228229CHAPTER 11
Measuring Outcomes of Doctor of Nursing Practice
Marguerite J. Murphy, Kathy S. Magdic, and Terri L. Allison
Chapter Objectives
1. Examine the current research available related to Doctor of Nursing Practice (DNP) outcomes
2. Explore rationale for the limited numbers of studies of DNP-related outcomes
3. Identify areas for future research related to DNP outcomes
Chapter Discussion Questions
1. Based on the literature supporting the DNP as the entry-level degree for advanced nursing practice and the American Association of Colleges of Nursing (AACN) The Essentials of Doctoral Education for Advanced Nursing Practice, what outcomes of DNP-degree-prepared nurses should be evaluated?
2. What factors have influenced the study of DNP outcomes to date?
3. What DNP outcomes should be considered for future study?
Though a practice-doctorate degree in nursing has been offered for more than 20 years, an organized effort to examine and make recommendations for future development of a nursing practice doctorate occurred in 2002 when the AACN convened a task force appointed for this reason (AACN, 2004). In 2004, the AACN proposed the development 230of practice-doctorate programs for nurses with roles specializing as an advanced practice registered nurse (APRN) or at an aggregate, system, or organizational level (AACN, 2006). Rationale supporting the need for the DNP degree included quality and safety issues in health care addressed in the Institute of Medicine’s (IOM’s) reports Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) and To Err Is Human (IOM, 1999), increasingly complex patient care, rapidly changing health care systems, and the shortage of nursing faculty (AACN, 2004). Advancing the number of doctorally prepared nurses is also supported by the IOM report The Future of Nursing: Leading Change, Advancing Health (IOM, 2010). DNP graduates are impacting health and health care outcomes as they implement quality improvement initiatives, apply evidence-based practice (EBP) changes, and explore the impact of system and practice changes. This chapter presents an overview of the DNP degree and reviews the outcome literature related to DNP practice.
AN OVERVIEW OF THE DNP
The DNP curriculum is based on The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006), which describes the competencies to be achieved by all DNP graduates and recognizes specialty practice competencies. The DNP Essentials comprise eight foundational outcome competencies preparing the graduate to function in complex health care environments (Exhibit 11.1). DNP education is specialty focused; the curriculum incorporates related content developed by national nursing specialty organizations intended to prepare the DNP graduate for specialized advanced nursing practice that is consistent with the DNP Essentials (AACN, 2006). Advanced nursing practice may emphasize direct care of patients and families or have a system, aggregate, or organizational focus associated with administration, informatics, or health care policy. The National Organization of Nurse Practitioner Faculties (NONPF) delineated nurse practitioner (NP) core competencies (NONPF, 2011), and in 2015 reaffirmed endorsement of the DNP degree as the entry level for NPs (NONPF, 2015). The American Association of Nurse Anesthetists (AANA) determines specialty practice competencies for certified registered nurse anesthetists (CRNAs) and adopted the position requiring the doctorate for entry into practice (AANA, 2007; AANA, 2013); The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) requires that nurse anesthetist students graduate with a doctoral degree by 2025 (COA, 2016). In 2015, the National Association of Clinical Nurse Specialists endorsed the DNP degree as a requirement for clinical nurse specialist (CNS) entry to practice, effective 2030 (National Association of Clinical Nurse Specialists, 2015). Other advanced nursing practice organizations have developed competencies for their respective specialties as well, including the American Organization of Nurse Executives (AONE, 2015), American College of Nurse-Midwives (ACNM, 2012), and Healthcare Information and Management Systems Society (HIMSS, 2015).
EXHIBIT 11.1 AACN Essentials of Doctoral Education for Advanced Nursing Practice
I. | Scientific underpinnings for practice |
II. | Organizational and systems leadership for quality improvement and systems thinking |
III. | Clinical scholarship and analytical methods for evidence-based practice |
IV. | Information systems/technology and patient care technology for the improvement and transformation of health care |
V. | Health care policy for advocacy in health care |
VI. | Interprofessional collaboration for improving patient and population health outcomes |
VII. | Clinical prevention and population health for improving the nation’s health |
VIII. | Advanced nursing practice |
AACN, American Association of Colleges of Nursing.
Source: AACN (2006).
