PROGRAM DIRECTORS’ PERCEPTIONS REGARDING THE INITIATIVE TO TRANSITION NURSE ANESTHESIA EDUCATION TO
THE CLINICAL DOCTORAL LEVEL by
Mary E. DeVasher
CYNTHIA HOWELL, Ed.D., Faculty Mentor and Chair RUSS MYER, PT, Ph.D., CAS, Committee Member MICHAEL VOLLMAN, R.N., Ph.D., Committee Member
Harry McLenighan, Ed.D., Dean, School of Education
A Dissertation Presented in Partial Fulfillment Of the Requirements for the Degree
Doctor of Philosophy
Capella University December 2007
UMI Number: 3296748 3296748 2008 Copyright 2008 by DeVasher, Mary E. UMI Microform Copyright
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Abstract
Program directors in nurse anesthesia educational programs were surveyed to determine their perceptions regarding the initiative to transition the degree level of nurse anesthesia education from master’s to a clinical doctorate. Proponents indicated a desire to move forward with the initiative. Program directors were aware that approximately 50% of schools of anesthesia exist within the university in disciplines other than nursing, and that the American Association of Colleges of Nursing (AACN) had no control over these programs. Concerns ranged from fear of programs closing due to inability to offer the degree, lack of qualified CRNA faculty, the impact on the future applicant pool, and concern that the AACN would supersede the American Association of Nurse Anesthetists/Council on Accreditation of Nurse Anesthesia Educational Programs as the accrediting body for nurse anesthesia education. Concerns included resistance and presumed reaction of other healthcare professionals, including anesthesiologists, toward the initiative.
Dedication
This dissertation is dedicated first to God, who has been with me every step of the way. Second, it is dedicated to my family. My husband, Bernard DeVasher, has truly been my strongest supporter. He has always encouraged me with any educational venture, even in this most time-consuming effort. I want to thank him for never complaining about the late, sometimes absent, meals, when after a long day of work as Program Director, I would switch gears to work on my doctoral studies. I love him dearly and long for the time when he and I can engage in hobbies again without the pressure of my doctoral studies—hobbies such as Bible study, travel, and hiking.
Our daughter, Alescia D. Bethea, has taken a journey with me that few daughters would take. She and I enrolled in our doctoral studies together. I would probably choose other fun mother-daughter things to do, but given that doctoral education was necessary for both of us to remain engaged in anesthesia education, I could not have chosen someone I love more to be my educational companion. I am so proud of her. While I am finishing only slightly ahead of her, my research findings are such that her research may possibly answer some of those unanswered questions mine found. May God be with you, Alescia.
Our son, Kameron DeVasher, a pastor in the Seventh-day Adventist Church, is engaged in earning his master’s degree with a focus in religious studies. He has offered encouragement to me on many occasions, always stating, “Mom, I’m so proud of you!” Son, your area of studies has eternal weight, preparing you to lead others to have eternal life; I love you, am proud of you, and wish God’s blessing on your studies and your work in your chosen career.
Acknowledgments
I would like to acknowledge those individuals who have been involved either in helping to code the interviews, edit my work, or have served on my dissertation
committee. These are: Dr. Phil Hunt, the President of Middle Tennessee School of Anesthesia, who has been most patient with me; Dr. Michael Vollman, a faculty member at both MTSA and Vanderbilt University School of Nursing, and a committee member who has been a mentor and powerful encourager; Dr. Russ Myer a committee member; and the Chair of the Dissertation Committee, Dr. Cynthia Howell.
Two other educators have offered other help and have been general
encouragers. Dr. Larry Lancaster, a faculty member at both Middle Tennessee School of Anesthesia and Vanderbilt University School of Nursing, offered editing assistance of some of my early projects in the course room as well as words of encouragement along the way. He was a blessing as he offered suggestions for my power-point presentation for my defense of the dissertation. Dr. C. William McKee, a faculty member at
Cumberland University, encouraged me as a shepherd to begin the doctoral studies originally, and without that first encouragement, the degree would likely still be a dream.
Finally, I’d like to give special acknowledgement to my daughter, Alescia. Having her take this journey with me has made all of the difference. I would likely have given up without believing that her educational future depended on her completing her doctorate, and my desire to be there with her. We have been able to offer strong support to each other.
Table of Contents
Acknowledgments iv
List of Tables viii
CHAPTER 1. INTRODUCTION 1
Introduction to the Problem 1
Background of the Study 4
Statement of the Problem 8
Purpose of the Study 9
Rationale 10
Research Questions 11
Significance of the Study 12
Definition of Terms 15
Assumptions and Limitations 17
Organization of the Remainder of the Study 21
CHAPTER 2. LITERATURE REVIEW 22
History of Nurse Anesthesia Education 23
Nursing Initiative for Clinical Doctorates 31
Current Nursing Literature Related to Doctoral Education 32
Nurse Anesthesia Response 35
Regional Accreditation Concerns 38
History of Doctoral Education 40
History of Doctoral Education in Nursing 41
Drivers and Proponents of the DNP 51
Effects of the DNP 56
Beliefs Related to the DNP and Faculty Preparation 59
Question of Data to Support Doctoral Education 61
Clinical Residencies as a Part of the DNP 61
Perceived Benefits of the DNP 62
Expressions of Concern About the DNP 63
Public Policy and Society Perceptions 69
Summary 72
CHAPTER 3. METHODOLOGY 73
Introduction 73
Methodology 74
Restatement of Research Questions 77
Setting of the Study 77
Instrumentation 78
Data Collection Procedures 84
Data Analysis Procedures 86
Ethical Issues 87
Summary 88
Organization of the Remainder of the Study 88
CHAPTER 4. DATA COLLECTION AND ANALYSIS 89
Introduction 89
Overview of Themes 93
Summary 133
CHAPTER 5. RESULTS, CONCLUSIONS, AND RECOMMENDATIONS 134
Introduction 134 Results 135 Conclusions 137 Summary of Recommendations 166 Summary of Conclusions 172 REFERENCES 175
APPENDIX A. TELEPHONE INTERVIEW QUESTIONS 180
APPENDIX B. CRNA PROGRAM DIRECTORS’ DOCTORAL
FEASIBILITY STUDY 183
List of Tables
Table 1. Summary of Number of Responses in 6 Questions Related to 11 Themes 94
Table 2. Research Question 1 96
Table 3. Research Question 2 103
Table 4. Research Question 3 110
Table 5. Research Question 4 115
Table 6. Research Question 5 120
CHAPTER 1. INTRODUCTION
Introduction to the Problem
In an October 2004 position statement, the American Association of Colleges of Nursing (AACN) declared that graduates of advanced practice nurse (APN) educational programs will have earned clinical practice doctorates by 2015 as the entry-to-practice degree. The AACN (2004b) defined advanced practice nurses as certified registered nurse anesthetists (CRNA), certified nurse midwives (CNM), clinical nurse specialists (CNS), and nurse practitioners (NP). The AACN has published drafts of a document, The Essentials of Doctoral Education for Advanced Nursing Practice, which outline the content that should be included in the clinical doctorate. These drafts have been found on the AACN Web site and continue to change as updates occur.
