Yale School of Nursing, Yale University's Graduate Nursing Programs

Yale School of Nursing

All Hands on Deck For Access to High Quality Health Care

October 18, 2011

by Nancy S. Redeker, Associate Dean of Scholarly Affairs & Professor
and Margaret Grey, Dean & Professor, Yale University School of Nursing

In a recent New York Times article (“When the Nurse Wants to be Called ‘Doctor’”, October 2, 2011), objections were raised about the use of the title “doctor” by nurses who have earned academic degrees at the doctoral level. Nurses earn doctoral degrees that represent advanced knowledge and skills in the discipline of nursing, an overlapping but distinct field from medicine. These degrees include the PhD that prepares nurses to conduct sophisticated health care research and, more recently, the Doctor of Nursing Practice (DNP). While the emphases in these two degrees vary, both represent advance professional knowledge in the discipline (science and art) of nursing. The nurses who have earned these titles do not aspire or pretend to be physicians. They have made very deliberate choices to become nurses. While many had the academic background to attend medical school, they chose nursing.

Most nurses who hold doctoral degrees do not use the title ‘Doctor’. They introduce themselves either without the title or indicate the discipline that they represent, so there is no misrepresentation. Misrepresentation is not uncommon in medicine. Medical students introduce themselves to patients as “doctor” and trainees, such as medical residents or “fellows” fail to inform the patient that they are trainees, thus misrepresenting themselves as attending physicians. These examples are in many ways more misleading than the nurse who identifies herself as a doctor of nursing practice. The solution is adequate representation - clear name-tags and accurate introductions by all health care professionals. However, bickering over the title “doctor” is only symbolic of the real issues at hand.

The real issue is that millions of Americans have limited, if any, access to regular health care. Advanced practice registered nurses (APRNs) have the education and skills, and have been demonstrated in multiple studies, to provide safe and effective care for 60-80% of patient needs. There are significant distinctions between the roles and skills of APRNs, such as nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives, (many of whom are now earning DNP degrees) and their physician colleagues. These distinctions reflect their complementary knowledge and skills. APRNs are skilled in health promotion and disease prevention, diagnosis and treatment of episodic, acute, and chronic health problems, and prevention of disability in people of all ages. The majority of APRNs work in primary care settings, but many work in acute care, community health, and long term care settings. While APRNs perform some functions that overlap with those of physicians (e.g., diagnosis and prescribing medications), they excel at supporting patients with scientifically-based lifestyle and behavioral changes and developing self-management skills that help them to manage their own health and are no less important to prevention and chronic illness management than the prescription of medications.  Lifestyle change and self-management are critical to addressing the major public health problems of obesity, diabetes, hypertension, and many other chronic conditions across the lifespan.

Despite consistently high levels of public satisfaction with APRNs and decades of evidence that they provide cost-effective care similar in quality and complexity to that of physicians, regulations in many states limit the level and scope of APRN practice.  Historical trends, politics, turf issues, reimbursement patterns, and regulatory barriers are obstacles to realizing the full potential of their practice. This is inefficient and a barrier to fully addressing America’s health care needs, especially in urban and rural settings where many APRNs practice. We concur with the Institute of Medicine’s recent recommendation that regulatory barriers to APRNs full scope of practice be removed (http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx).

Rather than fighting over titles or turf, we prefer an approach that focuses on the needs of the public. More highly educated providers are needed. All hands need to be ‘on deck’, including APRNs who practice to the full extent of their education and experience. Let’s stop arguing about titles and let’s work together to assure that the public has the full range of providers needed going forward.