231Early supporters of AACN and the DNP degree cited increasingly diverse and vulnerable populations, rapidly evolving health care systems, and increased complexity of care as needs for better prepared health care providers (Draye, Acker, & Zimmer, 2006; Marion et al., 2003; Mundinger, 2005). The IOM report The Future of Nursing (IOM, 2010), the DNP Essentials (AACN, 2006), and the AACN DNP Task Force Report (AACN, 2015) and various position statements from specialty organizations identify attributes to be achieved through practice-doctorate education preparing nurses in advanced practice to become leaders in the ever-changing future health care environment (Table 11.1). The early rationale and current national acceptance for the DNP degree continues to serve as the impetus for recommending the practice doctorate as the entry into advanced nursing practice.
A survey conducted by O’Dell (2012) of 175 academic institutions with a DNP program and 123 institutions (70.3%) responding, projected a total number of 10,331 DNP graduates in 2012 and 59,872 by 2015 (O’Dell, 2012). By the end of 2013, 251 schools offered the DNP degree and 68 additional schools were planning to begin a DNP program (Auerbach et al., 2014; Kirschling, 2014). The actual number of DNP graduates by the end of 2013 was 14,699 (Kirschling, 2014). Based on the AACN 2015 annual survey, 292 DNP programs were available; 62 postbaccalaureate and 66 postmaster’s DNP programs were in development; and a total of 4,100 students had graduated from 289 programs during that year (AACN, 2016; D. Fang, personal communication, September 27, 2016).
TABLE 11.1 Projected Attributes of DNP-Prepared Advanced Practice Registered Nurses
Attributes | Sources |
Leadership in patient care and health care systems | Bellflower and Carter (2006), Drayer et al. (2006), Marion et al. (2003), Marshall and Broome (2017), Montgomery and Porter-O’Grady (2010) |
Influence on health care policy | Bellflower and Carter (2006), Nelson, Cook, and Raterink (2013) |
Improve quality care and safety issues | Marion et al. (2003), Mundinger (2005), Mundinger et al. (2000), Nelson et al. (2013) |
Improve clinical management | Draye et al. (2006), Marion et al. (2003), Mundinger (2005), Mundinger et al. (2000) |
Improve interprofessional practice, interprofessional collaboration | Drayer et al. (2006). Nelson et al. (2013), Staffileno, Murphy, and Carlson (2016) |
Improve translation of evidence-based practice into health care | Bellflower and Carter (2006), Syler and Levin (2012), Terhaar, Crickman, and Finnell (2016), Waldrop et al. (2014) |
Improve health promotion/risk reduction | Draye et al. (2006) |
Improve coordination of care | Draye et al. (2006) |
Use of technology for data collection and analysis of information | Draye et al. (2006), Montgomery and Porter-O’Grady (2010) |
Doctoral-prepared clinical educators | Fang and Bednash (2017), Marion et al. (2003), Staffileno, Murphy, and Carlson (2016) |
DNP, Doctor of Nursing Practice.
232Although evidence exists in the literature regarding the positive impact advanced nursing practice has on health care outcomes, evidence reflecting the impact of DNP-prepared nurses is limited. Discussion about the need to document DNP outcomes is ongoing (Anderson, 2015; Love, Allison, & McArthur 2014); yet metrics to evaluate the impact of DNP graduates on care delivery are lacking (Berkowitz, 2014). Given the exponential growth in the number of DNP programs and graduates, outcomes associated with doctoral level advanced nursing practice require examination. A literature search using Cumulative Index to Nursing and Allied Health Literature (CINAHL), OVID, PubMed, and commercial search engines, such as Google Scholar and Bing, revealed no research studies specific to the impact of DNP-prepared nurses on health care outcomes. Reasons for this include insufficient number of DNP graduates to effectively study (Cronenwett et al., 2011), and DNP graduates are scattered across varied practice foci decreasing the likelihood of finding a concentrated group of DNP-prepared nurses to include in an outcome study. A landmark study by Aiken, Clarke, Cheung, Slone, and Silber (2003) which was reinforced by a study in 2008 by Aiken, Clark, Sloane, Lake, & Cheney, found that care provided by Bachelor of Science in Nursing (BSN) graduates demonstrated better patient outcomes than care provided by non-BSN graduates. A systematic review conducted by Stanik-Hutt et al. (2013) found that health care quality and patient outcomes associated with care delivered by NPs were comparable to that of physicians. Unlike findings from these two studies, similar aggregate evidence does not yet exist for graduates with a DNP degree. Many singular or anecdotal reports about DNP projects are published in the literature or presented at professional meetings; however, no research studies have been undertaken to evaluate the impact of DNP-prepared nurses on patient and health care system outcomes. Until such studies are conducted to measure the influence of doctoral-level advanced nursing practice, the impact of DNP preparation remains unknown.
