These discussions about the place of philosophy of science and the place of the scientific method in the DNP degree are important questions. In the brief period of its short history, it is not reasonable that absolute conclusions about the nature of knowledge development in this degree should have already been fully agreed on, much less codified. In other words, to say so quickly “we thought about it, discussed it, and know what the right course of action is” is folly. Indeed, Reed wrote in 2006, “And during the last decade, scholars within and outside of nursing increasingly acknowledged the role of human practices in knowledge production and critiqued orthodox epistemology with its one path to scientific knowledge” (Reed, 2006, p. 36). Arriving at some conclusion or set of conclusions about what the final scholarly work product of a DNP degree should ultimately be will not happen if we leave it to national accrediting agencies or specialty organizations to decide. There is already a growing body of literature now criticizing these types of bodies, external to the academy, for thwarting educational innovation through regulation (Dreher, 2008a; Lederman, 2014; Melnyk & Davidson, 2009; Neal, 2008). Although select members of these agencies or organizations may support the mission of knowledge development, it is not the chief function of these entities to which they belong. This mission—extending knowledge development in any discipline—is a responsibility for scholars chiefly in the academy (remember discussions in Chapter 2 about who belongs and who is best prepared to produce this knowledge?). We predict that this will happen because nursing practice scholars will likely conclude that many past and current DNP students are actually generating evidence for the discipline (yes, including even sometimes empirical evidence) by their current model(s) of clinical or practice inquiry. Others, admittedly, are not. Part of this journey begins with an expansion of the meaning of evidence to be addressed in this chapter (Rycroft-Malone et al., 2004).

With a decade using the new practice doctorate behind us, the kind of inquiry that is taking place in DNP programs toward degree completion needs a label. It needs to be articulated. It will require much more critical reflection and examination on the nature of knowledge development in a practice discipline for us to arrive at a consensus. We provide our own contribution to this discussion in this chapter by asking, is it: (a) practice knowledge; (b) Mode 2 knowledge (Glasgow & Dreher, 2010; Rolfe & Davies, 2009; Stew, 2011); (c) actionable knowledge (Coghlan, 2007; Pope, 2007); or (d) practice inquiry (Magyary, Whitney, & Brown, 2006)? We offer some further discussion points about this issue that is continuing to percolate in current academic nursing scholarly circles, particularly as DNP enrollment and number of programs have surpassed the total of PhD programs and there are reports of uneven quality.²

Nonetheless, we never want to hear again what some graduates³ at a national DNP conference and at an international conference on the professional doctorate have said, “They [the faculty] wouldn’t let me do that” or “They [the faculty] wouldn’t let me call it a ‘dissertation’ ” or, worse, “They [the faculty] wouldn’t let me call it research.”

Moreover, having also heard the following, we begin the discussion on evidence by asking what does it really mean when a DNP student proclaims, “I have to use existing research to implement a change that will improve practice?” Table 16.1 indicates Sackett, Strauss, Richardson, Rosenberg, and Haynes’s (2000) levels of evidence. This highly regarded internationally recognized classification of categories of levels of evidence, though not the only evidence-based classification available, is widely used to classify the scientific health knowledge that is produced en masse around the globe (Harbour & Miller, 2001; Petrisor & Bhandari, 2007; Rich, 2005).

As a full explanation of Table 16.1 is not possible in this text (a simple Internet search will wield a massive amount of information), the table can be summarized as follows for the purpose of our discussion.⁴ Primarily used for evaluating studies in clinical care, a (peer-reviewed) published paper is first classified according to levels 1 through 5 and sublevels a through c. These are indicated in Table 16.2. The higher the classification of level (1), the higher the likelihood that the study is valid, but not necessarily its clinical relevance or applicability. The lower the classification of level (5), the lower the likelihood that the study is valid, but again, not necessarily its clinical applicability. The sublevel classification is also rated from a (highest) to c (lowest), although in levels 4 and 5 there are not sublevels of classification (Petrisor & Bhandari, 2007). Finally, the study is graded A through D as follows: A: consistent level 1 studies; B: consistent level 2 or 3 studies or extrapolations from level 1 studies; C: level 4 studies or extrapolations from level 2 or 3 studies; and D: level 5 evidence or troublingly inconsistent or inconclusive studies of any level (Oxford Centre for Evidence-Based Medicine, 2010). Extrapolations are where data are reinterpreted to some degree in order to help form the recommendation, aside from the original study situation (Harbour & Miller, 2001). One helpful way to understand the concept of extrapolation in nursing research occurs when investigators use the word generalizable when discussing whether the data findings in one study population can be generalized (or extrapolated) to another population. We thus pose the following question: How will the published work product of the DNP student be evaluated and classified? This becomes a critical question if the work is truly designed to be published and disseminated.⁵ Whatever the debate, when it comes to working with colleagues from different health professions, Sackett represents the predominant scientific paradigm.