For this research, program directors of schools of nurse anesthesia were interviewed in order to determine their perceptions about this dynamic phenomenon. Specifically, it will explore their perceptions of the impact transitioning will have on their programs and on programs nationwide, as well as the benefits and concerns regarding implementing the AACN initiative if the nurse anesthesia professional association—the American Association of Nurse Anesthetists (AANA)—agreed with the AACN initiative.
In the months leading up to this initiative and following it, nurse practitioners and clinical nurse specialists have been actively engaged in open dialog concerning the
necessity of educationally transitioning from the master’s level to the clinical doctorate level. Some of the APNs were perceived as either being active proponents of
transitioning to a clinical doctorate (Bednash, 2006; Dreher, 2005; Lens, 2005; Marion et al., 2003; Mundinger, 2002; Williams & Hathaway, 2006) or leaning toward the
transition, though not necessarily in complete agreement with the actual proposal (Nelson, 2005; O’Sullivan, 2005; Wall, Novak, & Wilkerson, 2005).
Other APNs were perceived as being active antagonists of the transition (Meleis & Dracup, 2005), or urging caution in it (Baldwin, 2005; Bellack, 2002; Carlson, 2003; Edwardson, 2004; Ellis & Lee, 2005; Fulton & Lyon, 2005; Glazer, 2005; Robb, 2005; Whall, 2005; Wood, 2005). Anderson (2000) suggested that nursing should improve teaching within nursing programs and advance admission standards before it considers doctoral education.
These authors are mainly either NP or CNS advanced nurse practitioners. However, in nurse anesthesia-specific literature, by 2005 only three articles had been written addressing doctoral education. Faut-Callahan (1992), a CRNA and educator, was one of the first authors in nurse anesthesia literature to address doctoral education and offer support for a clinical practice doctorate. Jordan (a CRNA) and Shott (1998) surveyed CRNA program directors and practitioners regarding feasibility of doctoral education, and published their findings. One article in nurse anesthesia literature proposed a clinical practice doctorate modeled after the Virginia Commonwealth University Doctor of Physical Therapy (DPT; Clement, 2005).
The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) is an autonomous body of the AANA. Prior to 2003 the COA accredited programs at the
master’s level. In the trial version of the 2003 Standards of Accreditation, the COA, under the purview of the U.S. Department of Education’s Department of Eligibility and Agency Evaluation’s published standards to accredit schools that offer either clinical doctorates or research-oriented doctorates (Nagelhout & Zaglaniczny, 1997). It appeared that members of the COA, even in 2003, were aware of the coming movement for advanced practice nurses to transition from master’s- to doctoral-level education. The final version of the Standards of Accreditation is available to those associated with schools of anesthesia, but it is not widely published (COA, 2004, 2006).
Thompson, Faut-Callahan, and Beutler (2005) addressed CRNA doctoral education at the 2005 AANA Assembly of School Faculty Meeting. In June 2005 the AANA convened a summit to discuss doctoral preparation as an entry credential for the nurse anesthetist. Participation in this summit included nurse anesthesia educators and leaders, who affirmed the current professional educational program’s ability to produce competent practitioners. The participants acknowledged that in the future graduates will need additional knowledge and skills in areas such as technology and research. However, the participants in this summit did not support the 2015 date for doctoral credentials or the title of Doctorate of Nursing Practice (DNP; F. Maziarski, personal communication, June 15, 2005).
In the February 2006 AANA Assembly of School Faculty meeting, the DNP was addressed by the president of the AACN, Geraldine Bednash, speaking in favor of the DNP. Another speaker, Alaf Meleis of the University of Pittsburgh, spoke against the DNP, indicating that was not the time.
The AANA published an interim position statement indicating that the AANA did not as yet support the DNP but was continuing to investigate the initiative. The interim position statement, in part, stated, “The AANA cannot, at this time, support the AACN’s position on the clinical doctorate as entry into advanced practice since our initial review of the proposal raises serious concerns” (2006a, ¶ 1). Following the release of this statement, the AANA commissioned a task force to conduct an electronic survey of program directors concerning their perceptions related to the clinical practice doctorate, which appears to indicate the AANA has plans to readdress the interim position
statement.
Nurse anesthesia program directors will be charged with implementation of the DNP if the AANA does conclude the doctoral preparation as an entry credential to be advantageous to the profession. The focus of this study was to discover the opinions of program directors of schools of nurse anesthesia related to the initiative to move all programs of nurse anesthesia from the current master’s level to the doctoral level. Program directors were interviewed and asked to describe how this initiative would impact their educational programs.
Background of the Study
Program directors in schools of nurse anesthesia are facing the possibility of moving from their current master’s-level nurse anesthesia programs to offering a clinical practice doctorate. Those who were in the position of program director in the late 1980s and 1990s were required to move all nurse anesthesia program curricula from the certificate level to a master’s degree level. In the mid- to late 1980s, the COA mandated
that by 1998 the master’s degree would become the only recognized terminal degree in the discipline (Frels, 1992).
According to Mastropietro, Horton, Ouellette, and Faut-Callahan (2001a), between 1980 and 2000 the number of nurse anesthesia programs declined from 110 to 83, with 14 programs closing in 1985. The cause of these closures remains controversial. However, CRNAs believed the primary causes included a lack of administrative and anesthesiologists’ support, reduced program funding, strained relations between the AANA and the American Society of Anesthesiologists (ASA), and the trend toward development of master’s-level nurse anesthesia education. Anesthesiologists believed the causes of the closures related to the closure of hospital-based programs as a result of the mandated master’s degree, fewer resources in academic medical centers to support both nursing and physician programs, and a generalized shortage of nurses, especially critical care nurses (Mastropietro et al.).
Given the shortage of nurses and nurse anesthetists at present, nurse anesthesia program directors are directing energies toward educating nurses to become nurse anesthetists in order to help fill the vacancies of anesthesia providers in the nation’s operating rooms. Faculty members in those schools have met regional and professional eligibility criteria to educate students seeking master’s degrees. However, it is perceived that due to regional accreditation standards (Southern Association of Colleges and Schools [SACS], 2004), the educational level of these faculty members may not be adequate for them to teach at the doctoral level. The AANA (2006b) Web site revealed that the master’s degree is the highest degree of 62% of CRNAs directing schools of nurse anesthesia. Additionally, faculty members often do not have resources of time and
finances to be able to reengage in academic pursuit of personal doctoral education in order to meet the increased academic eligibility criteria. It is perceived that many nurse anesthesia faculty members do not have geographic access to doctoral programs, and if they were located where programs are available, it is likely that the clinical schedules associated with their clinical and teaching load would make attendance at regularly scheduled classes difficult, if not impossible.
