299CHAPTER 13

The Doctor of Nursing Practice (DNP)

Sarah B. Keating

OBJECTIVES

Upon completion of Chapter 13, the reader will be able to:

OVERVIEW

The movement toward a doctorate in nursing for advanced practice and leadership roles has grown tremendously over the past decade. According to the American Association of Colleges of Nursing (AACN), the DNP is the highest level of advanced nursing practice (AACN, DNP Fact Sheet, 2014a). AACN (2013b), in its annual report, listed a total of 217 existing DNP programs with another 97 planning to open. There were 40 states in the nation and the District of Columbia with DNP programs reported by AACN. In addition, nine states each have one clinical doctorate program accredited by the Accreditation Commission for Education in Nursing (ACEN, 2014).

Chapter 13 reviews the DNP, the nature of the professional doctorate and differences from research-focused degrees; its role in practice, health care, and education; the essentials of a curriculum for the degree as recommended by AACN; and the standards for accreditation by the ACEN and the Commission on Collegiate Nursing Education (CCNE).

300DIFFERENCES BETWEEN PROFESSIONAL AND RESEARCH-BASED DOCTORATES

Melnyk (2013) succinctly describes both the PhD and the DNP degree programs and their specific purposes and differences with implication for both practice and research. While nursing has a history for developing various titles for its doctoral programs, academe recognizes two types of degrees. The first is the research-focused PhD program or in the case of nursing, the PhD, doctor of nursing science (DNS). Research-focused doctorates emphasize nursing theory and research and educate nurses who are prepared to conduct research and foster the development of new knowledge in health care and nursing. Often, nurse educators in higher education prefer the research-focused degree for faculty who wish to teach in tenure-track positions. The rationale for this is that research-focused institutions prefer faculty prepared to develop new knowledge and theories in their respective disciplines. Academe in these institutions and other colleges or universities with productive research records award tenure to faculty members who demonstrate research productivity through publications, grants, and other scholarly works that advance knowledge in their disciplines. This results in keeping the curriculum up-to-date and prepares graduates who are abreast of changes in their disciplines and have the potential for further research.

The professional doctorate degree, including the DNP, prepares graduates for application of research to practice; another way to say it is to translate research into evidence-based practice. A few examples from other disciplines that have professional doctorates are the doctor of business administration (DBA); doctor of dental surgery (DDS); doctor of law (LLD); doctor of medicine (MD); doctor of pharmacology (PharmD); doctor of physical therapy (DPT); and doctor of psychology (PsyD). The doctor of education (EdD) is a recognized doctorate that in the past included research and dissertation requirements, although the current trend is for these types of degrees to carry the PhD in education title (doctor of philosophy). The EdD has become an applied professional degree that includes application of research and theories in education to evidence-based practice.

Nursing education programs are sometimes reluctant to hire DNPs into tenure-track positions owing to the DNP focus on applied research and translational science as compared to research for discovering new knowledge. However, the profession and educators recognize the role of DNP graduates for providing instruction and clinical supervision in undergraduate and graduate nursing programs owing to their expertise in evidence-based clinical practice and in translational science. Many DNP graduates demonstrate extensive research in practice that contributes to the science of nursing; therefore, they are eligible for tenure-track positions. DNP graduates who expect to teach in schools of nursing should compare tenure-track policies in potential employing institutions to other types of positions such as clinical faculty that are not research-focused, but still offer academic ranks from instructor to professor and the potential for job stability over time. For both the research-focused degrees (PhD, DNS) and the DNP, AACN (2010) strongly recommends taking courses in education if graduates intend to teach. The National League for Nursing (NLN) (2014) has a vision statement on doctoral preparation for nurse educators that emphasizes the need 301for evidence-based practice in education and the preparation of educators for teaching, assuming leadership in academe and health care systems, and conducting and translating research in nursing education. It lists recommendations to prepare nurse educators for the nursing profession, doctoral programs, and administrators of nursing education programs.

