THE doctor of nursing practice (DNP)* is a practice-focused doctorate and terminal degree for professional nursing practice (American Association of Colleges of Nursing [AACN], 2004, 2006a). In 2004, the AACN recommended that the DNP degree replace current master's degrees as the minimum preparation for advanced practice nurses (APNs) by the year 2015 (AACN, 2004), a point that has been hotly debated in the literature. In spite of the controversy surrounding the DNP degree, interest in offering the degree is gaining momentum in universities across the country. To date, more than 90 universities offer DNP programs and approximately 50 new DNP programs are under development (AACN, 2009a).
The advent of this new doctoral degree in nursing has led to some confusion among nurses about the doctoral-level education in nursing. Moreover, many nurses are unaware of the degree, the educational requirements for the degree, and the distinctions that are made between the DNP degree and the PhD in nursing. The purpose of this article is to lay out the historical context that led to the development of the DNP degree, describe the DNP degree, differentiate it from the PhD in nursing, and make explicit the role functions of DNP-prepared nurses. In addition, some issues about this particular degree as well as the implications of DNP-prepared nurses working in the emergency department will be explored.
THE HISTORY OF DOCTORAL EDUCATION IN NURSING
Historically, doctoral education for nurses has proceeded along a number of paths. In the early part of the 20th century, there were no doctoral programs designed specifically for nurses. As a result, nurses had little choice but to earn doctorates outside of nursing. These included the doctor of education (EdD) degree and PhD that were typically earned in the basic science fields such as anatomy and physiology (Carpenter & Hudacek, 1996; Marriner-Tomey, 1990). The first doctoral program designed specifically for nurses originated at Teacher's College, Columbia University, New York, in 1924. The degree offered at Teacher's College was an EdD, designed to prepare nurses to teach at the college level (Carpenter & Hudacek, 1996). Doctor of education degrees actually continued well into the 1960s to be the mainstay of doctoral education for nurses (Marriner-Tomey, 1990).
It was not until the mid-1930s that nurses were given an opportunity to earn a PhD in the field of nursing, but their options were limited because the only PhD in nursing was offered at New York University (Carpenter & Hudacek, 1996). Thus, many nurses interested in pursuing doctoral education earned the PhD in psychosocial fields such as psychology, sociology, and anthropology. This trend continued until nursing PhD programs became more popular and more accessible in the 1970s (Grace, 1978).
The 1980s saw an unprecedented growth in the number of doctoral programs in nursing (Lenz, 1990). Certainly, not all nursing doctoral programs were alike but they became distinctly differentiated by the type of degree offered: those leading to an academic research degree (the PhD in nursing) and those leading to a professional doctorate such as the doctor of nursing science (DNS). Snyder-Halpern (1986) found that both degrees focused on preparing teachers and applied researchers, but the preparation of clinicians was more often the stated primary purpose of the professional doctorate whereas the preparation of researchers was the primary purpose of the PhD programs. With regard to the practice doctorate, the DNS degree originated at Boston University in 1960 and "focused on the development of nursing theory for a practice discipline" (Marriner-Tomey, 1990, p. 135). Another avenue to the practice doctorate, the nursing doctorate, became available in 1979 at the Frances Payne Bolton School of Nursing, Case Western Reserve University, under the direction of Rozella M. Scholtfeldt. The nursing doctorate degree was designed to provide postbaccalaureate preservice nursing education, which would orient nursing approach to preparing professionals toward a competent, independent, and accountable nursing practice (Schlotfeldt, 1978).
Over time, the distinction between the practice doctorate in nursing (DNS) and the academic doctorate in nursing (PhD) became blurred. Moreover, it was noted that curricula in practice doctorate programs lacked uniformity (Marion et al., 2003). Therefore, in 2002, the AACN Board of Directors formed a taskforce to examine the current status of practice doctorates in nursing. In 2004, the AACN published a position statement on the practice doctorate, in which it noted that the curriculum requirements for the DNS had become very similar to nursing PhD degree requirements. Therefore, the AACN (2004) had characterized all DNS degrees as research degrees. In addition, the DNP degree was recommended as the terminal degree for nursing practice.
