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A proposal to establish a Doctor of Nursing Practice (DrNP) degree is currently before the University Senate for approval. This degree will be the first clinical nursing doctorate in the nation and will prepare nurses for the most advanced level of professional practice. This new degree is needed as a way of identifying and distinguishing those who have attained the highest level of knowledge, education, training, and practice independence.

Today more than 200,000 nurses have master's degrees in advanced practice; these degrees range from midwifery and anesthesia to primary care and psych/mental health. Columbia has long been a leader in establishing such degrees, including the oldest M.S. program in midwifery in the nation. All of the Columbia School of Nursing's master's degrees – as is true elsewhere – prepare nurses for practice in a specified site with limited authority to provide care. For example, most primary care nurses practice in outpatient clinics and offices without hospital admitting privileges or the authority to conduct ER evaluations for their patients or make specialist referrals to co-manage their patients.

In the past decade, regulatory authority for master's-prepared nurses has advanced more rapidly than educational requirements. Federal legislation in 1997 authorized nurse practitioners to bill Medicare directly (independently) for care to patients in any site. This legislation provides access to care and payment for treatment in outpatient and inpatient sites, although nurse practitioner education at the master's level only covers outpatient management. Each year more states expand the authority of nurse practitioners to prescribe drugs, and increasingly hospitals recognize master's-prepared nurses for inpatient care, either as consultants or as independent providers. Commercial insurers are slowly beginning to recognize nurses for independent reimbursement as well.

This progression occurred at a time when patients' expectations of their health care providers were changing. Chronic illness has become a major and enduring health issue; more than three quarters of the adult population has at least one chronic disease. Effective care requires not only competent diagnosis of new disease or illness, but also careful attention to lifelong conditions that can dramatically worsen without comprehensive continuous care. Perhaps most important, patients and payers are more often seeking providers with a focus on disease prevention, health promotion and partnership-oriented care – all characteristics that epitomize the nursing approach to patient care.

Nursing advancement follows decades of safe and well-accepted nurse practitioner practice and the expanding need for dedicated primary care providers. The slow but steady gain in authority is the result of bright nurses seeking out informal opportunities to learn what they need to know in addition to their master's-level training. But nurse practitioners are more frequently practicing at levels of knowledge and authority that exceed formal education and training and are learning the more advanced practice without established standards, curricula or certification. This is not the way to establish or assure quality patient care.

The School of Nursing's new degree proposal results from 10 years of scientifically evaluated demonstrations, peer-reviewed articles in respected professional journals, and policy development to secure the improvements in ongoing care. The faculty followed up their local successes by undertaking efforts to build a national consensus for an educational program that could replicate the quality and competence evidenced in the new Columbia nursing model of care. The school has engaged other leading nursing schools, nursing's professional organizations (the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties), and medical and health policy experts in developing the curriculum, title, certification and accreditation procedures to ensure uniform high standards for this program.

In 1993, Columbia University physicians, through the approval process of the Medical Board of Presbyterian Hospital, authorized admitting and co-management privileges for nursing faculty practitioners who cared for patients in two community-based primary care clinics. Columbia primary care physicians then participated in a randomized trial to test the effectiveness and safety of a fully independent nurse practice. The study, published in the Journal of the American Medical Association, demonstrated that these nurse practitioners were indistinguishable from primary care physicians in terms of outcomes, costs, and patient satisfaction.

These extended hospital privileges for faculty nurse practitioners are now part of the hospital bylaws. The nursing school's innovative models of care now include a thriving midtown practice in which the faculty nurse practitioners are reimbursed by all the major commercial insurers at the same rates as physicians, and patients can select a Columbia nurse practitioner as their primary care provider in all of these commercial plans.

Eight other leading schools of nursing are adopting or adapting the Nursing School's model for their forthcoming DrNP programs; all are making use of the history, science, and intellectual property of Columbia. It would be the university's loss if other schools formalized what was first conceived at Columbia.

Establishing a Doctor of Nursing Practice degree will institutionalize reliable, high-quality standards for education and training and assure that those who follow this model do so in a way that provides safe, superior care. All other health professions have already established clinical doctorates, including Columbia's recent approval of the physical therapy doctorate. And more significantly, an identifiable degree title for those who have reached the same level of academic and clinical achievement as other "doctors" will make it clear to the public – patients, payers and physicians – which nurses have the requisite education.

Dr. Mary Mundinger is dean of Columbia's School of Nursing.


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