At the Top of the Heap

Columbia Nursing alumni Patricia Maani-Fogelman, DNP ’05; Patricia Harren, DNP ’05; and Edwidge Thomas, DNP ’05, are highly accomplished clinicians, scientists, educators, and leaders. But if they hadn’t earned clinical doctorates in nursing, they would not be where they are today. 

In the 15 years since Maani-Fogelman, Harren, and Thomas became the first graduates of Columbia Nursing’s Doctor of Nursing Practice (DNP) Program, the demand for doctorally prepared nurse practitioners has boomed. Elderly and chronically or terminally ill patients are living longer; medically underserved populations are growing; and the supply of primary-care physicians is shrinking. The need for nurse practitioners (NPs) with the education to provide comprehensive, coordinated, evidence- and value-based care is more important than ever. Since the COVID-19 pandemic, public awareness of how pivotal nurses are to the compassionate and efficient delivery of care to both patients and their families has surged, says Vice Dean of Academics and Dean of Students Judy Honig, DNP ’05. “Throughout this pandemic, we have watched our nurses’ dedication to patient care and families,” Honig says. “Nurses bridge the gap for families who cannot be with their loved ones. They share very difficult, vulnerable times with them.”

In recognition of nurses’ invaluable contributions, the World Health Organization has designated 2020 as the International Year of the Nurse and the Midwife, inspiring Columbia to shine a light on the essential and expanding role for DNPs in today’s health-care workforce. 

Filling in the Gaps

In 2004, the DNP program was an idea whose time had come. 

Ten years earlier, in 1994, Columbia had established the Center for Advanced Practice (CAP), the first primary-care faculty practice in the country staffed with nurse practitioners. (The practice is now called the Nurse Practitioner Group.) CAP compensated its NPs at the same rate as primary-care physicians and gave them admitting privileges at NewYork–Presbyterian Hospital. In 2000, Columbia faculty members published a groundbreaking study in the Journal of the American Medical Association. Based on experiences at CAP, it showed no difference in outcomes for patients randomly assigned to nurse practitioners or physicians. Yet health and health care were changing rapidly, and nurse leaders like Honig and then-dean Mary Mundinger, DrPH, realized that CAP’s NPs were facing challenges for which they were not prepared. 

“CAP had many NPs who were expected to care for patients at the same level as physicians,” says Honig, a pediatric nurse practitioner who joined Columbia in 1988 and practices urban pediatric primary care. But the level of NPs’ knowledge about patient management, genetics, ethics, and the use of evidence and guidelines was not comparable to that of physicians. “We were accountable in ways that we were never accountable before,” she explains. “The demography was changing, pediatric and primary care were getting more complicated, and reimbursement and access to care were getting more challenging,” she continues. “The DNP program helped us fill in the education and practice gaps.”

Performing at the Highest Level

In 2004, Maani-Fogelman was creating a lung transplant program in Columbia’s Division of Cardiothoracic Surgery, when Mundinger recruited her to help develop and then join the nursing school’s first DNP class. 

As the transplant program’s senior NP and clinical chief, Maani-Fogelman had a demanding job that required in-depth knowledge of internal and pulmonary medicine, postsurgical follow-up, immunology, pain management, psychology, hematology, and endocrinology. She evaluated and managed severely ill patients with end-stage lung disease. She oversaw five lung transplant coordinators, educated staff nurses and patients, and worked on numerous quality improvement projects. She felt, however, that she could be doing more. “It took encounters with Mary to make me realize that something was missing,” Maani-Fogelman recalls. “Earning the DNP drove the academic piece of me that was lying quiet.” 

The program bolstered her clinically and gave her a firm foundation in program development, health care business management, and informatics. “It helped me see how big the scope of a nursing career can be,” says Maani-Fogelman, who went on to become an associate professor at Columbia Nursing. “I got more involved in lung transplant research and started publishing. I furthered my development in pulmonary care, critical care, palliative care, and cancer and started the nation’s first pulmonary palliative clinic.” Plus she began educating other clinicians in palliative care. “The DNP has made it possible for me to perform at the highest level,” she says.

