The doctorate of nursing practice (DNP) has been proposed as an education path for advanced practice nurses. This would have implications for neonatal nurse practitioners and is therefore an important issue for neonatal nurses to know about and be connected with in terms of ongoing dialog. This guest editorial has therefore been included to help keep our readers informed.
BACKGROUND
In October 2004, the membership of the American Association of Colleges of Nursing (AACN) adopted a position statement on the DNP. The position statement culminated an almost 5-year study on strategies to address knowledge needs for advanced practice, role expectations, and positioning within the healthcare delivery system. The position statement calls for advanced professional nursing specialization to occur at the doctoral level by the year 2015.1 Although this position statement has met with mixed responses by nurses and other disciplines, professional associations, and regional accrediting bodies, 24 programs are in operation as of fall 2006 and an additional 190 programs are in development.2
Since approval of the position statement, work has been completed by 2 separate task forces, one to develop the Essentials of Doctoral Education for Advanced Nursing Practice3 and the second focused on the DNP Roadmap Task Force.4 Reports from these task forces were ratified by the AACN Board of Directors in July 2006 and will be presented to the membership in October 2006. Both of these reports were developed to delineate the process by which the change to the practice doctorate would occur, entry points, and competencies for advanced practice. Plans are also underway to accredit these programs-a departure from the position that traditional doctoral education is not subject to specialized accreditation, covered only by the institution's regional accrediting body authority to offer programs at that level.
SCOPE OF CONTENT IN THE DNP
The Essentials document outlines 8 competencies that are a part of advanced nursing practice. These competencies are scientific underpinnings for practice, organization and systems leadership for quality improvement and systems thinking, clinical scholarship and analytical methods for evidence-based practice, information systems/technology and patient care technology for the improvement and transformation of healthcare, healthcare policy for advocacy in healthcare, interprofessional collaboration for improving patient and population health outcomes, clinical prevention and population health for improving the nation's health, and advanced nursing practice.3
Advanced nursing practice content is divided into foundational content that cuts across all advanced practice roles and content that is established by the distinct specialty in order to prepare graduates to sit for the appropriate certification examinations. AACN has been clear that the specialty content for advanced practice fits within the domain of the specialty organizations. Advanced nursing practice is further differentiated in terms of client population-individual and family, or community and systems level practice. Hence the advanced nursing practice term applies not only to the roles of nurse practitioner, clinical nurse specialist, nurse midwife, and nurse anesthetist but also to roles such as health systems administrator, nurse leader, and nursing informatics professional.
PROCESS OF REVIEW AND VALIDATION
AACN engaged in substantial efforts to bring stakeholders to the table both in the development of the Essentials and in dialog related to the Roadmap. Continuing dialog is taking place to ensure that varied positions are incorporated into the programs of study. Forty-four organizations/professional entities, including Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), American College of Nurse-Midwives (ACNM), National Association of Pediatric Nurses Associates and Practitioners (NAPNAP), and National Certification Corporation for the Obstetric, Gynecologic and Neonatal Nursing Specialities (NCC), participated in the October 2005 stakeholders' meeting.4 A significant percentage of public and private colleges and universities and academic health centers participated in regional meetings to provide input into the task force work. A series of teleconferences are currently underway to further clarify plans and seek feedback on the processes and expected outcomes.
Despite efforts to create scholarly dialog and collaboration, not all have viewed the DNP as a step forward. In an early response, Dreher et al5 indicated that models other than the DNP should be considered as routes to advanced practice. Their 4 premises included reflection that many disciplines use hybrid models, emphasizing both practice and research, potential for marginalization of DNPs who wind up in academia because of their limited research training, potential limitation of new nursing science because of the drain of resources required to offer the practice doctorate, and an alleged misconception that all professionals in a particular discipline are credentialed in exactly the same way.
Meleis and Dracup6 raised concerns that the practice doctorate may also marginalize the concept of nursing science. One of their premises is that while this degree may be viewed favorably by physicians and other healthcare professionals, the separation of practice and research may have deleterious effects, including loss of competitiveness in universities. Another premise is that attention directed to the planning and development of this degree may take attention at a time when the profession is otherwise poised to make an impact on safety and quality healthcare.
In general, many of the APN organizations have chosen to sit out the early discussions related to both the DNP role and whether the role should be mandated as the minimum credential by the year 2015.