THE ROLE OF THE DNP IN PRACTICE

When the notion of a professional/applied practice doctoral degree in nursing was first introduced in the late 1990s and early 2000s, there was much controversy from the profession and outside of the profession about the role of nurses with doctorates. Among the issues raised by nursing when the programs were fairly new were the many different nursing doctoral degree programs and titles that confuse the public and nursing such as, DNS, EdD, ND, PhD, and so on. Objections to the use of the title “doctor” were raised for fear the public would assume that the provider was a medical doctor. The Unified Statements by the organization representing nurse practitioners and faculty for nurse practitioner programs clearly state that nurses who earn the DNP have a right to title themselves as doctor, as no one profession has exclusive rights to this title (Nurse Practitioner Roundtable, 2014). Dennison, Payne, and Farrell (2012) point out that the doctorate is an academic degree and therefore the graduate is authorized to use the title of doctor, and they add that nurses with doctorates collaborate with other professionals and patients by identifying their role as nurses. Another source for promulgating the use of the title “doctor” was identified by Smolowitz (2011) in her interview of O’Dell, who with his associates founded the website Doctor of Nursing Practice (www.doctorsofnursingpractice.org; 2014). O’Dell discusses the continuing debate about the use of the title and the usefulness of the website for discussion of the issue by not only nurses but other disciplines as well. In addition, the website is a platform for discussions among DNP graduates and educators on issues surrounding the degree as well as current changes in nursing practice, the profession, and the health care system.

There are several major roles for DNP-prepared nurses in the health care system. One role is in advanced practice including those nurses who are clinical specialists, nurse anesthetists, nurse midwives, and nurse practitioners; however, this is not limited to these roles and could include others, for example, advanced practice community/public health nurses. Another essential role for DNPs is to apply research to bring about change in evidence-based nursing practice and health care. A major role is for systems leadership in public policy to improve health care. While the focus of the DNP is not to prepare nurse educators, graduates of DNP programs are involved in the clinical education of nurses and the AACN and NLN recommend that DNP graduates (as well as PhD graduates), who wish to have faculty roles, complete education courses to prepare for the teaching role (AACN, 2013a; NLN, 2104).

Grey (2013) discusses the issues related to DNP practice and education that summarizes articles on the DNP in a special issue of the Journal of Nursing Education. She states that the original intention of DNP education was to prepare nurses for advanced practice roles with a focus on population-based practice, that is, a 302professional practice degree. However, many of the existing MSN to DNP programs provide advanced practice education or advanced leadership strategies such as administration, health care policy, and for a few, education. As additional bachelor of science in nursing (BSN) to DNP programs graduate students, it is assumed that the graduates will enter into the previously master’s-prepared traditional roles of nurse practitioners, clinical specialists, nurse midwives, and nurse anesthetists. However, since the programs are relatively young, there is not sufficient evidence to demonstrate if this is true and studies to determine graduates’ employment placements are indicated.

Several articles in the literature describe some of the roles of DNPs in practice. Ferguson and Forest (2012), as graduates of a postmaster’s DNP program, describe how they as nurse practitioners applied the additional knowledge and skills gained from the DNP program to their practice. Included in additional knowledge and skills was a focus on population-based services, evaluation, and interpretation of evidence for translation into practice, all of which result in improved clinical services. They believe that as a result of their education, their clinical services (one is in acute care and the other in primary care) have gained in breadth and depth for the benefit of the populations they serve.

Dunbar-Jacob, Nativio, and Khalil (2013) reported on the types of positions graduates of DNP programs in Pennsylvania held in 2012. While the DNP is fairly new to the profession of nursing, some of the programs in Pennsylvania were started as early as 2006 and thus provide a possible sample of the outcomes from DNP programs. Of the 589 graduates of Pennsylvania DNP programs, the authors reported that about two thirds of the graduates were educated in administrative/leadership DNP programs and the other third graduated from advanced practice (nurse practitioner, clinical specialist, etc.) programs. Only 163 of the 589 had postgraduation placement data available, and of those, the majority practiced in acute care, with the remaining in academe. Clearly, additional national research is indicated to learn where DNP graduates are practicing, differences between postmaster’s and BSN to DNP graduates’ areas of practice, and if the programs are having an impact on increasing advanced practice nurses in the workforce as well as changing health care policy and practices.

