Nursing Center - Journal Article

Until recently there were few options for NPs seeking further formal education. NPs are educated at the graduate level, and most enter practice with a master's of science in nursing (MSN) degree. Those seeking an advanced degree in the field of nursing were traditionally given the option of pursuing a doctor of philosophy (PhD) or doctor of nursing science (DNS, DSN, or DNSc) degree, both of which focus heavily on nursing research. Although these degrees are invaluable to the nursing profession, they do not meet the needs of NPs wishing to focus on evidence-based clinical practice.

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The doctor of nursing practice (DNP) degree has emerged as a popular alternative and is gaining momentum in the NP community, leading to a sharp increase in schools offering this academic program. Originally developed as an ND, or nursing doctorate, at Case Western Reserve University in 1979, this program has evolved into what is now the DNP.1 Curriculum focuses on improving patient outcomes by enhancing knowledge and competencies in clinical, faculty, and leadership roles. One of the most enticing aspects of the DNP degree is the shorter program length (for post-master's students), which can be completed in approximately half the time of a PhD or DNSc program. The American Association of Colleges in Nursing (AACN) Essentials of Doctoral Education for Advanced Nursing Practice recommends that the DNP be the only practice-focused doctorate degree.2 The DNP degree has the potential to significantly influence the evolution of advanced practice nursing and impact practicing and potential NPs.

Background

The AACN first endorsed the DNP program in 2004 through the Position Statement on the Practice Doctorate in Nursing.3 This move was endorsed by a 2005 National Academy of Sciences' Report that called for "nursing to develop a nonresearch clinical doctorate to prepare expert practitioners."4 The AACN has proposed the DNP be a minimum entry-level education for all NPs by the year 2015. NPs currently in practice should be grandfathered. Specifically, the AACN states, "Nurses with master's degrees will continue to practice in their current capacities. Regulatory bodies should allow individuals credentialed to practice in one of the four APN specialties to continue to practice within the full scope of practice for that specialty."5

As a result of the AACN's endorsement, there has been rapid development of DNP programs in schools of higher education across the United States. In 2008, the DNP gained additional momentum as seven NP organizations collaborated to write Nurse Practitioner DNP Education, Certification and Titling: A Unified Statement. This group, known as the NP Roundtable, was formed to "collaborate, unify, and address issues of importance to NPs."6

The DNP degree was developed in response to a multitude of challenges faced by the nursing profession. Central to these challenges was the nursing shortage and the lack of qualified faculty available to educate individuals entering nursing programs. The degree also met the needs of current advanced practice registered nurses (APRNs) who found that their role was increasing in complexity and would be enhanced by further formal education. These clinically focused APRNs wished to pursue doctoral studies but planned a career as a clinician, not a researcher. In addition, many Master's-level programs recognized that their students were already taking many more credits than a typical Master's degree. Many Master's-level NP graduates had completed programs with credit loads similar to other practice doctorate degrees.

The DNP degree will move APRN preparation to a level comparable to that in other health professions. The success of other professions offering this educational option, including pharmacy, optometry, and physical therapy, paved the way for DNP development. Advocates think the DNP is a natural progression for APRN education, much like the evolution from certificate programs to MSN preparation in the 1970s.

Current interest in DNP programs has significantly increased. Currently, there are 122 DNP programs enrolling students at schools of nursing nationwide, and an additional 100 plus DNP programs are in the planning stages. DNP programs are now available in 34 states plus the District of Columbia. From 2007 to 2008, the number of students enrolled in DNP programs nearly doubled from 1,874 to 3,415, whereas the number of DNP graduates increased from 122 to 361.8

Implications for the profession

As nurses consider advancing their education, it is important to understand potential effects of the DNP degree. For current NPs, the acquisition of a DNP degree will not change their scope of practice; they are still held to the rules and regulations in the state granting licensure or recognition of APRNs. Those wishing to add or change their population focus must complete a comprehensive program that includes appropriate theory and 500 or more clinical hours with a preceptor. It is possible to incorporate this into a DNP program, which may be a wise choice compared to a post-master's certificate. Certification exams will continue to be population-focused and be offered to both MSN and DNP graduates who meet the requirements for testing. Presently, there is no separate DNP certification exam. DNP graduates may take an optional specialty exam, which will recognize their added knowledge but will not change their scope of practice.

