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Dentistry has a D.D.S. degree. Medicine has an M.D. Now nursing may have a Dr.N.P., if Columbia University approves the nursing school's proposed doctor of nursing practice program, which would be the first practice-level nursing doctorate in the world.

Outside of doctoral-level nursing researchers and teachers, the highest educational level achieved by practicing nurses is the master's degree. Nurse practitioners have been a part of the healthcare system for more than 35 years, and their numbers are growing rapidly. Now, the nursing school wants to offer nurses the option of studying for a nursing practice doctorate so they can gain more training and expertise to meet the increasing need for primary care in this country.

The nurse practitioner profession was born in the 1960s when extensively trained public health nurses were needed in rural areas with physician shortages. Master's degree programs sprouted to educate the nurses. Before the master's programs began, registered nurses (RNs) with bachelor's degrees had the highest level of education among practicing nurses.

To practice, each nurse practitioner must earn a master's in an advanced practice specialty and be state-certified. The United States has approximately 100,000 nurse practitioners, and though most work in collaboration with physicians, some run independent practices. Since 1998, Medicare has reimbursed nurse practitioners for medical services, at 85 percent of the physician's rate.

But the increased demand for nurse practitioners created a situation in which they are performing duties that require more training. Nurse practitioners, for example, in CAPNA, the Columbia University Advanced Practice Nurse Associates, have learned from physician colleagues to admit patients and coordinate care with specialists at NewYork-Presbyterian Hospital, but they did not learn these skills in their master's program. "Nurse practitioners are perfectly capable of performing these responsibilities, but we feel they should have advanced standardized training," says Dr. Judy Honig, who would be director of the proposed program. "Master's programs only train nurses to work in one setting, like an ambulatory care clinic. They do not give students clinical experience in all the settings in which primary care providers work."

The proposed program would provide students with experience in all clinical settings and would give them training in caring for more complex patients. Initially, the program would accept only experienced nurse practitioners, who would take one year of classroom and clinical courses and complete a one-year residency. Later, the program will be expanded to students with bachelor's degrees, who will spend four years taking pre-clinical and clinical courses before beginning the one-year residency.

"Our education is not so different from a M.D.'s, but is much more focused on the generalist point of view," Dr. Honig says. "We think the view of a nurse—with a focus on patient education and psychosocial needs—is well-suited to primary care."

Besides enhancing nurse practitioner education, the degree should signal insurance companies, hospitals, and patients that the practitioner is fully trained as a primary care provider. But the degree will become a widely accepted credential only if standards of education remain consistent as the degree is adopted by other schools. Dr. Mary Mundinger, dean of the School of Nursing, says the school has been working for two years with nursing and medical associations and deans of other nursing schools to standardize the Dr.N.P. degree across the country. The group will soon create a council that will develop accreditation standards to evaluate schools and a group that will set up a student credentialing process.

The proposed Dr.N.P. program has the approval of the Faculty of Medicine's Executive Committee, the Faculty of Nursing, and Dr. Gerald Fischbach, executive vice president and dean. It awaits approval by the Education Committee of the University Senate, the provost, the president and the Trustees. Final approval sits with the New York State Department of Education. Drs. Mundinger and Honig hope to enroll 10 to 15 students in the autumn of 2003.

"The timing is right," Dr. Mundinger says, "because nursing is now practiced at a doctorate level."


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