EDUCATIONAL PREPARATION FOR THE DNP

DNP programs continue to grow across the country and according to the 2013 Annual Report of the AACN there was a total enrollment in member AACN, DNP programs of 11,575 students (AACN, 2013a). Most DNP curricula are based upon The Essentials of Doctoral Education for Advanced Nursing Practice (2006). These eight Essentials include (1) Scientific Underpinnings for Practice, (2) Organizational and Systems Leadership for Quality Improvement and Systems Thinking, (3) Clinical Scholarship and Analytical Methods for Evidence-Based Practice, (4) Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care, (5) Health Care Policy for Advocacy in Health Care, (6) Interprofessional Collaboration for Improving Patient and Population Health Outcomes, (7) Clinical Prevention and Population Health for 303Improving the Nation’s Health, and (8) Advanced Nursing Practice. Each of these Essentials is described in detail by AACN and specific learning objectives are listed for each. AACN discusses the incorporation of specialty competencies for programs that prepare DNPs for advanced practice roles such as clinical specialists, nurse practitioners, nurse midwives, nurse anesthetists, and others. The National Organization for Nurse Practitioner Faculties (2014) lists specific competencies expected for the nursing practice doctorate and nurse practitioners. Program developers are directed to specialty organizations for the lists of competencies required for national certification in advanced nursing roles.

There are two major types of DNP programs. The first is the postmaster’s DNP program that admits nurses with master’s degrees who are nationally certified for advanced practice including nurse anesthetists, midwives, practitioners, and clinical specialists. Additionally, nursing administrators, managers, and other nurse leaders with or without national certification enroll in DNP programs to gain additional education and experiences for leadership roles in the health care system. These include administration, informatics, health care systems analysis, development of policies, and other leadership roles. Many of these programs were first initiated to meet the needs of master’s-prepared nurses wishing to earn a doctorate to advance their practice, act as change agents in the health care system, increase interprofessional collaboration, and gain professional credibility in a system with most of the major disciplines prepared at the doctoral level, for example, medical doctors (MDs), pharmacology (PharmD), physical therapy (DPT), psychology (PsyD), and so on. While it is expected that advanced practice nurses currently in practice who do not have the DNP will be “grandparented in” for licensure to practice in the states in which they are licensed and recognized, it is anticipated that many will wish to have the DNP credential. This is validated by the AACN report of Enrollments and Graduations in Baccalaureate and Graduate Programs, which reported that 1,742 students were enrolled in postmaster’s DNP programs (AACN, 2013a).

The other type of DNP educational program is to move the baccalaureate/BSN prepared nursing generalist into a DNP program. These programs prepare BSNs for advanced practice roles similar to the programs for advanced practice nurses at the master’s level, for example, certified registered nurse anesthetists (CRNAs), clinical specialists, nurse midwives, and nurse practitioners. Additional course work related to health care systems management and leadership at the doctorate level is included. In addition to the traditional advanced practice courses and roles, some BSN to DNP programs offer other options for roles in informatics and technology, health care management, and/or administration roles. Supervised clinical experiences are included in the programs to meet professional accreditation and/or certification standards and account for at least 1,000 hours of practice. Students have courses that include the content of the eight Essentials recommended by AACN (2006) as well as completion of the specialty role in which they are enrolled. Graduates are eligible for national certification depending upon the program of study’s specialization and meeting of eligibility requirements for certification.

Dennison et al. (2012) reviewed the history of DNP programs by tracing them from research-focused doctoral degrees to the nursing practice doctorate (DNP). The authors focused on the advanced practice roles of the DNP and linked them to 304the AACN Essentials (AACN, 2006). The article provides a model for curriculum planners for both the postmaster’s and the BSN to DNP programs with a table that ties the AACN Essentials to program competencies. The authors surveyed advanced practice specialty organizations for their positions on the DNP as entry into practice. While the organizations vary from requiring that all educational programs have the DNP as entry to advanced practice by 2022 to requiring the master’s but recognizing the doctorate for the future, there is consensus among the organizations that the doctorate includes competencies for advanced practice.