DNP OUTCOMES: PERSONAL AND PROFESSIONAL
Anecdotal reports regarding the impact of obtaining a DNP degree on individual graduates’ personal outcomes have been reported related to personal satisfaction with degree achievement and professional outcomes related to increased salaries, and movement into more desirable, higher level professional positions (Kung, 2012). A survey of self-selected participants reinforced reports that nurses entered DNP programs for the primary purposes of personal satisfaction, job advancement, or job change (O’Dell, 2012). A small study of 11 DNP graduates reported that all 11 were pleased with their decision to obtain the DNP degree and 10 of the 11 indicated that obtaining the degree had changed their practice (Melnyk, 2013). This study also supported job advancement or change as seven graduates (63.6%) experienced a job shift following graduation, assuming administrative and academic roles (Melnyk, 2013).
233TABLE 11.2 Average Annual Nurse Practitioner Salary Based on Education
The salary increase reported anecdotally is supported by the findings from the National Salary Survey for Nurse Practitioners and Physician Assistants for years 2011 to 2015, which indicated that the average salary of DNP-prepared NPs is higher than the average annual salary of master’s-prepared NPs (Advance Healthcare Network, 2015; Advance Healthcare Network, 2016; Jones, 2013; see Table 11.2). The authors did not explain the reduction of DNP-prepared NP salaries from 2014 to 2015. However, closer evaluation of the survey data indicates that greater than 50% of the respondents in the 2015 survey had 5 years or fewer years of experience (Advance Healthcare Network, 2016). The lower starting salaries of new NPs and growing numbers of DNP-prepared NPs may have impacted the average annual salary toward the lower end.
The DNP degree has been identified as having a positive impact on the empowerment of nurses to influence parity with other health care professionals and to impact health care (Dennison, Payne, & Farrell, 2012; Pritham & White, 2016). The issue of achieving parity with other health care providers is also a rationale provided in the AACN’s development of the DNP entry-level proposal (AACN, 2004). Research to determine the degree to which parity and empowerment are being achieved in DNP-prepared nurses is necessary to demonstrate the level to which these goals are being accomplished.
DNP OUTCOMES: DNP COMPETENCIES
The Essentials of Doctoral Education for Advanced Nursing Practice describes the foundational competencies expected of all DNP graduates prepared for specialized advanced nursing practice (AACN, 2006). Competencies in a particular specialty are determined by the national specialty organization for the particular specialty. The hallmark of DNP education is development of skills to search for, evaluate the quality of, and apply evidence to practice to create change and improve patient outcomes. The DNP graduate demonstrates leadership competencies in the translation of evidence for practice, directing quality improvement initiatives, influencing health care policy, leading or participating in interprofessional teams, and utilizing information systems and technology to transform health care (AACN, 2006; Berkowitz, 2014; Pritham & White, 2016; Redman, Pressler, Furspan, & Potempa, 2015).
In 2012, 3 years (2010–2012) of national survey data related to DNP outcomes were collected to answer the question: Are graduates of DNP programs utilizing these core competencies in practice? (O’Dell, 2012). While the number of self-selected respondents was small for each of the 3 years, 294, 359, and 248, respectively, some interesting findings were identified. The DNP degree was established for APRNs with a clinical focus as an 234NP, CRNA, nurse-midwife, or CNS, as well as for nurses whose practice specialty focuses on aggregate and systems including nurse executives and nursing informaticists. Data from the O’Dell survey indicated that the majority of students were in programs of clinical concentration, with above 60% of respondents indicating they were APRNs in each year for 2010, 2011, and 2012. The second highest area of DNP program emphasis among participants in the survey, approximately 20%, was advanced nursing practice with a leadership concentration for these same years (O’Dell, 2012). Results from the survey also indicated the number of DNP graduates assuming a nurse faculty role was increasing, a finding supporting one of the initial incentives for the DNP degree—to increase doctoral-prepared clinical faculty (AACN, 2006). Other findings indicated that the majority of DNP graduates feel competent in the DNP policy (Essential V), EBP (Essentials I, III), leadership (Essential II), and practice change (Essential VIII) competencies (O’Dell, 2012).