Pearson, Wiechula, Court, and Lockwood (2007) nevertheless do challenge this paradigm and write, “However, practice discourses across the health professions are characterized by ongoing, vigorous debate on the meaning of evidence when attaching this epithet [evidence] to healthcare practices” (p. 86). Indeed, Rycroft-Malone et al. (2004) suggest that in the practice domain, the concept of evidence is more complex and may mean something different from the traditional, objective, quantitative scientific explanation (Rycroft-Malone et al., 2004). The Joanna Briggs Institute in Australia has long been an innovator in the promotion of their FAME scale that categorized evidence-based health care studies according to four major evidence interests (termed the FAME scale): (a) evidence of feasibility; (b) evidence of appropriateness; (c) evidence of meaningfulness; and (d) evidence of effectiveness (Houde, 2009; Murphy, Robinson, & Lin, 2009; Pearson, Borbasi, & Gott, 1997). According to this model, “Any indication that a practice is effective, appropriate, meaningful, or feasible, whether derived from experience or expertise or inference or deduction or the results of rigorous inquiry, is regarded as form of evidence in the model” (Pearson et al., 2007, p. 87).

TABLE 16.1    Sackett’s Levels of Evidence

More recently, they have revised this model in their working paper “Supporting Document for the Joanna Briggs Institute Levels of Evidence and Grades of Recommendation” (Joanna Briggs Institute, 2014). Much of the work described in this document has been the result of a growing international recognition that most taxonomies that classify research studies favor experimental studies over observational studies. However, that becomes a design bias that does not necessarily reflect reality, where an observational study may actually be more valid. In other words, a true experiment may employ too many controls, creating conditions that are “almost too prefect” (Shuttleworth, 2008), leaving the phenomenon under investigation no longer under real world conditions. From the Working Party:

While the previous FAME scale classified evidence according to evidence of feasibility, appropriateness; meaningfulness; and effectiveness (Houde, 2009; Murphy et al., 2009; Pearson et al., 1997), the current model classifies evidence according to evidence of effectiveness; evidence of diagnosis (apply to studies assessing only diagnostic test accuracy, and when randomized controlled trial(s) [RCTs] are employed on important patient diagnostic tests, then evidence of effectiveness is sufficient); evidence of prognosis (“study findings are pre-ranked findings based on the study design and then upgraded or downgraded based on a number of factors,” p. 5); evidence of costs (these are not evaluated based on study design, but to the variety of locations, interventions, or procedures used in a study and where these financial factors will be considered in decision-making—i.e., the intervention was very effective but its costs are prohibitive); and evidence of meaningfulness (previously described in the first FAME model). Last, the Joanna Briggs Institute model tried to integrate qualitative findings in their evaluation of levels of evidence, something practically ignored by other taxonomies. However, in their revision of this, they downgrade the importance of credibility of findings, stating “it was deemed by the working party that this should not be considered when assigning a level of evidence, but rather when creating a summary of findings table and moving to recommendations” (Joanna Briggs Institute, 2014, p. 6).

So what does this mean? It sounds like there is a “bigger tent” for the evaluation of what constitutes evidence and thus help to move evidence to knowledge, where nursing knowledge development can be directly used. Dreher (2013) supports the more utilitarian usage of knowledge versus evidence and states:

We suspect as the DNP degree matures over time, there will be more refinement regarding the nature of practice knowledge development and its place in the wider epistemology of the nursing discipline. Therefore, in the spirit of scholarly discourse among members and future members of the academy, with an aim to advance the nursing discipline, we pose several questions about DNP clinical scholarship and stewardship.