Proponents of the DNP recognize the positive aspects of this new academic option. Additional NPs educated at the doctoral level will help alleviate the expanding nursing faculty shortage. The DNP is more accessible than traditional doctoral study because the programs are shorter in length (usually 1 to 2 years post-master's degree) and thus less costly, and programs are structured around the working professional. Traditional PhD programs usually require over 4 years of study and a dissertation.

Pursuing a DNP degree may incur more educational loan debt; however, the Bureau of Labor Statistics data for 2008 shows that median weekly earnings for individuals with doctoral degrees are over $200 higher than the earnings for those with less-advanced degrees.9 A 2009 national NP survey found the average annual salary for an NP with a master's degree was $89,392, while NPs with a DNP made $97,080.10 The DNP may also lead to more job opportunities, improved positions, and increased professional respect. For NPs who have spent their career in clinical practice, a clinical doctorate may seem like an appropriate choice.

Individual practitioner implications: When is it right for me?

Because a large number of NPs are aging baby boomers, some may feel it is too late in their career to pursue the DNP degree. In 2005, the average RN age was 43.5 years. This is projected to increase to 44.7 years by 2012.11 The mean age when American women retire, on the other hand, has declined over time, from age 67.6 at the midcentury to age 61.4 by the year 2000.12 The traditional retirement age of hospital nurses was previously age 55.13 One recent study showed that nurses expect to work well into their 60s, with the average age about 64.14 In today's postrecession job market, many nurses may choose to work into their 70s in order to increase their financial security. Increases in RN earnings and the economic downturn have resulted in a recent surge in RN employment. Interestingly, nearly all of the increases in the RN workforce were due to older nurses returning to the job market and an influx of non-U.S.-born RNs.11

DNP programs: One size does not fit all

DNP programs award practice doctorates; however, the focus of the program can vary from institution to institution. Leadership, education, administration, and/or healthcare outcomes are examples of program foci. An individual's area of interest will play a large part in steering them toward one program or another.

When choosing a program, students should note how and if the program is accredited or evaluated. DNP programs should adhere to criteria developed by the Commission on Collegiate Nursing Education (CCNE), a national accreditation agency. Practice doctorates with the DNP degree title are eligible to pursue accreditation by the CCNE. Research doctorates (for example, PhD and DNSc) and DNP programs with a nursing education track (major) are not eligible to pursue accreditation.16

In addition, programs adhere to the "essentials of doctoral education for advanced practice nursing" (commonly known as the "DNP essentials"). These standards identify foundational curriculum content and outcome-based competencies essential for all students pursuing the DNP degree, regardless of specialty or focus (see The essentials of doctoral education for advanced nursing practice).17

The DNP curriculum is conceptualized as having two components: "(a) DNP essentials one through eight are the foundational outcome competencies deemed essential for all graduates of a DNP program, regardless of specialty or functional focus; and (b) specialty competencies/content that prepare the DNP graduate for practice and didactic learning experiences for a particular specialty. Competencies, content, and practical experiences needed for specific roles in specialty areas are delineated by national specialty organizations."2

Separate competencies were developed by the National Panel for NP Practice Doctorate Competencies. This group, led by the National Organization of Nurse Practitioner Faculties, identified entry-level competencies for all NPs completing a DNP program. These competencies "build on the core and population-focused competencies for NPs."14 Students pursuing specific roles in specialty areas also need to meet competencies determined by national specialty organizations.

There are many elements that factor into choosing a DNP program. A nurse can enter into a DNP program from a baccalaureate, master's, or PhD program that meets the essentials competencies. Entrance requirements vary from program to program and may include a recent GRE, or graduate record examination (within 5 years), portfolios, a statistics course (within 5 years), references, and/or essays. In addition, many programs require that the student applying have a grade point average of 3.5 or better. Students may choose a program with requirements that suit their qualifications.

Because many individuals who wish to obtain the DNP degree are currently working, program length and distance from home are significant considerations in choosing to pursue the degree. Many programs have an executive style format, meaning that intensive classes are given for short periods. Some programs have online or distance learning where some or most of the course work can be completed from home on the computer. Part-time and/or full-time options, as well as number of credits required to complete the DNP are also considerations. (See Examples of U.S. DNP programs.) Clinical hours or practicums are required and can often be completed at the student's work place or at a nearby facility. Schools may or may not take on the responsibility of finding clinical preceptors; in some institutions, that is the responsibility of the student. Cost of the program, tuition reimbursement, and scholarship opportunities can also influence choice of institution or program.