Professional contributions of DNP graduates include publications in journals and podium and poster presentations (O’Dell, 2012), and is an area that is being recognized and evaluated as a DNP outcome measure (Broome & Riner, 2012; Newland, 2012). A survey by Broome and Riner (2012) identified over 300 articles published in 59 journals from 2007 to 2012, where at least one author displayed DNP credentials. The number of publications increased steadily over the 5-year period with most of the publications being focused on practice. Broome and Riner (2012) also identified interprofessional authorship of medical doctors (MD) and doctors of philosophy (PhD) with doctors of nursing practice (Essential VI). Using a different strategy than Broome and Riner (2012), Redman et al. (2015) conducted a database search for publications between 2005 and 2012 having at least one DNP-prepared author in attempts to determine DNP nurse productivity. The authors used publishing in areas of specialty or relevance to the DNP graduate as an indirect measure of leadership and demonstration of scholarship. Eight focus areas among 690 published articles were noted, including role of the DNP; nursing education; clinical practice; health delivery systems/quality and safety; policy, administration, business, and executive; ethics; and other (Redman et al., 2015). Based on review of the publications, DNPs are engaged in strategic roles in practice and education and have cultivated writing scholarship, consistent with the intended outcomes of the DNP Essentials. Redman et al. (2015) validate the need to document outcomes of DNP graduates, particularly measurement of the impact of translation of evidence to practice, ability to lead system and policy changes, and ultimately improvement in health care. The increase in publications and presentations by DNP-prepared nurses indicates the enhanced organizational and system leadership skills and practice impact (Broome & Riner, 2012; O’Dell, 2012; Redman et al., 2015) originally noted in AACN’s call for the DNP degree.
While the expected DNP competencies are well-defined, no studies directly link these outcome competencies to the DNP Essentials. Case examples and anecdotal reports about the impact of DNP-prepared nurses’ scholarly work are found in the literature. Abstracts from podium and poster presentations from professional nursing organizational meetings are abundant. Anderson, Knestrick, and Barroso (2014) and Burson, Moran, and Conrad (2016) describe DNP student projects as exemplars of excellence in clinical practice. Udlis and Mancuso (2015) found that the majority of responders in a study assessing perceptions about the DNP-prepared nurse believed the DNP degree improves the quality of patient care, safety, and outcomes and prepares nurses to be leaders within the health care system, with interprofessional collaboration and in creating change. Pritham 235and White (2016) describe DNP student outcomes in the context of Essentials I, II, and IV as demonstration of the value of the DNP-prepared graduate and provide recommendations for measuring the impact of the DNP according to all of the DNP Essentials. To fully examine the impact of the DNP degree on patient and health care outcomes, methods to assess DNP competencies and outcomes beyond anecdotal reports need to be developed.
DNP OUTCOMES: DNP STUDENT PROJECTS
As previously discussed, there are no published studies comparing the impact on health care outcomes of DNP-prepared graduates to non-DNP-prepared graduates in similar roles. In addition, there are few studies to date documenting the impact of the DNP graduate on the original established goals of improving nursing practice and enhancing leadership skills. The DNP scholarly project is a thread across DNP programs, with components that reflect the DNP competencies and the DNP Essentials (AACN, 2015). DNP projects demonstrate impact on patient care at a system or population level, use of EBP to provide innovative care, demonstration of leadership in system and interprofessional teams, influence on patient populations and professional advocacy through policy impact, and demonstration of financial considerations regarding health care decisions. The incorporation of competencies in the DNP project supports the examination of the agglomeration of DNP student projects to answer the question: Do the knowledge and skills gained by this doctoral degree translate into improved patient, system, and educational outcomes?
With the goal to discover areas where DNP graduates are focusing their efforts, an informal web search for DNP projects was performed. In addition, e-mails and phone calls were made to a number of schools with DNP programs requesting a list of DNP project titles and/or abstracts. The search yielded 512 DNP projects from over 51 schools; 243 were accompanied by abstracts. The remainder consisted of simple listings of DNP project titles. Project titles and abstracts were reviewed to identify emerging trends of the foci for DNP projects. If an abstract was not available for review, the project title itself was reviewed. Some titles were detailed enough to clearly identify the focus of the project; however, some titles were either too vague or not explicit enough to clearly appreciate the intent of the project. Broad categories were established in an attempt to categorize elements of the projects with regard to population, setting, and problem. As expected, many of the projects spanned multiple categories. Exhibit 11.2 provides examples of titles of DNP projects from each of the schools sampled.