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.7
In 2006, the AWHONN Board of Directors adopted a position statement that crystallized the dichotomy of support for the DNP. While that position statement endorses the DNP credential, it makes it clear that the AWHONN Board is not prepared to endorse the universal mandate that the DNP be the entry into advanced practice by the year 2015. The position statement goes on to state:
Before we would consider endorsing the universal adoption of the doctorate of nursing practice as an "entry-into-practice" degree for advanced practice nurses, a number of concerns must be addressed. Some of these concerns arise from the potential adverse effects the universal implementation of this entry-into-practice degree could have on the provision of health care services to the nation.
* Substantial evidence demonstrating that the clinical practice of a DNP prepared APRN is superior to that of a Master's prepared APRN in all practice settings.
* Evidence that there is or will be a reasonable market demand for this provider.
* Evidence that the costs to society to implement this degree will not detract from the initiatives needed to ensure an adequate nursing supply in light of the current nursing shortage.
* A real forecast of the public and private costs to the health care system for the migration of all APRNs to DNP level practitioners.
* The possibility that limited federal funds currently allotted for basic nursing education would be re-directed to the support of the DNP and the affect that would have on availability of programs for entry level nursing preparation.
* In an existing faculty shortage, the procurement of sufficient faculty to educate the increased number of doctoral and basic students given the proposed DNP.8
IMPLICATIONS FOR NEONATAL NURSING PRACTICE
Although much of the debate about the DNP has centered on issues that are more relevant to academic settings-tenure, equality in faculty practice, resource allocation, and development of nursing science, there are concerns being raised by practitioners. These concerns relate to time, cost, recognition, and employability.
A major concern relates to length of time from BSN to advanced practice preparation. Advanced practice education currently requires at a minimum 1 year of full-time study post BSN, and with part-time study many nurses spend 3 or more years to achieve advanced role preparation. Additional content included in most of the current DNP programs will almost double the required credit hours to degree for direct entry BSN graduates. Master's prepared graduates who choose to return for the DNP will spend almost as much time on the additional content as they did in their original advanced practice degree programs. One of the unanswered questions is whether there will be adequate return on investment in the additional costs of attaining advanced practice education.
Any time a program increases in credit hours there is an increase in the cost of attaining the degree. The increase in required hours and content will translate to increased costs of achieving the degree. Will practicing nurses choose to spend the additional money to achieve the degree? Will younger nurses be attracted to move into advanced practice preparation earlier in their professional careers, helping to reduce the impact of the aging nursing workforce? Will federal agencies such as the Division of Nursing continue to provide support through Advanced Education Nurse Traineeships? Even if traineeships continue will funds be sufficient to support students through lengthier programs? How will length of program affect availability of funds for part-time students? These questions and the future answers may determine professional response to both the degree and the timeline for full implementation.
While all of the issues presented are relevant in neonatal nursing practice, the issue of employability is probably the most significant to role and credential acceptance. Most neonatal advanced practice nurses are employed by healthcare organizations, particularly those who are clinical nurse specialists or neonatal acute care nurse practitioners. For them, the healthcare system controls employability and determines perceived value to the organization. So even if time and cost issues are effectively resolved there remains a concern that employing organizations may either be unwilling to pay for this new level of expert practice or may do so by reducing the number of advanced practice positions funded. Given this issue it is clear why AWHONN's Board of Directors has been unwilling to accept the timeline for conversion without the data outlined in their position statement.
FUTURE DIRECTIONS
It is clear that the DNP is moving forward as an advanced practice credential. The level of academic engagement in developing these programs is high and students are enrolling in the programs. It is also clear that AACN's position on advanced practice is in synchrony with the movement in many other professions either to the practice doctorate for professional entry (physical therapy-DPT, pharmacy-PharmD, clinical psychology-PsyD) or the practice doctorate for advanced role preparation (nursing-DNP, occupational therapy-OTD).
The challenges that remain, regardless of whether the profession accepts the 2015 conversion date, are to ensure that the increased education and attention to evidence-based practice improve patient and system outcomes, that the profession is able to demonstrate the value added by the credential to a variety of constituents, that efforts to improve advanced practice do not occur by sacrificing adequate attention to needs for basic licensure graduates or nursing science development, and finally that these new graduates in fact are advanced practitioners and not just a short-cut approach to increasing the supply of doctorally credentialed faculty.
Linda F. Samson, PhD, RN, BC, CNAA, BC
Dean, College of Health Professions, Governors State University, University Park, Ill
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