to get the PhD. You need to allow them to go directly from baccalaureate to a doctoral degree. Start them on a plan earlier.
That validated what we were doing and that made us feel we made the right decision.
People that hadn't voted for this were threatened and they thought this denigrated contributions they were making already.
This is not about not meeting a mark but it's about the mark is moving higher. We need to credential you appropriately for what we require you to learn.
So we have created the essentials documents for the doctor of nursing practice. The development of the standards is a consensus based process with people from all over the US.
By the fifth hearing we had people move away from saying why do it to saying how do we do it? How do we get there?
We now have 92 programs in place and 102 in the planning process. We found, and I think you will find when you listen that the students are telling you yes! They are saying they want this degree - I want to go there. The students are saying they want this.
Some people thought one thing that might happen would be it would take people away from research programs. That didn't happen. We've seen a 30% increase in our research programs. We're seeing people moving in both ways - they are moving early on towards research or towards practice and a Masters.
One of the things that happened is that more people started opening programs after the more prestigious programs started offering programs. They wanted to stay competitive.
The demand for nurses is skyrocketing. The same is happening for PAs. We have to be sure that we don't slow down the pipeline. We graduate about 46% of the people that come into these programs.
662 programs grant nursing degrees and some of them grant graduate degrees. What happens to these programs in terms of their ability to offer a doctoral degree? They form partnerships so they can continue to be a part of the process.
There is an issue of who is the faculty? The same question was asked when PAs and NPs started out. We would be bringing a diverse group together to teach these programs.
The faculty are organizing a program even when the dean is against it.
We're dealing with other issues as well. 2015 is not far away. There has been a real move to get there based on what we've done already. It's clear that it's the right thing to do. 50% of the programs are on that path now 4 years later.
I hope our experience is useful to you.
Bob McNellis: I'm the Vice President of AAPA. Thank you for taking time out to be here. Much of what we are going to hear in these days together are stories. Another important story in this is what happened with the US Army. We've asked Major Gruppo to tell the story of the Army's program.
Army: Major Len Gruppo
Good evening. It's a pleasure to be here. I'm humbled to be here speaking with you. I could talk for hours about this. Several years ago we recognized that our existing 12 month programs in Emergency Medicine and in Orthopedics weren't adequate in preparing graduates. Lengthening the program would give us the time we needed to train them appropriately.
We decided to do this in 18 months. PA school is about 50% of the time of medical school.
Emergency medicine was the first program to move in this direction. We thought whatever training we did the Physicians would have confidence in. We followed the guidelines they had developed as closely as possible. Similarly in orthopedics we came to the same conclusion with one difference.
A lot of things that orthopedics are trained in don't need 5 years of training - there are the non operative orthopedic conditions that don't need five years. If we provide this expertise it supports the physician to be making money for the community and doing what he does best.
There was something that happened that moved things along at a more rapid pace - the global war on terrorism. With casualties rising in Afghanistan and Iraq we needed to be better equipped at the point of impact.
We have PA's everywhere on the battle field. What if we trained them more? Could we possibly save some more lives? That was the main focus that drove us.
We put this together and we had physicians involved all the way. They were involved in concept, curriculum, philosophy, everything. Once they realized that we weren't going to call ourselves doctor in a patient care setting and we weren't going to be getting independent practice from them - they gave their full support. We received support from the highest levels at that point.
Let's talk a little about how we did it. It took several years of conversations and meetings to get this to the point where we had the first graduation in Dec 2007.
One of the biggest hurdles was cost. Who was going to pay for the training? How were we going to take these PAs out of the workforce and put them in this long training - and who was going to pay for it?
They owe three and a half years after they graduate to pay back their costs to the army. Most of these people are experienced PAs. They have at least 4 years experience or they aren't allowed to apply. When they move into residency they are fairly productive and add value to the hospital where they are trained. There is no direct billing for them but their preceptor sees more patients.
We had 2 emergency medicine residencies and 2 orthopedic residencies. When we looked at them we saw they were at the whim of the director at that location at that time. They were disjointed. We established a mini-residency review committee. We created a chain of command. We're getting them aligned.
Now the Army has 10 residencies in 4 different specialty areas. One isn't headed for a doctorate.
I would like to introduce Major Paige who is heading up the orthopedic doctorate and residency training. Also with us is Major Sherman. He's putting together the first orthopedic surgery PA program - not to produce surgeons but to free up surgeons.
We've had a hard time finding applicants. There are some hurdles to go through to get into this type of program. A cultural change from the ground up in PA school will fix some of this. About 10% of the residents are failing out of the program.
The other problems are good. We can't meet the demand. We've had several specialty groups asking us to make PAs for them. We've also been asked by the surgeon general to make as many residency graduates as we can as fast as we can.
This has opened some doors for us. We've had some opportunities open up for us for employment within the Army that we didn't have before.
The other opportunity is placing some graduates in remote locations. These are autonomous positions and we couldn't do it without this training.
To summarize, we had a recognized deficiency in training. We added 6 months to the program. We associated the degree with the program after examining the curriculum and comparing it to other allied health curriculums. The degree wasn't the original impetus for this.
We're overcoming the issues we have and the biggest challenge is to find as many of these folks as possible.
Discussion
Question: Do you know how scope of practice might change once someone has a DNP?
Answer: It will change in some instances. Right now scope of practice is fairly wide already. It's based on what they bring. Will you get more money because you have a DNP? Possibly not. You become narrowed in some places. Earnings will be based on contributions. The scope of practice is broad already.
There is the issue of being called doctor. I have a PhD and I'm called doctor. I don't think being called doctor means you are a physician. I am offended by the AMA saying we can't call ourselves doctor. We aren't aspiring to be a physician. There are nurses and there are physicians. The AMA is working to prevent us from being called doctors.
Question: Is there an issue of having doctorally prepared faculty to meet the demand?
Answer: Our physicians have always overseen the residency training and they are operating at the highest level for our practice. Even when we have all PA faculty with doctorates the physicians will have the oversight.
Question: Can you speak to the fact that the five PAs that were in the first program did not know they were going to get a doctorate? They did it to improve the care they provided to their patients.
Answer: The folks in the Army don't get more money they get more work. They are motivated by unselfish motives. We weren't sure they were going to get the degree when we first started this. They just wanted to get trained and go back and take care of more patients.
Question: If I understand it, post graduate training is 12 months. Does the extra 6 months make the difference? How does that get you to a doctorate?
Answer: That's what we figured was the time we needed to fit all the education we needed into. We then looked at these other professions and their training and we compared the hours they spend in 18 months and ours compared very favorably. The way you do it is 100 hours per week for 18 months straight. It's brutal.
Question: I think physical therapists take 3 years. To go from a masters to a doctorate is 2 years. In nursing we have these things called accelerated programs but in essence you get the same volume in a truncated timeframe.
Answer: Our programs are well over 80 credits. You have to have a Masters degree to apply. There is a distance learning opportunity available as well.
We try to adhere to 80 hours per week but in the in-patient situations we've exceeded that. We're trying to voluntarily go along with the physician guidelines but it's been difficult.
Much the same as the Army could be viewed as a large corporation with healthcare budgets and demands and never enough money many large HMOs could relate to the model the Army has.