IS IT “PRACTICE INQUIRY”?

Practice inquiry has been proposed both by nursing scholars at the University of Washington School of Nursing and by public health and physician scholars affiliated with several medical schools, including the University of California-San Francisco (Magyary et al., 2006; Sommers, Morgan, Johnson, & Yatabe, 2007). In the case of its use in medical schools (first described in Chapter 3), practice inquiry is primarily a “set of small-group, practice-based learning and improvement (PBLI) methods designed to help clinicians better manage case-based clinical uncertainty” (p. 246). The aforementioned nursing scholars have introduced the concept practice inquiry differently. For them it is:

Magyary et al. identify four specific domains of clinical research (efficacy research, effectiveness research, service systems research, and practice research) and propose the practice research domain be the particular emphasis for the clinical investigative focus of the DNP.⁶ They suggest practice inquiry “portrays clinical research competences that are integral with advanced practice and, thus, relevant to learn during a practice-intensive doctoral program” (p. 143). It does not quite seem logical, however, to equate “educating professionals to primarily engage in practice at the frontiers of existing knowledge”⁷ (p. 147) with the aims of practice research as outlined by the National Institute of Mental Health (NIMH, 1999).⁸ Comparatively, a 2006 program announcement by the NIMH (PAR-06–441) described the following as possible research exercises within the practice research infrastructure:

It should be noted that the work of NIMH in the practice research has continued. In 2012, the director of the NIMH, Thomas Insel, wrote on his director’s blog:

In his blog, he mentioned new work by the NIMH using a consortium of 13 health system research centers dedicated to improving patient mental health through research, practice, and policy using a reverse “from bench to bedside” approach. In the last decade or so, the solution for the lag in implementing research findings more quickly into practice has been to use a “from bench to bedside” translational research approach. However, Insel promotes the reverse framework and writes “we need to stop thinking about moving research [bench] to practice [bedside] and start thinking about moving practice to research⁹ (i.e., from bedside to bench). Maybe Dr. Insel is correct. Maybe the most cost-effective question would be to ask whether the current practice is effective rather than first what is the most effective method? We suggest this would require the practitioner/clinician scholar to think about clinical practice more inductively versus deductively, which is typically the more common form of reasoning in the scientific method where deduction is used to test hypotheses and theories (Bradford, 2015).¹⁰

Our question is whether these types of practice-oriented, clinical research questions can be answered under the umbrella of nursing practice inquiry in DNP curricula, and whether these questions are at the frontiers of existing knowledge or not (or beyond). Magyary et al. (2006) and the nursing scholars at the University of Washington School of Nursing should be applauded for one of the first forays into the context of what is the domain of practice doctorate knowledge development. Nursing scholars at nearby Oregon Health and Science University appeared to support this perspective as well (Pate & Crabtree, 2009). But we are skeptical that we have carved out the absolute boundaries of the practice inquiry domain at this time and even they state “it is important to be cautious and not prematurely differentiate between the 2 programs [DNP and PhD]” (Magyary et al., 2006, p. 147). We conclude the term practice inquiry is a good description of the likely domain of the practice doctorate practitioner/scholar, but we dispute that it properly describes what we should define or call the process or output of practice doctorate scholarship. Practice inquiry is just too oblique a concept (at least at present) for contemporary transdisciplinary usage. We will revisit this argument shortly.

IS IT “ACTIONABLE KNOWLEDGE”?

There is an argument that most of the final scholarly work product in some DNP programs could be termed action research, but this method is used by many disciplines. Our purpose here is not to evaluate the contributions of action research-oriented studies to the body of nursing science. Instead, we are trying to ascertain whether this method is appropriate for the DNP/professional doctoral student, and whether it should be the overriding umbrella over which DNP scholarship should be classified. Kidd, Kenny, and McKinstry (2015) describe participants’ perspectives of the meaning of recovery-oriented care in developing services for people with psychosocial disability associated with mental illness. Coghlan (2007) makes a case for action research in nursing, particularly for students interested in conducting research projects as “insiders in their own organizations” (p. 293). This method is aimed at creating actionable knowledge, which is designed to be used by both academic and practitioner communities (Adler & Shani, 2001). It is also described as a participatory, democratic, and egalitarian method (Drummond & Themessl-Huber, 2007).

