Dean MundingerThis article appears in the Clinical Scholars Review, Volume 6, Number 2. Full sample downloads of this journal are available on our website. This article is also cited in a recent news release from Columbia University, acknowledging this journal debut of a special section devoted to public health policy

The seeds of the idea for a clinical doctorate were sown in the late 1980s at Columbia. Nurse practitioner (NP) faculty initiated the first practice initiative that mirrored faculty practice in other disciplines; it was an integral part of their academic role, infused with evidence-based interventions and research collaborations. Within the span of 5 years, these practitioners were partnering with their physician colleagues to do even more. A unique opportunity arose in the early 1990s to develop an NP managed practice and to use the newly established practice as the prototype of NP independent functioning in primary care. With such a rare opportunity came the chance to compare an NP practice with a doctor of medicine (MD) practice opening in the same setting, at the same time, in the same discipline (primary care), in the same context, and with the same authority. Columbia physicians taught the Columbia NPs the skills, diagnostic sophistication, and processes of full scope care to assure the results were legitimate; without having the same authority, results would be flawed. The resulting randomized trial, to test the similarities in practice, was widely scrutinized by medicine and broadly celebrated by nursing when the results showed there were no differences in patient outcomes or quality of care.

Clinical Scholars ReviewIt was only a short step in our evolutionary thinking to find a way to standardize the new skills and knowledge the Columbia NPs had learned: authority across sites of care, with seamless oversight and coordination, more sophisticated diagnostic and treatment skills, better use of evidence-based practice, processes of ER evaluations, and admitting and treating hospitalized patients. This constellation of new advanced primary care practice was more comprehensive than the conventional primary care they and others had practiced, and it merited a new title and a standardized way to measure the resulting new scope of practice. The doctor of nursing practice (DNP) was our decision for these new nurses.

Knowing full well that our profession was eager and hungry to move its clinical practice forward, and knowing as well that our new title would be extremely attractive to any nurse aspiring to doctoral level accomplishment as an alternative to the research PhD, we knew we had to anchor this clinical title in a standardized and recognizable way. And we believed the best way to do so was to convince academic nursing leaders and our most eminent physician and health policy colleagues to advocate for these standards before the title moved like wildfire within academia, a title that could be used for any curricula, any outcome, or any competencies a faculty group might decide to use. The Council for the Advancement of Comprehensive Care (CACC) was the organization we formed to promulgate these high, common standards.

We were right that the title of the new degree would be much sought-after, and that action was necessary to keep the clinical focus central to the new degree, but we were wrong that we could forestall the diversity of content and competency that has nonetheless developed in DNP programs across the country. Most DNP programs focus on additive competencies other than advanced clinical practice and instead add competencies in nonclinical education, albeit at a sophisticated academic level, to give conventional master of science (MS) educated NPs background courses in business, ethics, informatics, and use of evidence. This brand of DNP assumes that the conventional clinical skill and knowledge gained at the MS level is sufficient for doctoral level practice if support courses at the doctoral level are attained. Other DNP programs do not even focus on advancing clinical practice but rather provide doctoral level education in competencies in administration and management. All DNP programs meet the newly argued idea that anything a nurse does is nursing practice, so under such reasoning, administration is nursing practice if the administrator happens to be a nurse. This kind of “Alice in Wonderland” thinking gives credibility to a DNP degree that has so many variable and dissimilar outcomes.

The reality of DNP degree development is that we will not have standardized clinical skills required within the DNP degree. This took us a step further in our CACC deliberations; if we could not standardize the higher clinical knowledge within academic standards for the DNP, then we would have to do so through a certification process that would distinguish those with the new higher level skills and knowledge.

Why were we so adamant that standards for the clinical doctorate were so imperative? Why not just let the many flowers bloom? For the same reason that essential skills and knowledge are now required in MS programs for NPs, standards are crucial for the public to know what competency their provider has achieved. One does not want to trust their complex and often urgent care to a nurse whose DNP is in administration or to an NP whose clinical training ended with their MS degree and specialty certification in ambulatory care; the highest level of care requires the most highly trained practitioner. We believed then, and now, that patients, other practitioners, and the public must know the level of competency of those providing care. Professional ethics and public accountability require that authority within a class must be limited to the lowest common denominator so that every single one in that class has at least the minimum competency. Without a distinguishing certification, those with the DNP clinical training would be limited to the same lower authority as those without the DNP, who had no additional clinical training beyond the master’s degree.

Even if there is broad agreement that clinical DNPs should have a distinguishing certification, there is no broad concurrence that the process we selected in CACC was the preferable route. We chose to establish the American Board of Comprehensive Care (ABCC) as an independent organization to develop a certification process. This was fairly innocuous, but the decision to develop an exam that tested the same medical competency as those receiving an MD license caused consternation in nursing and in medicine. So why did we do it?

We had two choices. We could develop a new exam with new questions—which would test the elements of knowledge and skill, which were the same as those the advanced clinical DNPs at Columbia had achieved, and which had been evaluated in the randomized trial— or we could develop an exam from an existing pool of questions that covered these same new skills of the clinical DNP. In the first option, we would have a huge task of developing new questions de novo, and many years before we would have enough exam takers to validate the questions and answers. In the second option, we would have validated questions ready to use. The issue for many naysayers, of course, is that the questions come from the same pool of questions used by the medical profession for MD licensing. We chose this route not just for ease in developing a reliable exam but also because we believed the additive knowledge and skill of a clinical DNP were skills also required of MDs and that this increasingly common skill set could be reliably—and influentially— combined. This is not such a big stretch in thinking. If the broader and more complex comprehensive care can be provided by either DNPs or MDs, they must, by definition, share a vast amount of similar skill. If so, why not test them with the same questions?

Some pleaded with us to go the separate route, test DNPs with nursing questions, build the recognition that nurses are high-level clinicians, and show that they are distinctive and different. We (CACC) agreed but noted that the DNP certification we developed only covers the more advanced and shared content of comprehensive care. A major requirement of the certification is that the test taker must be a nurse, already licensed, and certified at levels of nursing competence; the new DNP exam would cover the new and more complex skills that both MDs and NPs must have.

Another reason not to develop a second nursing exam is that it perpetuates the idea that nurses, although distinctive and different, are viewed by most patients as being secondary to physicians in knowledge and in authority. By using a parallel exam with MDs, testing the same competencies, it is more difficult to keep nurses in their lower hierarchical standing. It is a way to say nurses can meet the same standard, not a different one.

The clinical DNP with the Diplomate in Comprehensive Care (DCC) certification is a peer with physicians in comprehensive care, and these DCCs also have the unique and valuable set of nursing skills, knowledge, and perspective that physicians do not have. A test from a pool of questions used for medical licensing is only one part of the progression of nurse testing to finally arrive at doctoral level practice. As the depth of the health care shortage grows, the DCC can become the most sought-after and competent professional to fill the positions in comprehensive care. CACC and ABCC and the first 100 DCCs celebrate this wonderful future. Those who aspire to this same level of achievements should be selecting a DNP program that prepares them for the distinctive and identifying ABCC exam. It will set those DNPs apart from their colleagues who choose a DNP preparing them for an administrative career. But remember, patients should be able to make that distinction, and it is the certifying exam, not the degree that will make this clear.

Correspondence regarding this article should be directed to Mary O’Neil Mundinger, DrPH, Edward M. Kennedy Professor of Health Policy, Columbia University School of Nursing. E-mail: mm44@columbia.edu