Summary of DNP Projects
While it was difficult to determine the specific population for each project, the population ages ranged from neonates to the older adult, with the majority of the projects focusing on adult males and females. African Americans were the predominant minority race specifically identified as the population of interest, followed by Latinos, American Indian/Alaskan Natives, and Northwest tribes. International projects included Germany, Nigeria, Central Russia, Costa Rica, and Haitians in Dumay. Interestingly, there was an interest in issues related to veterans. There were a high number of project titles focusing on nurses, APRNs, and students. Many of the nurse-focused projects were directed toward education regarding practice change efforts or influence on attitudes. Settings for projects ranged from the community, long-term care, and retail health settings to hospitals and intensive care units.
236EXHIBIT 11.2 Examples of DNP Projects
Health Promotion Empowering Community Health: A Faith-Based Approach Promoting Nutritional Awareness and Improving Dietary Habits: A Community-Based Approach Clinical Decision Support System Improves Bone Mineral Density Screening Rates in 65-Year-Old Women Developing Evidence-Based Evaluation Strategies for a Campus-Workplace Violence Prevention Program Cardiovascular Disease Awareness: Promoting Healthy Lifestyles in African American Females Colorectal Cancer Screening in a Free Primary Care Program for the Uninsured Teenage Pregnancy: An Impact of the Healthy Choices Abstinence Program An Evidence-Based Toolkit to Prevent Meningococcal Meningitis in College Students Provider-Focused Process Improvement Project to Enhance Patient Participation in a Tobacco Smoking Cessation Program Bully Victim Identification and Intervention Program for School Nurses A Quality Improvement Initiative to Increase HPV Vaccine Uptake and Dose Completion Rates Using an Evidence-Based Educational and Reminder Strategy With Parents of Pre-Teen Girls |
Population/Diagnosis Focus Assessment of Male Partner Needs and Experiences During Labor and Birth Neonatal Hypoglycemia and Prompted Interventions During the Pre-Transport Phase of Care Childhood Obesity Prevention in the Context of Family Activity: Development of an Evaluation Tool for the PAK Family Activity Event Evaluation of a Multidisciplinary Clinical Intervention on Childhood Obesity at Seattle Children’s Hospital Perceptions of Body Image, Body Satisfaction, and Knowledge of Obesity-Related Health Risks Among African American College Students Improving Diabetes Self-Care Behaviors of Adolescents Through a School-Based Diabetes Care Initiative Missed Opportunities for the HPV Vaccine in 13-Year-Old Girls Receiving Care at NeighborCare Health A Transition Checklist for Adolescents with Sickle Cell Disease Examining the Influence of Structured Diabetes Self-Management Education on Patient Outcomes in an Outpatient Setting The Predictive Value of Second Trimester Blood Pressures on the Development of Preeclampsia Improving Patient Satisfaction with Better Pain Management in Hospital Patients ACES: A Quality Improvement Program to Improve Asthma Outcomes The Effect of an Evidence-Based Support Intervention to Facilitate Treatment Preference Decision Making by Surrogates of Persons With Incapacitating Dementia Translation of Autism Screening Research Into Practice Pressure Ulcer Prevention Protocol of Older Adults in a Nursing Home Setting Implementing an Evidence-Based Pain Assessment Guideline Within a Pediatric Transitional Hospital Setting |
Focus on Veterans Effectiveness of a Four-Item Screening Tool for Returning Operation Iraqi Freedom/Operation Enduring Freedom Veterans Gap Analysis: Transition of Health-Care from the Department of Defense to the Department of Veterans Affairs Cognitive Behavioral Therapy for the Treatment of Sleep Disturbances in Soldiers With Combat-Associated Mild Traumatic Brain Injury |
Hospital-Based Care The Evaluation of the Implementation of an Individualized Educational Program on the 30-Day Readmission Rate for Patients With Heart Failure in a Community Hospital Application of the Iowa Model of EBP to Promote Quality Care in the Peri-Operative Management of Pacemakers and Implantable Cardioverter-Defibrillators 237Evaluation of Cue vs. Schedule-Based Infant Feeding Protocols in the Neonatal Intensive Care Unit Implementing an Evidence-Based Risk Assessment Model for Chemotherapy-Induced Neutropenia Evaluation of an Evidence-Based, Nurse-Driven Checklist Designed to Prevent Hospital-Acquired Catheter-Associated Urinary Tract Infections in Intensive Care Units Patient Rounding in the LTAC Setting: An Opportunity to Positively Impact Patient Call Light Use, Patient Satisfaction, and Patient Safety Implementation and Evaluation of an Evidence-Based Oral Care Guideline in a Mechanically Ventilated Patient Population Improvement of Family-Centered Care Practices in the Neonatal Intensive Care Unit Evaluation of the Effectiveness of the Ruby Slipper Program in Reducing Falls on a Medical Surgical Unit Implementation of Early Goal-Directed Therapy in Management of the Septic Patient Inpatient Fall Prevention Program: Reducing Patient Falls Through Implementation of a Clinical Fall Prevention Team Quality Improvement Intervention Using Split-Dose Protocol for Bowel Preparation for Colonoscopy Transition Home for Patients With Heart Failure: A Pilot Program at a Critical Access Hospital Exploring Coping Mechanisms of Palliative Care Patients in an Acute Care Setting |