Today, Maani-Fogelman is the systemwide medical director of Palliative Medicine at the Guthrie Clinic in Sayre, Pennsylvania, which serves a largely rural, impoverished population. In addition to providing direct clinical care, she oversees all academic and clinical palliative care programs; develops and implements clinical protocols and quality assurance programs; and educates medical providers, residents, nurses, and other staff.

“There are not a lot of NPs in the country who are directors of medical programs,” says Maani-Fogelman, who is also a national educator for the End-of-Life Nursing Education Consortium, a national education initiative that the American Association of Colleges of Nursing (AACN) co-developed to improve palliative care. “For an NP to be doing what I’m doing here—integrating platforms that include business planning and strategic growth; EMR integration; clinical protocol development; and physician, resident, and nurse education on palliative medicine—is unheard of. It’s nontraditional. But it works. And it is the future: true interdisciplinary leadership across the spectrum of health care.”

Thinking About Problems Differently

Like Maani-Fogelman, Harren was deeply engaged in her nursing career when Mundinger tapped her to join the inaugural DNP class. She was already an advanced practice nurse with multiple certifications. She was also a senior transplant coordinator, recruited to create the adult and pediatric liver transplant programs, which would later become NewYork-Presbyterian Hospital’s Center for Liver Disease and Transplantation. 

But the more she learned about the DNP program, the more she saw its value. “I’d been an experienced nurse for a long time, but I learned so much in the DNP program that wasn’t available in my regular NP program, like how to run a practice,” Harren says. “The DNP program taught me how to look at problems from multiple angles, not just in terms of clinical protocols but also in looking for confounding variables in a patient clinical presentation and in terms of practice management, cost reporting, and billing,” she explains. 

Now the clinical director for all pediatric solid organ transplant programs and adult abdominal organ transplant programs at Columbia University Irving Medical Center, Harren divides her time between clinical and managerial duties. She cares for patients, collaborates on managed care contract negotiations, develops and implements patient and staff education initiatives, monitors transplant volume and outcome statistics, participates in recruiting physicians, and hires administrative and professional staff—responsibilities for which she says the DNP prepared her thoroughly. Echoing Maani-Fogelman, she notes that clinical directors also have traditionally been physicians. “They never would have considered a nurse for the role I have now,” Harren says.

Furthermore, Harren says that without the DNP she would not have been able to serve on committees of the American Society of Transplantation. “I have a Columbia doctorate that says I’ve advanced myself as a nurse. People value that.” She notes that the DNP carries particular clout at an academic medical center like Columbia, where scholarship matters as much as clinical expertise. “More than half of my NP staff are DNPs,” adds Harren, an assistant professor of nursing. “When we’re hiring, I look for the DNP because I know the education and training that it represents.”

Providing Value-Based Care

Thomas once thought that her nursing career would be a stepping stone to becoming a primary care physician for all populations, with a specific focus on immigrant and underserved communities. But years of caring for these communities, first as a nurse in the medical, surgical, and neurological intensive care units of NewYork-Presbyterian Hospital; then in her first role as a nurse practitioner at Kings County Hospital Center in Brooklyn, where she managed a largely immigrant Caribbean population with multiple uncontrolled chronic diseases; and subsequently at CAP, which ultimately became Columbia Advanced Practice Nurse Associates (CAPNA), drove her desire to improve patients’ health well before they developed complications from their chronic conditions. “I always felt that we had an opportunity to impact the course of patients’ conditions during their primary-care experience, that had we intervened and engaged them earlier to help them understand and manage their disease, they probably would have had a better outcome and not ended up in the ICU,” she says.

At CAPNA, Thomas had begun to put this holistic, comprehensive approach to care into practice. Still, she sought more. “I knew the DNP degree would give me a solid foundation in research, practice management, data analysis, and the ability to publish,” she says. “The degree provided me with the knowledge, skills, and training that positioned me well for a successful career in nursing.”

It also catapulted her into nursing leadership, first as CAPNA’s director of clinical services, then as director of clinical practice affairs at New York University College of Nursing; there, she managed a primary-care practice for underserved populations and developed a mobile health van program and today is the clinical lead of the Delivery System Reform Incentive Payment (DSRIP) program in Mount Sinai Hospital’s Performing Provider System. 