While not widespread, anesthesiologists are responding to the shortage of anesthesia providers by increasing the number of anesthesiologist-led Anesthesiologist Assistant (AA) programs. Within the past 5 years, the number of these programs has increased from two to four. Most AA anesthesia providers have no previous healthcare background (ASA, 2005). AAs are legal anesthesia providers under the supervision of anesthesiologists in a few states. In at least one other state, anesthesiologists have attempted, through the legislature, to mandate that they supervise all CRNAs, and that AAs become recognized anesthesia providers in that state (General Assembly of North Carolina, 2005).
How the move from master’s-level entry to doctoral-level entry will affect the current relatively harmonious relationships between nurse anesthetists and
anesthesiologists is unknown. In the past, one cause of disharmony between these groups involved education of nurse anesthetists. Historically, as nurse anesthesia educational programs continued to increase educational requirements and moved from being hospital-based to being university-hospital-based, nurse anesthesia educational programs were enveloped by schools of nursing in universities.
The genesis of this move appears to have been initiated when the ASA obtained a federally funded grant to perform a demographic study of anesthesia providers, to include both anesthesiologists and CRNAs. Nagelhout and Zaglaniczny (1997) stated that the study was reported to have been done in cooperation with the AANA, when in reality the only part the AANA had was supplying the researchers with a list of members. This was significant in that “one of the recommendations was for anesthesiologists to become more involved in the education and credentialing of nurse anesthetists” (Nagelhout &
Zaglaniczny, p. 11). The first time the AANA was aware of this recommendation was when the U.S. Department of Education’s Department of Eligibility and Agency
Evaluation, which had oversight of accrediting agencies, communicated with the AANA to determine how to fulfill the recommendation.
According to Nagelhout and Zaglaniczny (1997), “This set the stage for a major confrontation between the ASA and AANA in the mid-1970s concerning which of the groups was going to control the education and credentialing of nurse anesthesia
educational programs and their graduates” (p. 11). Ultimately, this led to incorporating nurse anesthesia education into the university framework and redesigning the AANA to form an autonomous council, the COA, to accredit schools of nurse anesthesia.
The displeasure of many ASA leaders with the AANA’s federal funding initiatives, along with concerns by some anesthesiologists that they were, in fact, participating in preparing their future competitors, led a sizable number of
anesthesiologists who were academic chairmen in institutions where nurse anesthesia educational programs were located to convert the nurse anesthesia training slots into medical residency training spaces and to close the nurse anesthesia programs (Nagelhout
& Zaglaniczny, 1997, p. 18). How anesthesiologists today will respond to offering clinical doctoral education to nurse anesthesia students is unknown, although it is anticipated that the ASA will resist such a move.
Nurse anesthesia program directors have established relationships with anesthesiologists, the gatekeepers to clinical experience. Often the relationship is symbiotic. Anesthesiologists offer clinical experience as an avenue to graduates for employment, and program directors receive clinical experience for their students. These program directors are the most likely individuals to understand how anesthesiologists will respond to transitioning nurse anesthesia education from the master’s level to the clinical doctoral level. They will also be the ones who understand there may be attempts by anesthesiologists to close clinical sites for nurse anesthesia students. Their collective voice has not yet been heard.
Statement of the Problem
It is anticipated that any forced transition from the master’s level to the doctoral level will present problems to program directors, who will be responsible for
transitioning master’s-level nurse anesthesia educational programs to the clinical doctoral degree level. Among these concerns are academic qualifications of faculty, resources to transition the program to a higher level, institutional and governmental hurdles, timing of such a move, title of the degree, and loss of clinical sites due to anesthesiologists’
concerns regarding offering clinical education to nurse anesthesia students who will earn clinical doctorates.
It was felt that there likely were concerns that were not anticipated when this study was proposed. Since this was a qualitative study with open-ended questions, it was believed these might be discovered as interviews of program directors were conducted. Therefore, this study attempted to discover the evolving perceptions of current CRNA program directors regarding the AACN initiative to transition nurse anesthesia
educational programs from the master’s level to a clinical doctorate level.
It should be noted that there are positive issues that surfaced as well, such as allowing CRNA practitioners to have parity with other healthcare providers, such as podiatrists and chiropractors, who have equal or fewer academic hours in their
background compared to CRNAs yet have earned clinical doctorates. Another positive issue is that creating a clinical doctorate would allow the advanced practice nurse, whose academic hours have expanded over time to far exceed those of master’s-prepared graduates in other academic fields, to have a degree that more fairly represents the time spent in education.
Purpose of the Study
This study had two purposes. The first purpose was to determine if the nurse anesthesia program directors’ perceptions regarding perceived benefits or concerns with moving from the master’s degree as the entry-level preparation to the doctoral degree as the entry level to practice are similar to responses in the literature published by nurses of other advanced nursing specialists. The second purpose was to determine if the responses of those program directors whose schools of nurse anesthesia exist within the discipline of nursing are similar to the responses of program directors from schools of anesthesia
that exist in disciplines other than nursing, showing whether or not they have similar concerns and/or perceive similar benefits.
Rationale
The primary concerns that program directors have to implementing doctoral education in their own programs of nurse anesthesia need to be explored. Such
exploration by personal interviews will add value to the current online survey of program directors being performed by the AANA doctoral task force. The AANA has not yet agreed to comply with the AACN initiative. Having additional information related to program directors’ concerns for transition to a doctoral level will assist the AANA in this decision making, as well as initiate groundwork for assisting programs to move in the direction of doctoral education should the profession decide to follow the AACN doctoral initiative.
Providing information related to CRNA program directors’ opinions about which curricular additions would benefit the nurse anesthesia profession and who should design the curricular additions seems prudent, if such information is revealed in the responses. In addition, while the AACN has mandated the DNP title for the degree, program directors’ opinions related to this title should be solicited. Also, program directors should be offered a venue to express why they prefer a given title. Suggestions related to the title of the degree would be important information for the AANA to have as they make decisions regarding whether to comply with the AACN mandate. This information could persuade the AANA to create clinical doctorate curricular inclusions and a degree title proposal exclusive of the AACN mandate.
Research Questions
The primary research focus was to determine what the initiative to have a clinical doctoral degree as the entry-to-practice credential for nurse anesthetists actually means to program directors. Given that the most recent Assembly of School Faculty meeting (February 2006) had one full day devoted to presenting topics both for and against this transition—with speakers such as Bednash (2006) and Meleis and Dracup (2005) representing the pro and con, respectively—it is likely that many of the responses of program directors will be repeats of those arguments. However, program directors may express opinions related to issues that have as yet been unaddressed.
The questions in the telephonic interview sought demographic information prior to examining the actual focus of the research, and was followed by six questions related to the topic. As a preamble to these six questions, the following statement was read to all participants:
There may or may not be barriers or concerns you have about being able to implement the AACN initiative in your program. This study is interested in exploring these. There may or may not be benefits you perceive would occur by implementing the AACN initiative in your program, this study is interested in exploring these as well. Please respond to the following:
If the AANA determines to support the AACN position statement that the degree for entry-to-practice of nurse anesthetists will be the doctor of nursing practice, and programs will be required to implement it by 2015:
1. What impact do you believe implementing the AACN initiatives will have on your program of nurse anesthesia?
2. What impact do you believe implementing the AACN initiative would have on nurse anesthesia education nationwide?
3. What are your general impressions of moving toward doctoral education as the degree for entry-to-practice?
4. Would you be satisfied with the title of the degree of nurse anesthesia graduates from a doctoral program being the DNP?