DNP COMPETENCIES
The DNP degree is described as a practice-focused doctorate and the terminal degree in nursing practice (AACN, 2004, 2006a). Recommendations and guidelines for the development of DNP programs are explicitly stated in the "Essentials of Doctoral Education for Advanced Nursing Practice" published by the AACN (2006a). As shown in Table 1, eight essential features of DNP preparation have been identified.
The AACN (2004) defines nursing practice as follows:
any form of nursing intervention that influences healthcare outcomes for individuals or populations, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and healthcare organizations, and the development and implementation of health policy. (p. 1)
The AACN's definition of nursing practice moves beyond historical definitions of nursing practice, which focus on direct care of patients, to include themes related to "outcomes for populations, administration of healthcare organizations, and healthcare policy" (AACN, 2004, p. 3). These same broad themes are consistently found throughout the Essentials of Doctoral Education for Advanced Nursing Practice described by the AACN, the Practice Doctorate Nurse Practitioner Competencies described by the National Organization of Nurse Practitioner Faculties (NONPF; Table 2), and the Institute of Medicine's (IOM's) recommendations for the education of healthcare professionals (Table 3; AACN, 2006a; IOM, 2003; NONPF, 2006).
To some extent, the emergence of the DNP degree might be viewed as a response to the IOM's call for sweeping changes in healthcare including redefining how healthcare professionals are educated (Chism, 2009). In 2000, the IOM's (2000) process to evaluate the improvement of healthcare began with a published report titled "To Err Is Human." This report summarized the errors made in healthcare that could be prevented. As a response, the second report titled "Crossing the Quality Chasm" was published by the IOM (2001). Within this report, the IOM (2001) proposed specific aims to improve healthcare and reduce errors. In an effort to meet these aims, the IOM proposed that healthcare professionals' educational preparation should include a set of competencies, regardless of their discipline. These competencies include the following: (1) provide patient-centered care, (2) function in interprofessional teams, (3) employ evidenced-based practice, (4) integrate quality improvement standards, and (5) utilize various information systems (Table 3; IOM, 2003). These competencies are reflected in the AACN's Essentials of the Doctoral Education for Advanced Nursing Practice (Table 1) as well as the NONPF's Practice Doctorate Nurse Practitioner Competencies (Table 2).
Each new DNP program will vary somewhat in curriculum content, but coursework that promotes achievement of DNP competencies is essential. Furthermore, it is imperative that curriculum content remain somewhat uniform across programs to maintain consistency and credibility of the degree (Chism, 2009). Finally, the curriculum content must also continue to focus on issues pertinent to advanced practice nursing.
In terms of professional practice, the DNP degree is listed as one of the two educational pathways (DNP or master's degree) for APNs. The Advanced Practice Registered Nurse Consensus Model, developed in 2008, delineates requirements for licensure, accreditation, credentialing, and education for APNs (Advanced Practice Registered Nurse Consensus Model, 2008), which DNP graduates will be expected to meet. However, the AACN does not require any additional certification (e.g., the Comprehensive Care Board Exam) for DNP graduates beyond current nationally recognized specialty certification (AACN, 2009b). Specialty organizations have and will continue to develop their own certification mechanisms (e.g., certification examination, portfolio, and peer review process).
THE DNP AND PhD COMPARED
The DNP degree is a practice-focused degree, whereas the PhD is a research-focused degree. The DNP degree prepares the graduate for expertise in practice. The curriculum of a DNP degree emphasizes leadership, evidence-based practice, healthcare policy, information technology, and interprofessional collaboration (AACN, 2006b). DNP preparation places less emphasis on theory and research methodology than a PhD (AACN, 2004, 2006b). In addition, the DNP scholarly project differs from a PhD dissertation in that the DNP scholarly project is grounded in clinical practice and demonstrates ways in which research impacts practice. A PhD dissertation demonstrates the development of new knowledge to be contributed to the discipline of nursing. However, the practice-focused and research-focused doctorates share a common goal regarding a "scholarly approach to the discipline and a commitment to the advancement of the profession" (AACN, 2006b, p. 3). Please refer to Table 4 for the AACN DNP/PhD contrast grid.
THE ROLES OF DNP GRADUATES
The DNP graduate's role is composed of a number of components. These components may include leadership, research, practice, education, and health and public policy (Chism, 2009). These roles may be integrated and adapted to meet the current needs of healthcare delivery and society (Chism, 2009).