Many DNP students are very interested in addressing problems within their own work environment, which can initiate intraorganizational change, including improvements in patient safety, for example (Rapala & Novak, 2007). A significant number of my own DrNP students chose to access populations in their work institutions and examined problems critical in their clinical specialty or to the organization. Physicians conduct clinical research on their patients all the time, especially on clinical research units; therefore, this practice should certainly be extended to doctoral nursing students as well. Pope (2007), a reader in health services research in a school of nursing and midwifery in the United Kingdom, describes some of the advantages and disadvantages of action research. Pope, however, promotes its distinctiveness as a method as it dually enables change while simultaneously conducting the respective research study. Nogeste’s (2008) work is an example of how the action research method has become popular in professional doctorate business programs (Doctor of Business Administration [DBA])¹¹ and describes how it can be used to both conduct research and solve a real-life problem situation. Certainly, this same method could be used by clinical executive DNP students and students who are also examining clinical problems.

IS IT “MODE 2 KNOWLEDGE”?

There is a strong case to be made that the focus of the professional/practice doctorate ought to be on the generation of Mode 2 knowledge (Glasgow & Dreher, 2010; Rolfe & Davies, 2009; Stew, 2011). Internationally, the concept of Mode 1 and Mode 2 knowledge is more prevalent than in the United States where it has barely penetrated in the nursing literature. The concept of Mode 1 versus Mode 2 knowledge was first described by Gibbons et al. in 1994 The New Production of Knowledge: The Dynamics of Science and Research in Contemporary Societies and more recently by Gibbons in a book chapter titled “Mode 1, Mode 2, and Innovation” (Gibbons, 2013). Mode 1 knowledge production was initially described as “ … a complex of ideas, methods, values, norms—that has grown up to control the diffusion of the Newtonian model to more and more fields of enquiry and ensure its compliance with what is considered sound scientific practice” (Gibbons, 1994, p. 2).

In other words, Mode 1 knowledge is traditional and disciplinary-specific and uses hypotheses that are generated, tested, analyzed, and then disseminated in peer reviewed, often minimally reputable to prestigious journals. Heath (2001) states that it is knowledge based on traditional notions of the objectivity of knowledge, either rational¹² or empirical, but which ultimately depends on the notion that knowledge must be based in some form of objective reality. Some community health-nursing scholars in describing methods of research appropriate for primary care inquiry indicate Mode 1 knowledge is hypothetico-deductive and linear in its orientation (Vydelingum, Smith, & Colliety, 2009). It is a broad generalization, but it is presumed the PhD graduate is supposed to generate original Mode 1 knowledge.

On the contrary, Mode 2 knowledge is generated in the context of application and has an orientation to knowledge that is practical, useful, translatable, and has derivative areas of meaningfulness across disciplines. Gibbons (1994) describes the following:

There is a very strong case to be made that the “good science” evolving from the DNP programs where nursing epistemology and practice knowledge development is valued is indeed being conducted within the framework of a Mode 2 knowledge production paradigm, even if this is not articulated or clearly realized. Rolfe and Davies (2009) indicate that second-generation professional doctorates will be the primary generators of this kind of knowledge production in the future, and that it will not occur within the confines of a laboratory or the rigid parameters of a traditionalist academic study. They state, “Under Mode 2, the link between theory and practice is more apparent, and because research takes place in the workplace, knowledge-production and diffusion are interlinked” (p. 1268). The emphasis here, however, is that at least from an internationalist perspective, the professional doctorate (like the DNP) graduate that produces Mode 2 knowledge is engaging in “research” (Dreher & Smith Glasgow, 2011). The resistance by the American Association of Colleges of Nursing (AACN, 2006) to eschew DNP students and graduates from engaging in the research enterprise (beyond translating, implementing PhD nurse scientists’ findings, and then disseminating them) is therefore problematic. The professional nursing doctorate model outside the United States embraces the research enterprise. Instead, it is characterized by a de-emphasis on the research enterprise in comparison to the PhD, but not the absence of it as is often the aim of the DNP (Armsby & Dreher, 2011; Dreher & Smith Glasgow, 2011).