5. What benefits do you believe would occur by transitioning master’s programs in nurse anesthesia to doctoral programs?
6. Do you have any concerns (academic, clinical or other) about
implementing the AACN initiative that these questions may not have addressed that you wish to share?
Significance of the Study Significance to Society
Nurse anesthetists administer approximately 65% of the anesthetics given in the United States, are the sole providers in approximately two thirds of rural hospitals in the United States, and are providing anesthesia in military institutions both in the United States and abroad (AANA, 2006a). Currently, there is a shortage of nurse anesthesia providers. The following is a statement released by Rodney Lester, then-president of the AANA, in response to proposed cuts to funding for nurse anesthesia educational
programs:
There’s a severe and growing national shortage of nurse anesthetists, who provide two-thirds of U.S. anesthetics and the lion’s share in rural and medically
underserved America and the U.S. Armed Forces . . . the average number of nurse anesthetist job vacancies increased 250 percent from 1998 to 2001. (2003, p. 1) If moving nurse anesthesia education from the master’s level to the clinical doctorate causes a decrease in the number of graduates for any reason, whether due to increased cost, decreased faculty to teach at the doctoral level, or closure of clinical sites, society will be impacted due to the potential of closing operating rooms and reduced access to surgery. This is likely to be more pronounced in rural and underserved areas where CRNAs administer a significant percentage of anesthetics. Further, at least one state’s society of anesthesiologists has quoted the documented shortages, and has
the North Carolina Society of Anesthesiologists (2006) suggesting that AA licensure will help to alleviate shortages of nurse anesthetists in North Carolina.
Significance to Healthcare
CRNAs provide anesthesia for hospital surgical patients, outpatient services, obstetrical services, podiatry clinics, dental offices, eye clinics, plastic surgery suites, and pain management clinics. In addition, they provide anesthesia for the U.S. military and the Department of Veterans Affairs.
CRNAs provide these anesthesia services safely and at reduced costs to patients and insurance companies, which helps control cost of healthcare (AANA, 2006a). Should the already short supply of CRNAs be compounded by lengthening educational
programs, increasing cost of educational programs, or closure of nurse anesthesia clinical educational sites, healthcare will be negatively impacted.
Significance to the Profession
Historically, the nurse anesthesia profession has fought political battles to have state nurse practice acts provide a certain amount of autonomy to nurse anesthetists. However, to revisit the nurse practice acts to include doctoral-level education as the entry credential for CRNAs to practice would cause these acts to once again become vulnerable to those who originally opposed the status these acts provided for advanced practice nurses. If these nurse practice acts are reopened, it is a concern that anesthesiologists will attempt to institute direct supervision of CRNAs or will attempt to legalize the services of AAs in various states.
Currently the number of PhD-prepared nurse anesthesia providers is unknown. The April 2005 White Paper on Nursing Practice Doctorates indicated that an
unanticipated side effect of developing the practice doctorate in pharmacology (PharmD) was that the numbers of PhD prepared pharmacists decreased (National Association of Clinical Nurse Specialists [NACNS]). The same article noted that moving advanced practice nurse programs to the clinical doctoral level may also inhibit the number of traditional PhD-prepared nurse scientists. This could lead to a decrease in the number of researchers and educators in nursing, thus further decreasing the evidence base for advanced nursing practice and nursing faculty. While practice doctorates are touted to increase safety in nursing practice, it could actually lead to a diminished evidenced base for sound advanced nursing practice, thus having a negative impact on the profession.
In order to continue as a profession, the profession must have accredited schools of anesthesia, and in order to meet accreditation standards, schools of anesthesia must have qualified faculty. Since some regional accreditation entities require academic degrees for teaching faculty, any decrease in PhD programs has the potential to further decrease numbers of appropriately qualified faculty.
In February 2005, approximately 54% of the nurse anesthesia programs existed within schools of nursing in the university. The other 46% existed in programs outside of nursing, in disciplines such as allied health, or as independent, anesthesia-specific
schools. The clinical doctorate initiative had its genesis within the accrediting entities for schools of nursing, not within those schools of anesthesia existing in other related
disciplines. For the AANA to follow a nursing accreditation mandate, without significant input from all program directors, would seem to be out of character for the AANA, which has celebrated its diversity. Choosing to make all schools of nurse anesthesia follow a
nursing model would bring homogeneity rather than diversity to AANA schools of nurse anesthesia, which could negatively impact the profession.
If the AANA does not comply with the AACN, those schools within nursing may be at risk. Also, for those schools that operate within nursing, to have to add curricular components suggested by the AACN may unduly lengthen their programs and make them less competitive with non-nursing programs due to the increased amount of time required to complete the program. Programs are in competition for the best students, and to unduly lengthen a program simply because it exists in nursing by meeting standards that the nursing accrediting body superimposes on the school, in addition to the accreditation standards of the anesthesia professional organization, could possibly make schools of anesthesia within nursing less competitive. Furthermore, the stakeholders of a particular school of anesthesia within nursing may determine that school no longer needs to remain within nursing, and seek to transition those programs from nursing to other allied health programs, or even become independent.
On the other hand, programs existing outside of nursing may experience a negative impact as well. It is possible that applicants seeking admission to schools of anesthesia will choose those that offer the more advanced degree, leading to a diminished pool of applicants for these programs.
Definition of Terms
Anesthesiologist. A Doctor of Medicine (MD) or Doctor of Osteopathy (DO) who has successfully completed an approved residency program and has been granted active hospital staff membership and full hospital privileges in anesthesia (COA, 2004). While
not an official term, these collectively are often referred to as medical doctors of
anesthesia (MDAs). In this study they are seen as gatekeepers to clinical practice, defined here as individuals who have authority and political power to determine who can provide anesthesia in a given facility.
Certified registered nurse anesthetist (CRNA). A registered nurse who has completed a full, accredited program of nurse anesthesia and has passed the national certification examination for nurse anesthetists, and continues to participate in a
prescribed number of continuing education activities. Since 1998 all graduates from nurse anesthesia programs have earned master’s degrees. There are currently programs of nurse anesthesia that offer post-master’s doctoral programs in nurse anesthesia. Prior to 1998, some programs only offered certification and no specific degree. Only in 1987 was it mandated that students entering nurse anesthesia educational programs needed to possess baccalaureate degrees. Thus, today among those CRNAs who practice anesthesia, there are several levels of academic preparation (Mastropietro et al., 2001b).
The Essentials. Refers to the evolving document produced by the Task Force of the AACN charged with the development of curricular expectations that will guide and shape DNP education. The Position Statement refers to the October 2004 statement by the AACN that by 2015, APNs graduating from educational programs would earn clinical doctorates. APN involves four specialist groups of nurses, nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives (AACN, 2004b).