Leadership
All APNs are noted to be leaders, whether formally or informally (Buonocore, 2004; Carroll, 2005; Joyce, 2001; Mastal, Joshi, & Schulke, 2007). Leadership is also evident within roles such as an advocate, problem solver, idealist, and role model (Garrison & McBryde-Foster, 2004). Through the expertise developed in a DNP program, the graduates are especially qualified to assume various leadership roles in healthcare. Furthermore, they may possess specific attributes that will enhance their leadership ability in any setting (Table 5).
Interprofessional Collaboration
Doctor of nursing practice graduates also develop skills in interprofessional collaboration. The IOM has deemed that skills in interprofessional collaboration are necessary for all healthcare professionals (IOM, 2003). Additional preparation in interprofessional collaboration will promote behaviors that encourage healthcare teams to work together to improve healthcare outcomes. Ideally, DNP graduates will assume leadership roles that facilitate open communication across professions and foster teamwork (Chism, 2009).
Expert Clinicians
Doctor of nursing practice graduates are considered expert clinicians before entering a DNP program. However, many skills garnered through a DNP program may improve their ability to provide high-quality healthcare (Chism, 2009). For example, DNP graduates receive additional preparation in evaluation and implementation of evidence-based practice. Gibbs (2003) related that evidence-based practitioners adopt a process of lifelong learning that involves continually asking questions of practical importance to clients, searching for the current best evidence relative to each question, and taking the appropriate action that is guided by the evidence. The goal of evidence-based practice is to promote optimal healthcare outcomes, which are based on critically reviewed clinical evidence, for individual patients, families, and communities (Chism, 2009). DNP graduates may therefore directly impact the overall improvement of patient care through their skill in evaluation and implementation of evidence-based practice.
Information Technologies
Doctor of nursing practice graduates also receive additional preparation in information technologies. Increased preparation in information technologies is also consistent with the aims of the IOM (2003). Utilizing these skills will improve patient care through the use of technologies such as electronic medical records, data mining, PDAs, and other communication resources. DNP graduates may also help decrease others' fears and reluctance to use these types of resources. As role models, these graduates will reduce barriers regarding the use of information technologies (Chism, 2009).
Healthcare Policy
As APNs, DNP graduates are expected to be advocates for high-quality healthcare. "DNP graduates are prepared to assume a leadership role in influencing and shaping policies that affect nursing practice" (Mullin, 2009, p. 142). Involvement in healthcare policy may take on many forms from simply becoming informed to actual appointment to a political office (Mullin, 2009).
Scholarship
Scholarship is another important role for the DNP graduate. Scholarship may be defined as "activities that systematically advance the teaching, research, and practice of nursing through rigorous inquiry that is significant to the profession, creative, can be documented, can be replaced or elaborated, and can be peer reviewed through various methods" (AACN, 1999, p. 3). Scholarship may be demonstrated by conducting independent research in collaboration with PhD colleagues, knowledge development, presenting at conferences, or publishing in peer-reviewed journals. Regardless of the type of scholarship, this role is very important for professional development as well as disseminating the contributions of DNP graduates. It is evident that as more DNP graduates become involved in scholarship, the nursing profession will benefit from the unique perspectives and contributions of the practice experts.
Upon reviewing the various roles of the DNP graduate, it may become evident that there is much overlap and integration of these roles. The 21st-century healthcare environment requires unique solutions from leaders who directly impact nursing practice. Through involvement in leadership, evidence-based practice, information technology, healthcare policy, and scholarship, DNP graduates are uniquely prepared to contribute to the improvement of healthcare delivery (Chism, 2009).
ISSUES RELATED TO THE DNP DEGREE
As expected, with the development of this innovative degree, there are certain issues that many DNP graduates may face. These issues include use of the title "Dr.," educating others about the degree, faculty shortages, and program enrollment (Chism, 2009). The ways in which DNP graduates deal with these issues will shape the future of healthcare delivery and nursing education (Chism, 2009).