Some students choose a particular program or school because of its reputation, focus, and/or faculty. Some students may want to focus on executive/management skills, while others may want to focus more on education. Prospective students should have a good idea about their area of interest or where they see their future career. Students may want to work with a particular faculty member and/or participate in specific research that is ongoing at a particular school.

Workload and/or program rigor are considerations as well. Most DNP programs have a required capstone project. Because the DNP degree involves mastery of nursing practice, this capstone project often differs from original research or a dissertation. For example, a capstone project can be in the form of a practice portfolio that examines the impact or outcomes of practice and documents practice scholarship. Another example of a final DNP project is a practice change initiative represented by a pilot study, a program evaluation, or an integrated literature review.2 Programs at institutions such as Vanderbilt and Ohio State University refer to their projects as "scholarly projects," and Columbia University has a "portfolio."

Future issues

All DNP practitioners will need to follow legislation that may influence their practice. Maintaining membership in your professional nursing organization is essential to follow the dialogue on particular issues that may influence nursing practice. The following are some examples of ongoing issues and associated organizations that can potentially affect doctorally prepared, APRN CNP practice.

The NP Roundtable works hard to influence federal legislation.6 One example is the HR2350/S1174 Preserving Patient Access to Primary Care Act of 20096; the NP Roundtable is working to remove all physician-exclusive language in favor of terms such as clinician, healthcare provider, or an actual listing by profession in any healthcare legislation.

The Coalition for Patients' Rights (CPR) was established in 2006 to give patients a choice of providers and fight barriers to quality care. As of January 2010, the CPR consists of 38 organizations comprised of a variety of licensed healthcare professionals who provide safe, effective, and affordable healthcare to millions of patients each year.19 The CPR believes it is important to examine all healthcare providers' education, accreditation, certification, and licensure and "assess whether state laws and regulations governing physicians practice contain outdated language."20 Other concerns include "the implications of current state laws that allow physicians to practice in any specialty, regardless of the individual qualifications to do so."20 The CPR also advocates for "the practice rights of its members for the sake of their patients."21 Support statements from over 35 organizations can be found on the CPR's website as well as media resources. The American Nurses Association (ANA) (a 2006 founding member of the CPR), reaffirmed its support in December 2008 "for a patients' ability to choose their healthcare provider."21 The ANA continues to rally, along with members of the CPR, the "common cause of ensuring that all patients have access to quality care."21

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Table. The essentials of doctoral education for advanced nursing practice

Each state's professional society tracks the number of providers a state has and will need in the next 10 years. Sadly, the results of these studies document over and over again the shortage of physician providers to provide primary care to the patients of a particular state. In fact, the American College of Physicians (ACP) released an article in February 2009 that stated "doctors and NPs must collaborate to improve primary care."22 The ACP recommended that "any demonstration project of the patient-centered medical home model should include one run by an NP." The American Medical Association (AMA) still states that DNPs must practice under "direct appropriate physician supervision,"23 but this is much less apt to happen as the physician shortage increases. AMA position may also slowly disappear as states implement the NCSBN (National Council of State Boards of Nursing) APRN model act/rules and regulations, which calls for independent practice.24 Clearly, the AMA and ACP have different views regarding a pilot of NPs as leaders of a medical home model, one that hopefully in the future would be called "health home."

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Table. Examples of U.S. DNP programs

One aspect of DNP education, accreditation, certification, and licensure that the AMA and ACP do agree on is that DNP credentialing should not be obtained through step 3 of the medical licensing exam of the National Board of Medical Examiners. Step 3 exam content reflects generalist medical practice in the United States.25 The discipline of nursing should educate, accredit, certify, and license doctorally prepared, APRN CNPs.

Conclusion

The challenges of the DNP practitioner and their role in the delivery of patient-care services to our society will go on for years; but clearly the time has come for better communication, collaboration, and commitment on the part of all health professionals in order to foster healthcare reform in the 21st century.