Entry-to-practice degree. Nurse anesthesia graduates must have “acquired knowledge and skills in patient safety, perianesthetic management critical thinking, communication and professionalism” (COA, 2004, p. 23), and have earned a given
degree, currently a master’s, in order to practice their profession. This does not assume those CRNAs practicing anesthesia prior to a mandate to elevate the degree level will not be able to practice, nor does it address the issue of grandfathering these practitioners, as this will need to be addressed by state boards of nursing.
Program director. A CRNA administrator with a graduate degree who, by position, responsibility, and authority, is actively involved in the organization and administration of the entire program of nurse anesthesia. The graduate degree must be from an institution of higher education accredited by a nationally recognized accrediting agency (COA, 2004).
Assumptions and Limitations Assumptions
Philosophically, the fundamental assumption in this study is that reality regarding the topic is not concrete; rather, it is subjective and is constructed by the multiple
realities, or perspectives, of those participating in the research. Thus, this study followed a postpositive, naturalistic paradigm. Epistemologically, in this paradigm it is assumed that the distance between the researcher and the participant should be minimized. Thus, participants were personally interviewed telephonically (Polit & Beck, 2004).
The role of the values of the researcher in this study is inevitable, and were acknowledged as the researcher was part of the group that was interviewed. Therefore, from an axiological standpoint, this study followed a naturalistic, postpositivist paradigm. The emphasis focused on a specific phenomenon: the evolution of the professional or academic degree in nurse anesthesia. The emerging interpretations were a reflection of
the participants’ experiences. Their voices are important to understanding the phenomenon; thus, the methodology used in this study was the qualitative research tradition of phenomenology. Specifically, the methodological assumption was that of social constructivism, or interpretivism (Polit & Beck, 2004).
It was assumed that those individuals included in this study were program
directors who are familiar with the COA Standards for Accreditation and are aware of the initiative generated by the AACN to transition the degree for entry-to-practice from the master’s level to the doctoral level by 2015. Because nurse anesthesia educational programs exist within a variety of settings within universities, such as nursing, biology, and allied health, or as single-purpose graduate degree-granting institutions, it was assumed the responses of the program directors were viewed from their own perspective. It was assumed, however, there would be common themes among their respective
responses.
It was also assumed that all program directors would have some knowledge and experience with the intermittent disagreements between the ASA and AANA. These program directors likely have faced some resistance from anesthesiologists related to clinical experience for their students.
Limitations
At the time of this study, the AANA had developed a task force to conduct a survey of program directors using an e-mail survey tool. This tool is a modification of a survey by Jordan and Shott (1998). It appears there are yet unexplored perspectives of program directors toward this phenomenon that are not covered by the AANA task force
tool. Therefore, this dissertation is directed toward discovery of these yet unexplored perspectives.
However, because program directors have been exposed to the AANA task force tool, this exposure could possibly affect their responses to questions in this study. This prior exposure would produce a pretest/posttest measurement effect, and could become a limitation.
The fact that the researcher has been involved with a previous transition is a bias. In addition, the researcher had concerns that supporting the AACN mandate would cause a diminished access to clinical sites, having already been told by anesthesiologist board members of her particular program that they will fight it, even to the extent of closing the program of nurse anesthesia education, which also is a bias. Such closure of one of the three largest schools in the nation could significantly impact the number of nurse anesthesia graduates. Given these noted biases, the researcher had to carefully control voice, tone, and reaction to responses to questions as she interviewed program directors.
The interviewer, as a program director, will likely have a professional
acquaintance with some of those who were interviewed; however, although this could present a limitation, it should also aid in the establishment of a good rapport, considered to be important in conducting interviews, as indicated by Fontana and Frey (2005).
There are fewer than 100 program directors in the total population; therefore, this study was conducted by personal interviews until theoretical saturation was achieved. A limitation was that not all program directors were interviewed, so there existed a
possibility that key opinions may be left undiscovered in this study. That the researcher is also a program director and conducted the actual interviews may have made the
respondents feel more comfortable in answering questions. However, it could also
present a limitation in that personal feelings of the researcher may have been perceived to be involved. Thus, great care was exercised to assure that personal feelings were not intimated in the questions. The actual interviews were transcribed by an uninvolved transcriptionist, and two nonanesthetist, doctorally prepared nurses agreed to participate in the coding.
It was anticipated that program directors would have some views that are alike, particularly if transitioning to the doctoral level causes the length of the program and the cost of attendance to increase. Some will likely feel forced to follow the initiative since they exist within schools of nursing and the AACN accredits these schools. Those who are not within nursing may not feel the urgency about meeting the initiative. Both groups may have a concern that anesthesiologists who have been supportive of nurse anesthesia programs and have offered clinical experience to nurse anesthesia students may decide not to support programs that offer a clinical doctorate, thus putting clinical experience for students in jeopardy.
This study had a narrow focus: the discovery of program directors’ perspectives in nurse anesthesia related to how, if the profession of nurse anesthesia concurs with the AACN initiative to transition programs of nurse anesthesia from the master’s level to the doctoral level, it will affect their own programs. Additionally, program directors were asked to respond to how they believe this would affect nurse anesthesia education nationally. Because interviewing proceeded until theoretical saturation was reached, not all program directors were interviewed; thus, a limitation was that not all program directors had an opportunity to have input in this study.
The actual qualitative design of the study presented a limitation in that qualitative research, due to the small sample size, has a decreased generalizability of the findings to all programs of nurse anesthesia. However, it was assumed that there would be a high degree of transferability, defined by Polit and Beck (2004) as the “extent to which qualitative findings can be transferred to other settings, as another aspect of a study’s trustworthiness” (p. 41). Additionally, since the researcher provided the interpretation of the results, the findings were subject to interpretations of the researcher.
Organization of the Remainder of the Study
Chapter 2 discusses the pertinent literature related to nurse anesthesia education, the evolution of nurse anesthesia educational programs’ curricula, and other advanced practice nursing literature related to education and the emerging history of the DNP curricula. Chapter 3 describes and discusses the qualitative research methodology selected to respond to this phenomenon. Chapter 4 presents the analysis of the data collected by the mechanism set forth in chapter 3. Chapter 5 presents a summary of the conclusions elicited from the analysis of data presented in chapter 4. Additionally, it presents recommendations for further study.
CHAPTER 2. LITERATURE REVIEW
This chapter includes the literature reviewed in preparation for the study. It is organized by first introducing the reader to the history of nurse anesthesia education, to include its origin in hospital-based educational programs, and references some of the events that moved nurse anesthesia education into university settings, to include some of the issues facing nursing in general within the university framework. The literature traces the evolution of programs of nurse anesthesia from granting certificates into the graduate framework, offering master’s degrees. It addresses nursing and nurse anesthesia literature specific to the current initiative to move advanced practice nursing, including nurse anesthetists, education from the master’s level to the clinical doctoral level, and the response of the AANA, the professional organization of nurse anesthetists, to this initiative.
The literature review addresses requirements of regional accreditation for faculty teaching at the doctoral level. It reviews the history of doctoral education in general, then it follows with a review of the history of doctoral education in nursing. A section of the literature review is devoted to researching titles of nursing degrees. As the DNP is a new degree, the literature review includes topics related to which branch of nursing actually began the initiative.
