A little old, but worth revisiting.

NurseWeek: New Doctoral Degree Aims to Advance Nursing Practice : New programs for DNP are enrolling students, but many issues remain unresolved. :

New Doctoral Degree Aims to Advance Nursing Practice
New programs for DNP are enrolling students,
but many issues remain unresolved.
By Lorraine Steefel, RN, MSN, CTN
May 9, 2005
Under new American Association of Colleges of Nursing (AACN) guidelines adopted October 25, 2005, advanced practice nurses and other RNs seeking top clinical roles will be educated at the doctorate level. By 2015, all programs that prepare APNs — nurse practitioners, midwives, anesthetists, and clinical nurse specialists — will be established to grant the Doctor of Nursing Practice (DNP). Doctorates will not be required for APNs currently in practice. They will maintain authority to practice, as occurred when APN education transitioned to the master’s level.
“This is a patient care issue,” says AACN Executive Director Geraldine (Polly) Bednash, RN, PhD, FAAN. “APNs will be better prepared for the complex health care system and will have the authority to intervene, which will help patients get better care.”
Though many schools of nursing are moving in this direction, the transition from master’s to DNP is not without controversy.
A matter of degree
DNP advocates say it’s time to commit to the development of clinical practice knowledge at the highest level possible. Of the two types of nursing doctorates — research- and practice-based — educational programs for terminal degrees in nursing tend to focus on research. McEwen and Bechtel’s 1999 Survey of Doctoral Programs in Nursing reports that 88% of the 70 existing doctoral programs in the U.S. award PhDs.1
“The DNP is a practice degree that prepares graduates to assume full leadership roles in clinical practice, clinical teaching, and action research,” says Ann O’Sullivan, RN, PhD, CRNP, CPNP, FAAN, president of the National Organization of Nurse Practitioner Faculties (NONPF). Here, nursing practice refers to direct patient care by clinicians and direct care policies, programs, and protocols that expert nurse clinicians organize and improve on, says AACN’s Position Statement on the Practice Doctorate in Nursing .
In addition to acknowledging their expertise, the DNP provides APNs and nurse leaders parity with medical doctors, pharmacists, and dentists. “If other health science disciplines award doctoral degrees for their highest level of practice, why would nursing do less?” says Phyllis Zimmer, RN, ARNP, MN, FNP, FAAN, faculty, FNP Program, School of Nursing, University of Washington, Seattle.
The DNP is different from — but not less than — the research doctorate. Faculty who hold the DNP will have the best preparation for clinical teaching, says Joyce Fitzpatrick, RN, MBA, PhD, FAAN, professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland. The clinical teacher should be the expert clinician who prepares nurses for basic and advanced clinical practice. According to Fitzpatrick, the majority of PhD graduates don’t assume positions in which their primary responsibility is research. They teach in the clinical arena when often they are no longer expert clinicians.2
Though proponents say the practice degree more adequately speaks to the educational and professional needs of APNs, others support the better-known PhD.
“The PhD prepares nurse scientists, but its research component is driven by the fundamental knowledge needed for practice; and this knowledge is translated into practice,” says Afaf Meleis, RN, PhD, DrPS (hon), FAAN, dean, School of Nursing, University of Pennsylvania, Philadelphia.
Science will answer important practice questions as evidenced by the research programs across the country relating to patient care and clinically important questions — pain management, sleep issues, coping, and living with chronicity.
“We need to be translating these programs instead of developing another degree that will create another tier in academic life,” says Meleis.
The PhD is a respected, rigorous academic degree, says Kathleen Dracup, RN, DNSc, FAAN, dean, School of Nursing, University of California, San Francisco. In the 1990s, the few opportunities for PhD nurses included teaching or conducting research. Now hospitals hire them as chief nursing officers; directors of education, research, and quality improvement departments; and in other clinical roles. “Why add a new professional degree when you can practice with the PhD as other disciplines do?” she asks.
A matter of curriculum
Current APN programs are credit-dense — some near twice the length of master’s programs in other disciplines.