Psychiatric-Mental Health Tele-Psychiatry: Pilot Training Program for Washington State Department of Corrections Psychiatric Prescribers Enhancing Mental Health Services Utilization Among African Immigrants and Refugees in the Northwest Heightened Mental Health Awareness on a Diverse, Urban Public University Campus Through a Medical Outreach Campaign Developing a Treatment Guide for PTSD Evaluation of Alcohol Management Practices in a Community Hospital Educating Nurses About Postpartum Depression in the Acute Care Setting Examining the Effectiveness of an Aggression Management Program in an Inpatient Psychiatric Setting Psychiatric Nurse’s Attitudes and Perceived Barriers About Medical Emergency Teams: A Quality Improvement Project Implementation of a Mental Health Screening Tool by School Nurse Practitioners |
Cultural and International Focus Implementation and Evaluation of a Model of Expanded Nursing Practice in Germany: A Pilot Program Case Study From the Urban Village in Central Russia: Evaluating Barriers to Vaccine Administration and Vaccine Compliance Improving Cardiovascular Health for Haitians in Dumay Using a Community Organization Approach A Multi-Factorial Tailored Intervention to Improve Adherence in Uninsured and Underserved African Americans With Hypertension Education of Incarcerated African American Males on Sexually Transmitted Diseases Can an Educational Intervention Lower Blood Sugar Levels in Latinos at Risk for Developing Diabetes Mellitus Storytelling, a Cognitive Behavior Pain Management Strategy for American Indian and Alaska Natives Evaluation of the Impact of Information on HPV, Cervical Cancer and PAP Smear Knowledge Among Costa Rican Women Enrolled in HPV Vaccination Trial Policy Development to Improve Quality of Life Outcomes of Breast Cancer Survivors in a Northwest Tribal Community Evaluation of Spanish Diabetes Group Visits at a Community Health Center |
Technology Use of the Electronic Health Record in the Measurement of Nurse Practitioner Performance Tele-Visitation: A Strategy to Reduce Distress Among Isolated Blood and Bone Marrow Transplant Patients Post-Transplantation 238Using Computerized Physician Order Entry (CPOE) to Improve Prescribing of Analgesics and Benzodiazepines to Persons 65 and Older Feasibility of a Webinar for Coaching Patient With COPD on End-of-Life Communication The Use of Documentation Prompts as an Intervention Strategy for Primary Care Providers Managing Children in Out of Home Placement Identification and Elimination of Barriers to the Use of a Technology-Based Patient/Family Education System Crisis Team Training of Perinatal Health-Care Professionals Using Simulation Technology Treatment Fidelity Evaluation of Tele-Health Stage-Based Motivational Interviewing Interventions My Papp: An Android App to Educate About Pap Testing Home But Not Alone: Telephone Support for the First-Time Breastfeeding Mother Efficacy of an Electronic Integrative Protocol in Managing Alcohol Withdrawal Syndrome: A Quality and Safety Initiative Development of Smartphone Application to Detect Hypertension in Children and Adolescents An Evaluation of a Text-Messaging Program to Achieve Smoking Cessation Among Young Adults |
Health Policy Policy Development for Prenatal Care Assurance: A Strategic Approach to Improve Maternal and Infant Health Among American Indian and Alaska Native (AIAN) Communities in Washington State Methicillin-Resistant Staphylococcus aureus (MRSA) Infection Control Policy at First Place School: A Policy Development in a Vulnerable Community Public Policy Involvement and Behavioral Intentions Toward Health Policy Research Among Nurses With Professional Doctorates |
Professional and Administrative Nursing Strategies to Improve Patient Flow in an Urgent Care Facility Nurse Manager Leadership Development Program Evaluation Transformational Leadership Behaviors of Successful Nurse Managers Integration of Nurse Practitioner Practice Into a Patient-Centered Medical Home Roadmap to Improved Trauma Outcomes: The ACNP Practice Model The Use of Mentoring by a Nurse Executive to Affect Nurse Managers’ Use of Transformational Leadership Behaviors Does the DNP Change Clinical Practice? Developing a Farm Team: Succession Planning for Nurse Managers Examining and Reducing Distractions and Interruptions During Medication Administration Emotional Intelligence and Nurse Managers: Does Coaching and Training Make a Difference? |