As stated previously, we would suggest that the AACN’s Essentials document may already be largely out of date (AACN, 2006).¹⁴ Produced in 2006 at the beginning of the contemporary DNP degree movement, it was created before there was a critical mass of DNP graduates and before anyone could report with any credibility on outcome data and/or what the first graduates’ new practice domain would actually resemble. Moreover, with many more DNP programs in operation now than PhD programs, there ought to be a heightened urgency to discuss the future logistics of the production of evidence for our discipline. Is not any doctoral graduate after all part of the new knowledge economy? (Fink, 2006)¹⁵ Reed does suggest that Mode 2 knowledge may be central to an emerging epistemology and indicates, “it seems logical that a nurse–patient practice-centered model rather than a researcher-centered model of knowledge production be employed” (Reed, 2006, p. 36). Whether or not the language and discourse surrounding Mode 1 and Mode 2 knowledge will ultimately affect the nursing discipline and find its way into our literature more substantively remains to be seen.

OR IS IT “PRACTICE KNOWLEDGE”?

With a plethora of DNP programs, there is likely going to be a shift or a practice turn in our nursing epistemology (a term used by Reed in 2006) away from the overtly theoretical to the practice-focused and directly and expeditiously translational. Our view is that practice knowledge, by the simplest description, is the by-product of practice research. One example of practice knowledge arising from DNP investigation is from Dr. Alis Panzera, a women’s health nurse practitioner specializing in urology, who first reported that symptoms of interstitial cystitis (IC) in women (N = 407) were statistically related to reports of insomnia (Panzera, Reishtein, & Shewokis, 2011). Her team concluded that “screening for particular symptoms, such as nocturia and pain, and then managing these symptoms could lead to better sleep quality. Examining the area of largest impairment may help providers target their approach to optimal care of patient symptoms” (p. 164). This is actually an example of two things. First, her statistical evidence led her to be able to translate her evidence into practice knowledge (i.e., suggested screening by advanced practice nurses for IC symptoms that may readily contribute to sleep disruption). Second, this DNP student had easy access to subjects so her study was powered at the alpha level of 0.5 and allowed her to make statistically significant conclusions and simultaneously contribute to evidence-based practice (EBP) too.

Practice research is characterized by Magyary et al. (2006) as “the type of research designs and methods that are relevant and particularly germane to examine clinical questions related to the complexity of everyday clinical situations” (p. 141). Barkham and Mellor-Clark (2003) indicate that the domain practice research, along with the other domains of clinical research described by the NIMH (2006; efficacy research, effectiveness research, and service systems research) are research areas “placed within the paradigms of evidence-based practice and practice-based evidence” (p. 319). Using the principle of parsimony¹⁶ (all these being equal, the most frugal or simplest explanation is best) and principle of syntactical simplicity, we would subsume each of these four separate domains of clinical research into a singular domain (Bunge, 1961). We believe that they can be combined and reframed coherently to represent the expanse of practice knowledge development. In other words, “practice research produces practice knowledge.” Extending this analysis, because the nature of practice encompasses inquiry into efficacy, effectiveness, and even into health systems inquiry—practice research can be the unifying domain. Another rationale for subsuming these four domains as one (practice research) is also because most current DNP programs emphasize the practitioner and clinical executive role under the rubric of a practice doctorate (AACN, 2006).

Reed (1996) also offered a decade earlier a description of practice knowledge that actually emanated from a revisiting of the works of the renown Hildegard Peplau. Reed has written that “Specifically; a closer look at Peplau’s theory demonstrates an approach to knowledge development through the scholarship of practice; nursing knowledge is developed in practice as well as for practice” (p. 30). Reed further states, “In this postmodern era, knowledge development is no longer only a concern of theoretical nursing; it is a concern in practice” (p. 30). How prescient Reed was practically a decade before the surge of a new practice doctorate in nursing. Peplau herself later articulated that nursing practice itself was not a research endeavor, but she did emphasize it is a scientific and scholarly endeavor (or should be) (Peplau, 1988). Do we emphasize this characterization of nursing practice today in our baccalaureate programs? In other words, do we talk about nursing practice as scholarly? From her classic and heralded Interpersonal Relations in Nursing (1952), Peplau makes a statement that is prophetic and is referenced by Kikuchi in the epigraph that introduced Chapter 3:

One interpretation of this (and of Kikuchi) is that there is a large body of phenomena in nursing that is unique to the nursing discipline, is complex in its manifestation, and is incredibly challenging (perhaps impossible) to explore using traditional empirical methods of inquiry. Interpretative methods offer an alternative, but even those have their own peculiar limitations relative to the study of nursing phenomena. Madeleine Leininger faced this herself in her translation (or adaptation) of very traditional anthropologically oriented enthnographic methods into her creation of the ethnonursing method (Leininger, 1985). As a contemporary example, we offer two scenarios of nursing sensitive phenomena that challenge our understanding and method of inquiry.

Again, we do not need to wait for the PhD student to answer these questions.¹⁹ If anything, it literally begs inquiry (practice inquiry) by the postmaster’s DNP student who has been treating these kinds of patients for years as an adult, family, or women’s health NP. The most appropriate scientific method can be selected from a host of quantitative, qualitative, or mixed-method options (practice research) in order to ultimately advance the evidence base of nursing (practice knowledge). Furthermore, the findings and implications of this study could have far reaching immediate implications (translational) for other primary care providers (physicians and physician assistants, certified midwives, etc.), and thus it would be transdisciplinary in application, too.

 CONCEPTUALIZING PRACTICE KNOWLEDGE

We offer three conceptual diagrams or figures that try to explicate the domain of practice knowledge development within the larger universe of potential nursing scientific inquiry. Figure 16.1 identifies the process of practice knowledge development from inquiry to product (output) that we just outlined in Case 1.

The first and largest arrow represents the possible pool of inquiry by nursing practice scholars. In our definition, practice inquiry is not a method of inquiry but represents a larger domain of yet analyzed, correlated, explored, tested, hypothesized, and conceptualized (among other modes) data. It is a universal pool of nursing and nursing related (e.g., health, etc.) phenomena that is poised for inquiry by a practice nursing scholar (input). The second arrow represents the chosen scientific method. These methods may be empirical, intermediary/analytical (all the methods that fall between the classic empirical, traditionalist, and quantitative methods, and the interpretive and classically qualitative), or interpretive/classically qualitative methods (process).

The last arrow represents output or practice knowledge. An extremely important point is that this knowledge is generated by the doctoral advanced nursing practice student/practice scholar. It is not the everyday practice knowledge often termed personal practice knowledge that is “grasped in a conscious moment of encountering and interacting with a specific patient” and “developed via the dialectical relationship that is created between each patient and nurse” (Mantzoukas & Jasper, 2008, p. 321) This practice knowledge can have a clinical or organizational orientation and thus would fall within the four domains of clinical research or under the singular rubric of practice research identified earlier. Finally, as described in Case 2, its best representation occurs when this practice knowledge is readily translated through interdisciplinary applications. The two primary care providers working in the same office but from different disciplines (medicine and nursing), should be looking at their aggregate data on weight for their patients and discussing their disciplinary approach so as to improve overall outcomes (just like the monitoring of Hb_1ac levels).

FIGURE 16.1    A model of the path to practice knowledge generation.

A PROPOSED MODEL FOR SCIENTIFIC INQUIRY IN NURSING

First, Figure 16.2 places Figure 16.1 in context of the larger universe of scientific inquiry in nursing science. Here, the Venn diagram first displays an outer square box, which contextually has permeable lines that imperfectly encase the two equivalent circles. Everything inside the box and that which lies outside the permeable lines (representing maybe a future pool of data not yet known) represents the pool of inquiry for nursing science and nursing practice and all the related disciplines and related knowledge that are credible for the theoretical or practice nurse investigator to draw from. For purposes of representation, the Venn diagram (and the square surrounding it) is presented two-dimensionally in this text, but in reality, knowledge is multidimensional. By definition, a Venn diagram is a representation of classes or categories and their possible intersection or overlap. In this figure, however, the overlapping area of intersection is far more rich and complex. This is discussed in detail in this section.

FIGURE 16.2    Model of scientific inquiry in nursing and overlap between competing paradigms.