“The DNP program is expanded with appropriate doctoral content, and the degree recognizes the amount of work that goes into the APN program,” says Margaret Fitzgerald, APRN, MS, BC, NP-C, FNP, FAAN, president of Fitzgerald Health Education Associates and family nurse practitioner at the Greater Lawrence (Mass.) Family Health Center, Inc.
Zimmer describes the proposed DNP curriculum for the School of Nursing at the University of Washington, Seattle, as an enhancement of an already strong master’s program. It will include a residency component that supports the integration of knowledge into practice and focuses on practice management skills. What’s more, health policy coursework with a focus on leadership development will enable graduates to become change agents in the health care system.
“As scientific knowledge, practice opportunities, and technology have evolved, so too have the expectations of APN practice,” says Zimmer. There is growing complexity of patient care and service delivery with a strong emphasis on evidence-based care. APNs are not simply caring for well individuals: They are caring for those with complex health needs and concurrent psychosocial problems.
Those opposed to the DNP point to research indicating that the quality of care provided by nurse practitioners is equal to that of physicians.3
“We have a proven, quality product educating APNs the way we are currently educating them and have attained some parity across nursing specialties at the master’s level,” says Linda Cronenwett, RN, PhD, FAAN, dean and professor, School of Nursing, University of North Carolina, Chapel Hill. Research shows that APNs improve patient outcomes and reduce cost. In this era of cost containment, Cronenwett asks, will this be so of doctorally prepared APNs who may command a higher salary?
Dracup wonders if a discipline should create a longer graduate program and new sets of initials for the APN role that is already so successful. Rather, for nurses who want to maintain their clinical practice, the PhD program should reflect a more clinical component, housed in the PhD curriculum but with a flexible formula that allows for more time in practice and research, she says.
“Master’s-prepared APNs can gain experience in their specialty areas and then choose whether or not to go on for a higher degree, obtain a PhD, and become specialists in their clinical field,” says Dracup.
A matter of change
There are at least eight nursing practice doctorate programs accepting students nationwide and more than 60 under some phase of development. To reduce confusion, AACN calls for the DNP as the title for the practice-focused doctorate and recommends phasing out the ND degree.
“Though much needs to be done, a stunning amount of activity has occurred,” says Bednash. The Essentials Taskforce, chaired by Donna Hathaway, RN, PhD, FAAN, dean, University of Tennessee Health Sciences Center, Memphis, is developing curriculum and content requirements and identifying the competencies for the DNP. The Roadmap to 2015, chaired by Carolyn Williams, RN, PhD, FAAN, dean and professor, School of Nursing, University of Kentucky, Lexington, is examining program development, master’s to doctoral transition programs, and regulations and licensure. The Commission on Collegiate Nursing Education is initiating a process for accrediting the new programs.
Rather than taking an official position, APN organizations — American Academy of Nurse Practitioners, the National Association of Pediatric Nurse Practitioners, the National Association of Nurse Practitioners in Women’s Health, the American College of Nurse Midwives, and the American Academy of Nurse Anesthetists — are adopting a wait-and-see approach, carefully discussing the pros and cons and exploring the effects the DNP would have on nurses, their profession, and their patients.
The National Association of Clinical Nurse Specialists (NACNS) remains neutral until concerns voiced in their recently disseminated “White Paper on the Nursing Practice Doctorate” are addressed. The document reports the DNP passed by 54 votes (160 for, 106 against) at the October Deans’ Meeting in Washington, D.C. Only those in attendance were able to vote, despite membership of more than 500 schools.
“This is a huge professional paradigm shift for which there should be more extensive dialogue,” says Angela Clark, RN, PhD, CNS, FAAN, FAHA, immediate past president, NACNS. “Opportunity for discussion from national stakeholders to look at some of the complex issues would be a positive outcome.”
Dracup foresees a mixed reaction from APNs. Some will think it’s just what they wanted — an entry-level, terminal degree in practice rather than the PhD. Others will balk at returning to school — the huge commitment of time and money — when they have a viable practice and have already met APN state and professional organization requirements. Will the DNP signify an evolution of practice excellence or stir up more controversy within the nursing community? Time will tell, she says.