Women wearing mortarboards.

Pushing Back Against Credentialism

Tuesday, September 12, 2023

This past year, UCSF’s School of Nursing quietly stopped accepting applicants to the master’s entry program in nursing (MEPN), a program that allowed people with a bachelor’s degree in a non-nursing field to become registered nurses in one year and master’s prepared nurses in another two.

UCSF didn’t release a statement on why they paused this program - it wasn’t announced to my year at all, in fact - though the webpage linked above suggests that the program might return as a doctoral level program in response to national pressure for nurse practitioners to have doctoral rather than master’s degrees.

Simultaneously, this same national pressure is leading the UCSF School of Nursing to require a doctoral degree to teach in the SON, a move that will cause us to lose nursing faculty amid an ongoing nationwide nursing faculty shortage.

Graduating from a MS program just as that degree is being devalued is frustrating, but what’s happening at UCSF is part of a broader trend in nursing - credentialism.

Credentialism is when someone’s qualifications are assessed not on their knowledge and experience but on the letters they have after their name. It’s neither a new trend in nursing nor a problem confined to nursing, but the constantly churning alphabet soup of letters nurses carry after their names makes the trend particularly apparent in our field.

Historically, registered nurses earned diplomas rather than academic nursing degrees, often at the hospitals where they would eventually work. As nursing became increasingly professionalized, the diploma gave way to associates, bachelors, and masters degrees.

In the 1960s, as more physicians became specialists, a shortage of primary care providers led to the creation of nurse practitioners. Originally, NPs were nurses with many years of bedside experience who entered primary care after receiving additional training and a certificate. Over time, the years of required nursing experience were reduced, while the certificate program eventually became a M.S. degree.

The current push towards doctoral degrees in nursing is probably not about some additional skillset that one can only get from a terminal degree. More likely, this is related to the bizarre turf war between physicians and nurses over who gets to be called “doctor” or practice medicine independently.

The American Medical Association with their campaign #stopscopecreep contend that NPs are taking physicians’ jobs and have substandard training that endangers patients. While concerns about differences in training may be valid, there’s also a lot of bad faith criticisms towards NPs that seem to have more to do with preserving power structures than protecting patients.

Meanwhile, the American Association of Nurse Practitioners, put on the defensive, insist that post-graduate training is unnecessary for independent practice. This puts student and new grad NPs in the odd position of having their own professional leadership argue against clinical training opportunities in favor of more years of school and more academic credentials.

Constructive approaches to this situation might include expanding post-graduate training opportunities for NPs and improving the quality of NP education. Retiring the use of honorifics in patient care settings is one approach to reducing patient confusion, while physicians worried about NPs “taking their jobs” might do better to blame the private equity firms that purchase healthcare systems and replace physicians with NPs so they can pay them less money.

Requiring more credentials for NPs and nursing faculty won’t get us out of this mess. With the exception of universities that get to charge more tuition for DNP programs (at UCSF the DNP is currently over $10,000 per quarter), it’s unclear who stands to benefit.

Requiring a doctoral degree for nursing faculty will worsen the existing nationwide faculty shortage by creating additional restrictions on who can teach. It will also push people to go back to school for terminal degrees not because they’re passionate about their field, but because they will lose their job or not be taken seriously if they don’t.

Student NPs will have to take out more loans to complete DNPs while new grad NPs will have to compete for scarce residency programs because professional bodies value credentials over clinical experience. It seems unlikely that any of this will be beneficial to our actual patients.

Even with the push for terminal degrees, the barrier to entering the nursing field has been and still is much lower than for the medical field. This is especially true if someone is working class, first generation to college, raising a family, or otherwise marginalized.

Racism, patriarchy, and classism within the greater hierarchy of medicine has meant that nurses are often seen as subordinate to physicians and the struggle over who gets to be called “doctor” is deeply intertwined with racialized and gendered power structures in medicine.

However, there’s more than one way to challenge power dynamics. Nursing seems to have chosen the path of greater credentials in a struggle to be seen as an independent and legitimate profession.

Pushing doctoral degrees is not going to move us in a positive direction. If anything, it just buys into the hierarchy and elitism of the medical community by enforcing the idea that one’s professional titles determine one’s value.