Addressed within the literature review are opinions related to the impact this initiative will have on educational resources and other economic issues. Also addressed are opinions of those who are proponents of the DNP and those who have expressed concerns about doctoral education for advanced practice nurses. These include beliefs about faculty preparation in order to be qualified to teach in a doctoral program, data supporting doctoral education, and the suggestion that clinical residencies should be part of any doctorally prepared advanced practice nurse. The literature review revealed opinions related to the benefits of the DNP, as well as concerns. The concerns include those related to public policy and society perceptions.
These articles were reviewed and included to give the researcher and readers an understanding of the educational, professional, and societal milieu within which the AACN initiative has arisen. There are only a few publications from nurse anesthetists related to the clinical doctorate; however, there are many publications from other
involved nursing specialties; thus, the literature review was conducted to find issues that nurse anesthetists may share in common with other advanced nursing specialties.
History of Nurse Anesthesia Education
Nurse anesthetists were among the first medical professionals to have specific training in providing anesthesia. The educational history of these anesthesia providers has evolved from being hospital-based to the university.
Hospital-Based Educational Programs
The Franciscan Sisters of St. John’s Hospital in Springfield, Illinois, were among the first to initiate a hospital-based program to prepare nurses to be nurse anesthetists in
the late 1800s. The same order of Sisters made significant contributions as nurse
anesthetists in Minnesota. The Sisters of St. Francis convinced Dr. William W. Mayo and his sons, William and Charles, that the Sisters would build a hospital if the Mayos would take charge of it, and the doctors agreed. Two nurses were assigned to do the anesthesia, and Dr. William Mayo, believing “there was no reason why intelligent nurses would not make good anesthetists” (Nagelhout & Zaglaniczny, 1997, p. 5), accepted the
responsibility of educating these nurses. Alice Magaw, who was the successor of one of the two original nurses in that facility, has been given the title of Mother of Anesthesia.
Historically, beginning with the discovery of ether in the United States, anesthesia was first relegated to the
Disinterested medical student or . . . some other untrained individual. . . . Morbidity and mortality were encountered as a result of poor anesthesia
technique. It became clear that in order for surgery to advance there would have to be dedicated professional anesthetists. Doctors were not interested in making anesthesia a full time practice because anesthesia was totally subordinate to surgery and had a much lower professional status. . . . For these reasons, surgeons drafted nurses into anesthesia practice. (Waugaman, Foster, & Rigor, 1999, p. 5) According to Waugaman et al. (1999), Alice Magaw, one of the earliest nurses to provide anesthesia, was noted to have kept meticulous records and published her
observations of 1,092 anesthetic cases in the St. Paul Medical Journal. In 1906, she published a review of over 14,000 anesthetics for surgery in the journal Surgery, Gynecology and Obstetrics. These documented records were used in California in the 1930s as evidence that the practice of anesthesia was not the practice of medicine.
In the early history of nurse anesthesia, most nurses providing anesthesia were trained in the facility in which they worked. However, in 1909, in response to the
for nurse anesthesia providers were developed—one in the East, at Massachusetts General Hospital, and one in the West, in Portland, Oregon, at St. Vincent’s Hospital. The latter was a full week course. By 1917, Lakeside Hospital in Ohio sponsored a 6-month course of nurse anesthesia education. However, at Lakeside the first documented conflict between physicians and nurses administering anesthesia arose when the Ohio State Medical Board passed a resolution that declared that anesthesia was strictly a practice of medicine. This, and two subsequent court cases in Kentucky and California in 1917 and 1936, respectively, addressed the question of whether nurses who deliver anesthesia were engaging in the practice of medicine, and led to a tightening allegiance among surgeons, hospital administrators, and nurse anesthetists. Data to support that anesthesia was not the practice of medicine included Alice Magaw’s early publications.
Waugaman et al. (1999) recounted that in 1930 Agatha Hodgins presented a paper at the ANA suggesting that nurse anesthetists organize into a “coherent and acting body” (p. 9). However, “philosophical differences with mainstream nursing, as represented by the ANA, eventually prompted nurse anesthetists to remain independent of that group” (Waugaman et al., p. 9). Thus, the National Association of Nurse Anesthetists, later renamed the American Association of Nurse Anesthetists (AANA), was formed with the primary purpose of improving nurse anesthesia education and to advance clinical practice (Waugaman et al.). Nagelhout and Zaglaniczny (1997) inferred that while advanced practice nursing had not been thought of, Hodgins in 1931 believed nurse anesthetists were a very specialized group of nurses, “not exactly nurses, but they were not physicians either; rather, professionally, they were somewhere between the two” (p. 7). The first
priority of the AANA was to establish standards for educating nurse anesthetists, and for certification of anesthetists following graduation from accredited programs.
Anesthesiologists Barash, Cullen, and Stoelting (1997) traced a similar history of nurse anesthesia, by stating the following:
Anesthesiology evolved slowly as a medical specialty in the United States, in part because of the presence of . . . nurse anesthetists. . . . Many American surgeons . . . regarded anesthesia as a technical art that could be left to anyone. . . . The most compelling argument to be advanced in favor of nurse anesthesia was that of skill: a trained nurse who administered anesthetics every working day was to be preferred to a physician who gave anesthesia only rarely. . . . Many prominent surgeons preferred nurse anesthetists and directed the training of the most able candidates they could recruit. The Mayo brothers’ personal anesthetist was Alice Magaw. George W. Crile relied on the skills of Agatha Hodgins. (p. 26)
To verify that today the two major anesthesia providers work in relative harmony, with the present leaning toward a more congenial practice environment, Waugaman et al. (1999) stated
Most nurse anesthetists and anesthesiologists continue to work well together, considering the fact that much of what they each do connotes direct competition between two very distinct provider groups. In fact, today nearly 80% of all nurses and anesthesiologists work within some definition of an anesthesia care team where both the nurse and the physician provide substantial efforts toward the care of patients. (p. 9)
From Hospital-Based to University-Based
As nurse anesthesia programs continued to increase educational requirements and moved from being hospital-based to university-based, and as nursing developed advanced practice specialties, nurse anesthesia educational programs began to be enveloped into schools of nursing in universities. The genesis of this move appears to have been initiated when the ASA obtained a federally funded grant to perform a demographic study of anesthesia providers, to include both anesthesiologists and CRNAs. Nagelhout and
Zaglaniczny (1997) stated that the study was reported to have been done in cooperation with the AANA, when in reality the only AANA participation was supplying the researchers with a list of current members. This was significant in that “one of the recommendations was for anesthesiologists to become more involved in the education and credentialing of nurse anesthetists” (p. 11). The first time the AANA was aware of this recommendation was when the U.S. Department of Education’s Department of Eligibility and Agency Evaluation, which had oversight of accrediting agencies, communicated with the AANA to determine how to fulfill this recommendation.