Education Acute Pain Management: A Nursing Education Program for Improved Outcomes Disaster Preparedness and Response: Implication for Nurse Practitioner Education Predictors of the First-Year Nursing Student at Risk of Early Departure An Educational Intervention to Implement SBAR for Nurse Provider Telephone Communication Acute Pain Management: A Nursing Education Program for Improved Outcomes Evaluation of Nurses’ Education Program on End-of-Life Care |
Practice Models MD-NP Collaborative Practice: Models, Barriers and Improvement Strategies Use of Nurse Case Managers in Diabetic Care 239Collaboration in an Outpatient Clinic Setting: Strengthening Care for Patients Nurse Practitioner–Led Heart Failure Clinic Development of an Online Learning Module Focusing on the Principles of EBP for Newly Hired Registered Nurses Integrating Cardiology Acute Care Nurse Practitioners Into a House Staff Model of Care: Development of Performance and Value-Added Outcome Measures Promoting the Coordination of Care for Patients With a Diagnosis of Chronic Illness and Substance Abuse in a Managed Care Organization The Development of a National, Multimodal, Multidiscipline Evidence-Based Clinical Practice Guideline for the Prevention and Management of PONV/PDNV in Adult Patients |
COPD, chronic obstructive pulmonary disease; DNP, Doctor of Nursing Practice; EBP, evidence-based practice; HPV, human papillomavirus; LTAC, long-term acute care; PAK, physical activity kit; PONV/PDNV, postoperative and post-discharge nausea and vomiting; PTSD, posttraumatic stress disorder; SBAR, situation, background, assessment, recommendation.
As might be expected, chronic disease was a major focus, specifically, cardiovascular disease, valvular heart disease, heart failure, stroke, diabetes, hypertension, liver disease, chronic obstructive pulmonary disease (COPD), asthma, and end stage renal disease. Other disease-specific foci included various cancers, HIV, obesity (especially childhood obesity), transplant, dementia, attention deficit disorder, and autism. Pain, end of life, hospice, and palliative care were noted as areas where health care needs were identified. Additional projects addressed women’s health, psychiatric mental health, disaster preparedness, and use of technology, informatics, and telemedicine.
Within these populations, settings, and diagnoses, projects were focused on health promotion strategies, development and evaluation of practice guidelines and quality improvement initiatives, practice models, models of care transition, interdisciplinary care, and health policy changes. Projects focusing on academic curriculum development, continuing education, and administrative topics, such as leadership and system changes, were also included. This review supports the practice doctorate’s broad scope of impact identified by Burson et al. (2016).
DNP projects have been identified as examples of clinical excellence (Anderson et al., 2014; Burson et al., 2016), demonstrating the impact of the practice doctorate. The use of digital repositories for DNP projects has been recommended by AACN (2015) to “archive and share . . . the work and outcomes [of the DNP projects]” (p. 5). As dissemination of DNP scholarly projects grows through publications, supported by growth of digital repositories, DNP projects will continue to serve as a source to document impact of practice-doctorate outcomes until higher levels of evidence become available.
RECOMMENDATIONS FOR DNP OUTCOME STUDIES
The current focus on health care outcomes, compounded by the ongoing monitoring of educational outcomes, highlights the need for research of DNP-related outcomes to 240document the impact that DNP-prepared nurses have on quality of care, policy reform, and reduced costs. Research that demonstrates a positive impact in these areas can be used to garner support of key decision makers, such as legislators, health care providers, the community, third-party payers, and administrators (Newland, 2012). Data demonstrating the effectiveness of DNP-prepared nurses is necessary to demonstrate to employers the contributions that DNP-prepared nurses can make to the health care system (Burson et al., 2016; Pritham & White, 2016).
Policy
DNP graduates have impacted policy initiatives primarily at the local and regional levels (O’Dell, 2012); however, nursing has a history of leading policy change at a national level, such as the Magnet® process, which is affiliated with the AACN (American Nurses Credentialing Center, 2008; Leavitt, 2009). The DNP Essentials and early supporters of the DNP degree cited leadership in policy reform to improve health care outcomes as a key role. There have been case reports of DNP-prepared nurses being appointed to state and national advisory commissions to shape health care delivery through impacting policy (Pritham & White, 2016). It has been suggested that all nursing researchers should examine policy implications of their research (Leavitt, 2009); however, documentation of widespread transition of research findings into public policy reform led by nurses with practice doctorates is lacking. The analysis, synthesis, application, and evaluation of evidence is a cornerstone of DNP education and practice, placing DNP-prepared nurses in the role to serve as the advocate to champion policy change.