Grey (2013) reiterated the original intent for the DNP program to prepare nurses for advanced practice. Based on a review of the conference held by the Committee on Institutional Collaboration that was sponsored by nursing school deans, she identified similarities (consensus) and differences (controversies) across programs. Based on her observations and a review of the literature, Grey calls for consistency among DNP programs’ curricula; that the “product” be defined according to the roles that graduates are prepared for; that the BSN to DNP and the postmaster’s to DNP graduates be similar; that education include interprofessional collaboration and not just intraprofessional collaboration; and that nurse educators determine the curriculum, not other disciplines with outside interests.

Frantz (2013) provides an overview of the resources that schools of nursing need when planning, implementing, and sustaining a DNP program. Included on her list are the necessary faculty members and their qualifications; resources such as classrooms and simulation facilities; the infrastructure for delivering courses online and on campus; potential collaboration between the PhD and DNP programs’ course faculty and, possibly, other academic institutions; faculty and student practice opportunities; health care agencies’ resources for clinical experiences (both advanced practice and administrative); and administrative and staff support specific to the DNP program.

Honig and Smolowitz (2009) describe the initiation of a clinical doctorate program at Columbia University that emphasized advanced practice. First, the authors explained how faculty members for the DNP program were recruited and prepared by enrolling advanced practice nurses from various specialties and clinical experiences in the first cohort of scholars to earn the doctorate. They continue with a description of the processes the school underwent such as university and state approvals, how the curriculum tied to the AACN Essentials, how the scholarly project related to the final practicum, and the formative program evaluation they underwent to ensure the quality of the program.

A topic of concern that arises at many national DNP nursing faculty meetings is students’ scholarly writing abilities. Shirey (2013) describes one school of nursing’s strategy to promote students’ scholarly writing skills. It is a developmental approach that occurs throughout the program and is learner-focused. It consists of a five-step process that starts with an assessment of scholarly writing skills and culminates in a faculty-mentored, publishable, scholarly written capstone project. Writing skills assessment and development are integrated throughout the program in various courses. The process is described as the “SMART” model, that is, strategies, methods, assessment of outcomes, related to teaching/learning.

Yet another skill essential for graduates of DNP programs is that of interprofessional leadership. Montgomery and O’Grady (2010) describe an 305integrated approach to acquiring these skills at the University of Maryland postmaster’s DNP program. All students, whether in advanced practice, informatics, education, or administration, participate in two courses to develop evidence-based leadership skills. With faculty support, students self-assess leadership skills and develop a multidimensional and interactive “mind map” that culminates in the application of leadership skills to address an issue in the health care system. While these latter articles pertain to the implementation of the curriculum, they are useful to program developers as the program of study is developed.

PROGRAM EVALUATION AND ACCREDITATION

Program evaluation and accreditation are essential to the quality of DNP programs. Each school of nursing that has a DNP program usually has a master plan of evaluation for all programs and the DNP is included. DNP programs, in addition to the usual layers of approval within the home institution, are subject to the institution’s governing board’s approval, and if they are preparing entry-level advanced practice nurses, depending upon state regulations, they must undergo program approval by their state board of nursing. Program evaluation provides the data for assessing the effectiveness and quality of the program. Developing evaluation plans that incorporate all of the parameters of the program for assessment are important but it is also essential that plans are in place to implement the assessment. The methods for collecting and analyzing the data, the persons responsible, and when and how the findings from the analysis are used for program improvements are key factors to include.

Specific to DNP program accreditation are the roles of the ACEN (2013) and the CCNE (2014). The Standards for Accreditation of Clinical Doctorate Programs by the ACEN (2013) can be found at www.acenursing.net/manuals/SC2013.pdf. There are six standards:

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