According to Nagelhout and Zaglaniczny (1997)
The displeasure of many ASA leaders with the AANA’s federal initiatives, along with concerns by some anesthesiologists that they were, in fact, participating in preparing their future competitors, led a sizable number of academic chairmen to convert nurse anesthesia training slots into medical residency training spaces and to close the nurse anesthesia programs. (p. 18)
Further, Nagelhout and Zaglaniczny (1997) stated, “This set the stage for a major confrontation between the ASA and AANA in the mid-1970s concerning which of the groups was going to control the education and credentialing of nurse anesthesia
educational programs and their graduates” (p. 11). The challenge was public and occurred simultaneously with transformations in the criteria by which the Office of Education recognized accrediting agencies (Nagelhout & Zaglaniczny). Ultimately, the ASA challenge and the changes in the Office of Education led to incorporating nurse
anesthesia education into the university framework, and redesigning the AANA to form autonomous councils, among them the COA, to accredit schools of nurse anesthesia. The membership confirmed the new organizational structure in August 1975 at its annual meeting. The ASA challenge
Brought about a rapprochement between nurse anesthesia and mainstream nursing, a schism that had existed since the AANA’s organization. Nursing believed that allowing physicians to take over the professional credentialing process of a long-standing nursing specialty could lead to other attempts by medicine to gain control over other nursing groups. (Nagelhout & Zaglaniczny, p. 12)
Nursing and Nurse Anesthesia Within the University
In the 1980s a few of the schools of anesthesia had moved into a university setting. Underpinning much of the dialog regarding nursing and nurse anesthesia
education has been the recurring controversy regarding whether or not nursing should be offering academic or professional degrees. Faut-Callahan (1992) referred to
considerations within this evolutionary conflict by comparing the difference in the
Bachelor of Arts degree and the Bachelor of Science degree. The former was a liberal arts degree, not intended for preparing those who earned it to enter a specific profession. The latter was intended so its recipients could be prepared to enter a discipline or profession; however, rather than the 4 years typically required for the Bachelor of Arts degree, the Bachelor of Science degree often took 5 years to complete. Early nursing baccalaureate degrees were placed in a Bachelor of Science framework rather than within a specific professional discipline, with initial programs taking 5 years to complete. However, subsequent programs were shortened to 4 years, with the clinical component being reduced in order to complete the degree requirements in the abbreviated time. Nursing became accepted into the academic framework; however, this move sacrificed the ability to be in complete control of the admission/graduation requirements and the curriculum, as these were set by the college of nursing within the university.
This reduction in clinical preparation within the baccalaureate level led to graduating nurses who were not prepared to move into specialty practices of nursing without lengthy preceptorships or internships. When baccalaureate programs in nursing were well established, it was natural that they should begin to consider graduate programs in the specialties of nursing. However, beyond basic nursing, whether at the diploma, associate, or baccalaureate level, many nurses were being prepared for specialties in nursing, such as nurse anesthesia, in certificate programs.
Moving into the academic graduate framework, according to Faut-Callahan (1992), may have given a perception of academic credibility, but not without a price. Among the costs was that, because of the genesis of nursing outside of the university, nursing assumed an “educational inferiority complex, that it has been striving to overcome” (Faut-Callahan, p. 99). An overcoming mechanism seems to have been to reject the concept of a professional degree, rather than to embrace it. Thus, living in the academic framework led to the actual specialization component being further reduced. Certificate to Master’s Degree
Moving nurse anesthesia programs to the master’s level was a task not without problems. In the late 1990s, the COA mandated that all nurse anesthetists graduating from schools of nurse anesthesia must earn a master’s degree. According to Mastropietro et al. (2001a), between 1975, when the majority of nurse anesthesia programs existed in a certificate framework, and 2000, the target date for all graduates from schools of nurse anesthesia to earn master’s degrees, the number of schools of anesthesia declined from 195 to 83. It was believed that this decline resulted from the closure of schools unable to meet the stronger educational and accreditation requirements introduced during that era.
McCall et al. (1997) indicated that there were 96 changes in program directors’ positions in nurse anesthesia between January 1, 1990, and September 1, 1996.
Therefore, as program director positions tend to have a high degree of turnover, it is likely that not all program directors today will recall moving programs from the certificate to the master’s level, and thus may have little appreciation of the issues involved in transitioning a program to a higher degree level.
From Master’s to Doctorate?
Over the years, and particularly since World War II, there has been debate about the appropriate degree for entry level to nursing. Leaders in nursing preferred that the baccalaureate degree be the degree level for entry-to-practice, and the degree
recommended for the more advanced specialties in nursing, such as anesthesia, was the master’s. While the dilemma regarding the entry-level degree in nursing remains unsolved, most of the advanced specialties in nursing have moved to requiring the
master’s degree as the entry-to-practice degree. Now on the horizon looms the possibility that doctoral education will be required for advanced practice nurses for entry-to-practice. The current focus seems to be on preparation for the profession by achieving a
professional, or clinical, degree, rather than an academic degree such as the PhD. When doctoral programs were first introduced into nursing, the question again arose regarding which degree was appropriate—a professional or an academic one. As earlier nursing educators had steered the course into academia, once again academic degrees seemed more popular or in higher demand.
Discussion has been intermittent within anesthesia circles about the possibility of moving nurse anesthesia educational programs to the doctoral level. Three authors have
contributed to nurse anesthesia literature information related to doctoral education for nurse anesthetists since the early 1990s: Faut-Callahan (1992), Jordan and Shott (1998), and Clement (2005). Chronologically, the first of these introduced the need to establish clinical doctorate nurse anesthesia educational programs. The second surveyed both program directors and practitioners to determine the feasibility of doctoral degrees for entry into practice and to investigate educational avenues for CRNAs to complete the doctoral degree. Clement offered the most recent of these publications, wherein she proposed a model for nurse anesthesia education in a program that exists in an allied health discipline in a university.
Nursing Initiative for Clinical Doctorates
In 2004, the AACN published a Position Statement that all APNs, including certified registered nurse anesthetists, would earn a clinical practice doctorate degree. This recommendation seemed to advocate recognition, at long last, of the value of a professional degree. It did not deny the route taken toward academic degrees; it simply included practice degrees as appropriate in addition to academic degrees. The AACN, following the lead of the National Organization of Nurse Practitioner Faculty (NONPF), recommended this degree be called a Doctorate of Nursing Practice (DNP), which would be the highest level of practice, and would become the terminal practice degree (AACN, 2004b). The AACN Position Statement provided examples of practice-focused degrees other disciplines offer as entry-level degrees, and included Doctor of Medicine (MD) and Doctor of Dental Surgery (DDS).
The title Advanced Practice Nurse, according to the AACN (2004b), includes four direct care roles: certified nurse midwife (CNM), certified registered nurse anesthetist (CRNA), clinical nurse specialists (CNS), and nurse practitioner (NP). The AACN Position Statement concluded that the amount of time it currently takes to complete master’s degrees in these specialties was not congruent with the degree earned
The AACN (2004a) published a document of frequently asked questions regarding the Position Statement on the Practice Doctorate in Nursing. This document indicated that the AACN membership has targeted 2015 as the year by which the current level of preparation of advanced practice nurses would move from the master’s degree to the doctoral level. Both this document and the Position Statement refer to an upcoming AACN DNP Task Force that would outline how to facilitate a plan for transitioning currently master’s-prepared APNs to doctoral level. This indicates educational programs would be faced with the challenge of not only educating currently enrolled students seeking the initial degree, but it would also need to make accommodations for those practicing APNs to complete the requirements to earn this advanced credential.
