In 2004 the American Association of Colleges of Nursing (AACN), the organization that promotes quality standards in nursing education and represents more than 690 member schools, released a position statement on the practice doctorate in nursing. The AACN proposed that the Doctorate of Nursing Practice (DNP) be the minimal entry-level requirement for advanced practice nursing (APN). This includes roles currently prepared at the master's level-clinical nurse specialist, nurse anesthetist, nurse midwife, nurse practitioner (NP), and any future-defined advanced practice roles. The DNP position statement was approved by the AACN member schools (AACN, 2004).
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The DNP position statement was driven by information such as the Institute of Medicine report (IOM, 1999), To Err is Human: Building a Safer Health System, that reviewed facts surrounding errors in healthcare. One fact that contributes to error is the fragmented nature of the healthcare delivery system. In a subsequent publication, Crossing the Quality Chasm, the IOM (2001) stressed the healthcare system does not use resources wisely. According to the IOM, nurses' advanced practice roles encompass ever-expanding patient-care services, resulting in an increased knowledge base for clinical skills in leadership in the delivery of healthcare. Within this framework, the DNP was born.
The full impact of the DNP position statement will hit in 2015 when every new entry-level APN must have a DNP. Masters programs will no longer be the standard for advanced practice. Current master's level APNs are being encouraged but not required to obtain the DNP. What does the DNP offer that the master's degree does not offer? How does the DNP differ from the traditional Doctor of Philosophy (PhD) in nursing? What do DNP's do?
PRACTICE VERSUS RESEARCH
The first thing to clarify is that the DNP is a practice doctorate. Many healthcare professions prepare entry-level practitioners with a practice doctorate including pharmacy (PharmD), physical therapy (DPT), occupational therapy (DOT), and of course, medicine (MD and DO [osteopathy]). Nursing prepares its entry-level professional practitioners at the baccalaureate level (BSN). The focus of the DNP is advanced practice, specifically the highest level of nursing practice. Advanced practice "refers to any form of nursing intervention that influences health care outcomes...including the direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations, and the development and implementation of health policy" (AACN, 2004, p. 3). Nursing, with its focus on health-promotion, restoration, and maintenance-holds the key to addressing burgeoning healthcare crises related to chronic illness, care throughout the lifespan and especially for the aging population, and healthcare disparities. APNs are key to designing, evaluating, and improving healthcare settings and systems throughout the nation (IOM, 2010).
As a practice doctorate, the DNP is distinct from a research doctorate or PhD. Both the DNP and PhD are "terminal" degrees in nursing, that is, the highest end degrees the profession awards. The DNP is the terminal degree for nursing practice; the PhD is the terminal degree for nursing research. According to the AACN (2006), the DNP holds the following differences between a PhD in nursing:
* less emphasis on theory and meta-theory
* considerably less research methodology content
* emphasis on nursing practice in the degree's research requirement
* different dissertation or end research/project requirements
* clinical residency requirements
* emphasis on scholarly practice.
The PhD prepares nurses to design and conduct research, develop theory, and progress the science of nursing. The DNP prepares nurses to be leaders in the practice setting, evaluating and implementing the science developed by nurse researchers (AACN, 2012).
The emergence of the DNP certainly has caused confusion. For current APNs, controversy lies in the fact that the broader base of knowledge the DNP is trying to establish in advanced practice is causing confusion rather than clarity. Master's-prepared APNs feel like their training is being questioned. Note however, the AACN's rationale for the DNP included the fact that currently APNs "are prepared in master's-degree programs that often carry a credit load equivalent to doctoral degrees in the other health professions" (AACN, 2012, Introducing the Doctor of Nursing Practice, para. 1). The AACN states the DNP will build on master's APN preparation by adding "evidence-based practice, quality improvement, and systems leadership, among other key areas" (para. 2).
The medical (physician) community has raised questions about the label "Doctor," which many believe should be reserved for physicians. Of course, the title "Dr." is an academic title, used freely in many settings. In healthcare settings we call other doctorally prepared professionals who are not physicians by the title "Dr." such as psychologists, pharmacists, or various therapists. Interestingly enough, the APN of the future is being labeled as the "doctor nurse of the future." The idea is that this "doctor nurse" will be a gateway for primary care that is lacking in general medical practice. Currently, nurse practitioners (NPs) are opening up healthcare access throughout the country, and satisfaction and outcomes with NP care are consistently high (i.e., Aragon & Pickett, 2011; Furlow, 2011). There is a serious shortage of physicians to provide primary care and more than 165,000 NPs (half of whom are family NPs), ready to meet this need (American Academy of Nurse Practitioners, 2012). The DNP will continue to provide patients with the assurance that their primary care provider has met the standards of doctoral level practice.
Another question is whether the DNP further confuses patients. Does this degree only add to the alphabet soup after our names? The rationale for the DNP is to transform practice-in primary care, hospitals, and healthcare systems. The DNP is not "better" or "higher" or to make nurses look like physicians. While healthcare hashes out the logistics of this issue, each APN needs to continue to clarify for patients his or her role in the patient's care. Furthermore, current APNs must choose the educational path that best fits their career and stage of career planning while recognizing position statements from the AACN and IOM (2010). Whether we like it or not, or understand it or not, the DNP is the future of advanced nursing practice.
A CHRISTIAN RESPONSE
As someone who pursued a DNP as a master's-prepared NP, I (Kristene) must say I did not pursue this degree for any other reason than to enhance my understanding and skill in the clinical setting. I saw the DNP as an opportunity to substantiate the career path I already had chosen as an APN. I became a Diplomate of the American Board of Comprehensive Care (ABCC), passing the certification exam for DNPs. This exam, developed by the ABCC, the National Board of Medical Examiners, and the Council for the Advancement of Comprehensive Care, "tests DNP graduates' medical knowledge and understanding of the clinical science considered essential for the sophisticated practice of comprehensive care, with emphasis on patient management in ambulatory care settings" (ABCC, n.d.). I (Kathy) pursued a PhD because of research and theory interests. I continue to be involved in scholarship and advancing the knowledge base of nursing. I also practice as an entry-level professional nurse (staff nurse). As Christians, we think about being confident and secure in our faith and the paths God led us to follow in nursing. Like the Apostle Paul in 2 Corinthians 10, we are working to not compare ourselves to others; to not worry or boast about ourselves but "boast about the LORD" (v. 17).
Our goal as Christian APNs should be to pursue excellence as we each "do our best to present yourself to God as one approved, a workman who does not need to be ashamed" (2 Timothy 2:15, NIV). In whatever career path we are led professionally, we are all called to do our best. As DNP programs increase throughout the country, each existing APN must answer the question of whether or not to pursue the DNP. Most importantly, as Christian APNs, our confidence must lie in the assurance of God's plan for us (Jeremiah 29:11). Professionally, emotionally, or spiritually, we can rest in the assurance that God has specific plans for us and will give us the strength and wisdom to carry out his plans. As the discussions of the advanced practice doctorate surround us, we can take confidence in our own and God's plans as God leads one step at a time!