DSRIP is a federal program that incentivizes states, through Medicaid funding, to improve health-care quality, cost-efficiency, and outcomes. To obtain full DSRIP funding, states must meet certain performance goals, such as reducing avoidable hospitalizations, halting Medicaid spending growth, and making managed care payments value-based. To achieve such goals, New York promotes Performing Provider Systems (PPSs), coordinated care networks that involve partnerships between a lead hospital and other providers. Mount Sinai is one of these networks, and Thomas’ functional role is that of chief medical officer of the PPS. “I’m not aware of another nurse running a PPS in the New York State DSRIP.” 

Thomas provides strategic direction and clinical leadership to maximize the $400 million that Mount Sinai’s PPS can earn. “Our network has about 82 metrics we need to meet to get our full allotment of dollars,” she explains. These metrics reflect numerous factors, including the design, implementation, and quality of clinical programs, practice improvements, and financial operations. 

“There are 350,000 lives attributed to Mount Sinai’s network, and 300 partner organizations—including Mount Sinai Health Systems, the Brooklyn Hospital Center, about eight Federally Qualified Health Centers, care management organizations, skilled nursing facilities, community-based organizations, and pharmacies,” Thomas says. “My role is to collaborate with partners in designing clinical improvement strategies, deciding where to dedicate our resources, monitoring partner performance on clinical outcomes, and making sure we’re holding everyone accountable.”

Under Thomas’ leadership, Mount Sinai’s PPS has achieved significant clinical improvements—increasing comprehensive screening rates for diabetes and clinical depression, improving diabetes and hypertension monitoring and management, and reducing potentially avoidable hospital admissions and readmissions. “We’ve made amazing strides in moving the dial on improving health outcomes for our Medicaid patients,” she says.

She credits her role in these achievements to her doctoral education and the skills she gained in how to navigate the health care system, manage population health, and improve patient care. “Without the DNP, there is no way I would ever have been considered for such a role.”

The State of the DNP

Columbia’s DNP program—recently ranked first in the nation by U.S. News & World Report—has flourished, experiencing a nearly tenfold increase in enrollment since it began 15 years ago. “Most studies say we’re headed for a primary-care workforce shortage and a booming population with more complex medical needs,” Honig says. “NPs are that workforce.” 

Among these complex medical needs are respiratory crises like those associated with COVID-19, which, along with a spate of other issues, require nurses with the education and experience to practice at the highest level of the profession. “Our number-one ranking speaks to the way we prepare our DNPs: to meet the needs of patients, families, and the health-care system,” Honig adds. 

Yet there are concerns about the focus of the degree that Honig and Mundinger attribute to a 2004 AACN position statement, which expanded the definition of “practice” to include nonclinical care—and to the consequent emergence of nonclinical DNP programs. “The fatal flaw was defining practice in such a broad way that anything a nurse does in health care practice is considered nursing, whether it’s policy, informatics, or administration,” Honig says. “There are many DNPs who aren’t advanced clinicians. Significant numbers of nurses with a baccalaureate degree are pursuing a DNP in leadership and administration and other nonclinical roles.”

According to a 2019 paper that Mundinger co-authored for the journal Policy, Politics, and Nursing Practice, only 15 percent of the nation’s 553 DNP programs are clinically focused programs. The paper expressed concern that “two different types of programs ... use the same degree designation,” leading to “potential confusion about what ‘nursing practice’ could mean.” 

In fact, the proliferation of nonclinical DNP programs threatens to hamper NPs’ opportunities for advancement, believes Mundinger, as well as the autonomy, authority, and respect they are accorded. “We shouldn’t be using the DNP degree and title for nurses trained as administrators,” she says. “It is unrealistic to promote full clinical practice authority and reimbursement for DNPs unless the public can unambiguously rely on who can be identified as a DNP.”

According to Honig, Columbia plans to keep the DNP clinically focused and to provide all students, from novices to advanced practice nurses, with the full breadth of clinical education and experience that the degree has historically represented. “Our school has maintained a philosophy of preparing very strong clinicians who appreciate and understand the context in which care is delivered,” Honig says, “and we take this responsibility very seriously. Our graduates, with their clinical skills and deep understanding of the complexity of health care, are making a difference in the lives of patients and their families—and are poised and educated to seize career opportunities.”

This article originally appeared in the Fall 2020 issue of Columbia Nursing magazine.