Evidence-Based Practice
As the number of hospitals striving for and maintaining Magnet status increases and the implementation of EBP in health care delivery continues, there will be growing needs for leadership and mentors in this area (Burson et al., 2016; Melnyk, Fineout-Overholt, Gallaher-Ford, & Kaplan, 2012; Syler & Levin, 2012). The DNP-prepared nurse is the logical choice to help fill these roles as one of the main foci of the practice doctorate is the use of EBP to transform health care and policy to improve health care and health care systems (Burson et al., 2016; Melnyk, 2013). The impact of DNP-led EBP changes needs to be documented in the areas of quality care, patient outcomes, cost reduction, and employee satisfaction (Melnyk et al., 2012). Research on the impact of implementation of EBP clinical guidelines on patient care outcomes is warranted in a multitude of settings and a variety of patients. The use of EBP is not limited to the clinical practice setting. Research is needed in academic arenas to determine the most effective teaching modalities, curriculum structure, and the impact that DNP-prepared faculty have on educating nurses of tomorrow.
Quality and Safety Improvement
The Quality and Safety Education for Nurses (QSEN) expanded its recommended knowledge, skills, and attitudes (KSA) to the advanced nursing practice level, with the APRN expected to take the leadership role in combining EBP, information technology, and outcome measures related to quality and safety processes (Cronenwett et al., 2009). These 241recommendations were supported in word or in spirit by the national organizations representing APRNs. The quality and safety arena is open for research concerning outcomes related to DNP-level nursing practice, to include evaluation of the educational curriculum using the APRN KSA as an outcome measure for DNP students and graduates. The KSA can also be used to select quality and safety outcomes to be monitored and impacted by DNP-prepared nurses.
Academic Education
As the number of DNP programs is expanding across the United States, research to demonstrate the quality and rigor necessary to adequately prepare DNP graduates is vital. DNP graduates require the skillset to be practice change leaders, a skillset that includes “[use of] informatics, secondary data analysis, team science and implementation science” (Broome, 2012, p. 112). What educational methodologies effectively prepare DNP students with this knowledge and these skills? What faculty is necessary to guide the development of leaders at this level? What courses are needed to provide the foundational concepts and encourage application of the concepts to prepare for practice in the future health care setting? These questions need to be answered with research focused on outcomes to guide decisions in the academic arena. Additional research is needed with regard to the impact that DNP-prepared faculty have on the outcomes related to the education of nursing students, the impact of tenure versus non-tenure-track appointments for DNP-prepared faculty, the leadership of DNP-prepared faculty in academic settings, and the impact practice requirements have on DNP APRNs who are full-time faculty.
SUMMARY
Jamesetta Newland reminds her DNP students, “Upon graduation, it can’t be business as usual. People have to see a change in how you practice” (Newland, 2016, p. 6). The impact DNP-prepared nurses have on patient, health care, and policy outcomes is becoming more evident as the numbers of DNP graduates increase and studies analyzing these outcomes become more prevalent. The review of the literature demonstrates an increased number of articles about outcomes related to DNP-prepared nurses; however, most of the articles reflect anecdotal comments, include a small sample size, or utilize a case study approach. More robust research related to DNP outcomes has been called for in a number of articles and editorials. Research supports that APRNs educated at the master’s level are highly competent, providing care with equal if not better outcomes than physicians (Stanik-Hutt et al., 2013). However, future questions needing answers include: (a) How do outcomes achieved by DNP-prepared nurses compare with outcomes achieved by non-DNP-prepared nurses? and (b) Will the master’s-prepared APRN be as well prepared to provide care in the increasingly complex and diverse health care system as the DNP-prepared APRN? Health care policy decisions, such as the Affordable Care Act, and future initiatives proposed by leaders in the field of health care, such as the Josiah Macy Jr. Foundation, the IOM, and the Robert Wood Johnson Foundation, have and will continue to open the door for DNPs to shape the course of health care through projects developed to positively impact outcomes. This, in turn, should drive the need for research as 242to who is best prepared with the knowledge, skills, and abilities to demonstrate positive outcomes. Will it be the DNP-prepared nurse? The expectation is that it will be; however, research is needed to validate that assumption.