Second, the large left centric circle represents Mode 1 knowledge or theoretical knowledge. The further to the left any individual study falls within the circle, as the arrows on the bottom and top of both circles pointing left indicate, the more abstractly theoretical the study. Furthermore, such studies are increasingly less oriented to purely EBP and have limited translational capacity. These types of studies would likely have a very low classification on Sackett’s level of evidence, but could still represent serious and rigorous scholarship, just not highly applicable or translatable. Within the same circle, the further to the right any study falls, until the overlapping area of intersection, the more it skews toward practice (whether clinical or organizational) and toward the most rigorous EBP knowledge. We address the area of intersection shortly.

Third (and conversely), the right large centric circle represents Mode 2 knowledge or practice knowledge. Within this circle, the further to the left any study falls, again until the overlapping or area of intersection, the more it does skew toward practice (whether clinical or organizational) and toward practice-based evidence (PBE) knowledge. However, as the arrows on the bottom and top of both circles indicate (they both point to the left), further to the right any individual study falls there is an opposing effect. Studies falling more to the right would be classified as less practice-focused with less emphasis on practice knowledge. They would be moving in the opposite direction away from the overlapping area of intersection and away from a PBE orientation and be less translational (and perhaps less valid).

Finally, the overlapping area of intersection is a very critical area where it might be said the DNP and PhD degree may truly converge, morph or fuse, or be fairly indistinguishable (at least when it comes to the final research product of the doctoral degree or according to the nature of the scientific investigation). Fink (2006) indeed indicates that as the nature of the kinds of directly applicable and translational research changes (what we could call the burden to make research today relevant now or immediately), the “scholarly workplace” (p. 38) for the professional doctorate and the academic PhD will also converge and the distinctions between the two degrees may disappear.²⁰ What does this mean?

The overlapping area of intersection coming from the right (Mode 2/practice-oriented knowledge) signifies the best PBE. Barkham and Mellor-Clark state, “Studies derived from a practice-based paradigm have high external validity because they sample therapy [referring to a specific psychotherapy study] as it is in routine practice” (Barkham & Mellor-Clark, 2003, p. 321). Furthermore, by emphasizing investigation of the practice component in real-time, these types of studies address the applicability of analyzing results within a service or clinical setting with a very high likelihood of immediate translational implications. PBE has somehow become the contretemps (or the reverse) to the larger EBP movement (Geanellos, 2004; Hellerstein, 2008; Horn & Gassaway, 2007; Leeman & Sandelowski, 2012; McDonald & Viehbeck, 2007). However, even before such terminology (specifically PBE) was being used, there were pioneering clinicians who were creating it. In perhaps the most illustrative case, early HIV clinicians/providers experimented with their own inductive drug combinations. They then discovered that they were highly effective in individual patients (or in select groups of patients) long before the respective clinical trials were conducted to confirm the efficacy of any respective therapeutic regimen. These early HIV specialists (mostly physicians but also a very large cadre of nurse practitioners) practiced primary care in very real time and literally “experimented” (Garrett, 1999, p. 1). In Garrett’s (1999) article “The Virus at the End of the World,” she reports on Dr. Michael Saag, who at the time was supervising the research and care of nearly a thousand patients with HIV/AIDS in Alabama, writing, “In one year, 57 of Saag’s patients collectively took 189 different drug formulas, with only three patients taking the same mix of HAART drugs” (p. 1). Like Dr. Saag, they relied on practice evidence to drive their decision making, because medication adherence studies, drug efficacy studies, especially ones that controlled for the diversity of confounding social, metabolic, and other variables, were scarce (Moitra, 2009). One contemporary argument regarding the merits of PBE over EBP knowledge in HIV medicine is stated as follows:

One driver of recent discussions of “evidence” in HIV prevention is the idea that, rather than ever more tightly defining the conditions under which an intervention might work, prevention research would be better served by a methodology designed to identify those interventions that are robust enough to withstand local variation and implementation. A novel goal of HIV prevention research should be to move beyond the ideal of “best practices” indicated by RCTs and toward a range of good practices, applicable under broader circumstances, and gleaned from multiple ways of knowing.²¹ (San Francisco AIDS Foundation, 2008, p. 2)

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