Current Nursing Literature Related to Doctoral Education
Current literature pointed to evolving academic degrees for nurses in advanced clinical practice. Carlson (2003) stated
There is an expected decline in the number of physicians in primary care settings, and as access to primary care services from physicians decreases, some believe the clinical doctorate [for advanced practice nurses] could offer an increased assurance of receiving high-quality care to those patients receiving care from NP’s. (p. 2)
According to Mundinger, in an interview with Yox (2005), when describing Columbia University’s new doctorate in nursing practice degree, advancing to the clinical doctorate will allow graduates to fill the gap left by the declining number of medical doctors in primary care medicine, particularly in underserved areas. Mundinger stated that while it has not yet happened, the goal of a nurse holding a clinical doctorate would be “to care for patients independently, in all healthcare settings” (as cited in Yox, p. 2). As Columbia University began the DNP educational process, one of the first steps was to secure admitting privileges for nurses in order to comanage the patients’ care. Mundinger stated they had “significant help of our medical school colleagues, [thus] the knowledge and skill base of these nurses increased” (Mundinger, as cited in Yox, p. 2). As primary care medicine was not fully available in their area, and because of the relationship forged with the physicians, they were able to “convince the insurers to include us in their list of approved primary care providers” (Mundinger, as cited in Yox, p. 2).
The relationship described between the primary care physicians and the advanced practice nurses by Mundinger (2002) seems not to follow the same relationship described by Nagelhout and Zaglaniczny (1997), when anesthesiologists, concerned that they may be preparing their future competitors, set about to close clinical sites, thus interrupting the clinical education of students preparing to become CRNAs.
Marion et al. (2003) referred to the practice doctorate as one that will prepare clinical faculty. Fitzpatrick (as cited in Carlson, 2003) suggested that “the clinical
doctorate would be an important degree for faculty whose interests lie in teaching clinical skills and professional development but not in participating in research” (p. 1). However, The Essentials (AACN, 2006b) indicated that in order for advanced practice nurses
earning clinical doctorates to teach, they will likely need to add further coursework to prepare them for the teaching role.
Fitzpatrick stated, “The dominant skills needed by faculty teaching in schools of nursing at the basic levels (BSN and AD) and the advanced practice level (clinical master’s degree) are expert clinical skills and skills in clinical teaching” (as cited in Carlson, 2003, p. 3). Carlson stated, “The PhD degree provides neither of these sets of skills, nor should PhD programs prepare either clinicians or clinical teachers. Rather, it is unethical to accept students into PhD programs that do not develop research careers” (p. 3).
Marion et al. (2003) discussed the several degrees granted in nursing, describing the PhD as being devoted to research; however, the doctorates in nursing science, which she outlined as titles of DNS, DNSc, and DSN, together with education (EdD), appear to show little difference between them and the PhD. She further stated that of the doctorally prepared nurses, “the majority do not spend their time in direct patient care, but rather in research (11%), education (32%) and administration (30%)” (p. 2). She believed having these roles prevents current doctorally prepared nurses from maintaining the clinical skills necessary to teach advanced practice nurses. Marion et al. noted that one of the key drivers of the practice doctorate movement was the faculty shortage crisis. She stated
The current shortage of nursing faculty is impeding the progress of expanding nursing educational programs to address practice shortages in most healthcare arenas. . . . Predictions are that this faculty shortage will continue to rise significantly. Clinical teaching necessitates advanced clinical expertise. (p. 1) According to Marion (2003) practice doctoral programs usually include elements of courses that add breadth to the particular discipline, such as applied research,
biological sciences, finance and business in healthcare, health care delivery and clinical leadership. Carlson (2003) summarized the programs of study to contain “knowledge, skill building in the areas of scholarly practice, practice improvement, innovation and testing of care delivery models, evaluation of health outcomes, health policy/change agent, leadership in establishing clinical guidelines, and clinical expertise for advanced practice nursing” (p. 2).
Marion et al. (2003) summarized the documents prepared by the NONPF, referring to the core competencies as the “gold standard for maintaining and shaping quality NP educational programs, serving as a guide for national curriculum and policy development” (p. 1). She further stated that
NONPF is interested in shaping new educational models emerging in response to the opportunities and needs for NPs and advanced practice nurses . . . yet the nursing leadership pipeline is at risk (eg.[sic] the faculty shortage, the impending baby-boomer retirement). The preparation of NP clinical leaders peaked in 1998 . . . the number of graduates from NP educational programs has declined by 14.8%. (p. 2)
Nurse Anesthesia Response
In a presentation to the AANA Assembly of School Faculty, Thompson et al. (2005) stated
Clinical practice is a significant component of nursing as a clinical discipline. Nursing is also a research discipline and development of the research doctorate has been the focus of the nursing profession. Although nursing has promulgated the research doctorate for the last 35 years, it has failed to alter the clinical
credential. Instead, nursing has continued to expand the time, increase the credits, and emphasize the rigor in the preparation of Advanced Practice Nurses as expert practitioners. Fitzpatrick (2003) calls this failure to raise the academic level for our profession’s clinical experts a continuation of nursing’s anti-intellectualism. This retains preparation of Advanced Practice Nurses at severely reduced levels in comparison to faculty of almost every other discipline. (p. 1)
In this meeting, Jeff Beutler, Executive Director of AANA, responded to questions from the attendees about adequacy of faculty. He made statements that the AANA needed to determine how many educators were needed, the degrees necessary, the criteria for educators, and the possible need to pick or evangelize current students as future faculty. He stated that an AANA faculty development boot camp might be in order (personal communication, February 27, 2005). It appears that present nurse anesthesia faculty development is in a state of uncertainty. The profession is willing to urge faculty development forward; however, the barriers that would impede this progress need to be explored.
The master’s degree has been the terminal degree in nurse anesthesia, as evidenced by the mandate that all programs would offer the master’s degree by 2000 (COA, 1994). Today programs of nurse anesthesia education exist in two major formats. The first and dominant format, of approximately 54% of the nurse anesthesia educational programs, includes those housed within schools of nursing, offering the degree of Master of Science in Nursing. The second, comprising approximately 46% of nurse anesthesia educational programs, includes those within other disciplines within the university, such as schools of allied health or biology, and offering an array of degree titles such as the Master of Science in nurse anesthesia, or simply the Master of Science. Program directors operating schools of anesthesia in either of these two major formats are likely to face similar concerns to those in the other format, and concerns specific to the discipline in which they exist.
In response to the October 2004 AACN Position Statement that by 2015 the degree for entry-to-practice would be a clinical doctorate degree, the AANA convened a