Title Issues
The term doctor or docere in Latin translates as "to teach" with "doctrine" being what is taught (Skinner, 1970). Merriam-Webster Online Dictionary (2008) defines the term doctor as "a learned or authoritative teacher; a person who has earned one of the highest academic degrees conferred by a university; a person skilled in the healing arts, especially one who holds an advanced degree and a license to practice." Bailey (2003) explained that the term doctor refers to any person with a doctoral degree in any field, not specific profession. These definitions of the term doctor are provided to explain the true meaning of the term. This is pertinent for both DNP graduates and other various professionals, especially when questioned regarding their title or educational preparation (Chism, 2009).
This issue has been debated among certain professional organizations. The AACN and American Academy of Nurse Practitioners have recommended that when using the title "doctor," one should follow it by his or her professional designation, for example, Dr. Smith, Nurse Midwife, or Dr. Jones, Nurse Practitioner. This will reduce confusion and aid to educate others about the educational preparation of nurses. It is the responsibility of both DNP graduates and nurse educators to appropriately educate others about the title "doctor" and the educational preparation of nurses (Chism, 2009).
Education
With regard to educating others about the DNP degree, this is also the responsibility of DNP graduates and nurse educators. A clear understanding must develop regarding what the DNP degree is, as well as the definitions of medicine, nursing, and nursing practice (Chism, 2009). According to American Nurses Association (1995), nursing is "the diagnosis and treatment of human responses to actual or potential health problems" (p. 6). Medicine has been defined as the "science and art of dealing with the maintenance of health and prevention, alleviation, or cure of disease" (Merriam-Webster Online Dictionary, 2009). Hence, medicine is focused on the diagnosis, treatment, and alleviation of disease and disease states. Nursing practice includes both the act of caring for individuals, families, and communities in an effort to promote health and well-being as well as the relationship that develops between a nurse and a patient (Chism, 2009). To speak to one's educational preparation, one needs to truly understand one's profession (Chism, 2009).
Faculty Shortages
Other issues regarding the DNP degree are associated with the rapid development of programs across the country (Chism, 2009). This presents valid concerns regarding faculty availability to teach those who are enrolling in these programs. The AACN (2006c) reported that schools of nursing turned away 41,683 applicants across the country in 2005. The primary reason cited for this was the insufficient numbers of faculty to teach the students (AACN, 2006c). Who will teach the new DNP students in the future when faculty availability has already been an issue? One possible solution proposed involves appointing new DNP graduates as faculty, especially for clinical content. In some academic institutions, this will require acceptance of DNP-prepared faculty (Butler, 2009).
Program Enrollment
On a related note, the momentum of enrollment into these programs has, to date, not been an issue (Chism, 2009). However, will this momentum continue? It appears that the productivity and enthusiasm of new DNP graduates will greatly influence the numbers of DNP students entering programs. It is also imperative that DNP graduates publish their projects and remain involved in scholarship to disseminate the contributions they make to the profession and discipline of nursing. The most effective marketing involves DNP graduates demonstrating their value to both healthcare delivery and the nursing profession.
IMPLICATIONS FOR EMERGENCY NURSING
The DNP degree has implications for emergency nursing. These implications include the emerging opportunities for DNP graduates in this setting. Most likely, these opportunities will include roles in research, public policy, and leadership.
Research
While not prepared as a research expert, the DNP graduate has increased preparation in nursing theory, research methodology, and statistics. Furthermore, the DNP final project is a scholarly project that demonstrates ways in which research impacts clinical practice. Therefore, the DNP graduate has experienced the process of research that will improve their ability to initiate research activities in emergency care. Ideally, a partnership will be established with a PhD colleague to provide consultation and support. More importantly, the emergency APN has a vantage point of clinical concerns within this care setting. The DNP graduate in emergency care has the clinical experience and the additional skills necessary to develop evidence-based solutions.
Public Policy
The unique issues presented in the emergency department such as "the shortage of experienced nurses, the decreased number of physicians in the workforce, and high patient volumes resulting in crowding" (Ray, 2008, p. 555) provide ideal opportunities to become involved in policy and advocacy. The development of a policy regarding these pertinent issues will directly impact patient care but often must be examined at an organizational level. DNP graduates are prepared to advocate for healthcare policy at an organizational level that is necessary for shaping the policy, particularly in emergency care.
Leadership
Finally, the DNP graduate in emergency care will likely be called to engage in various leadership roles. Jagim (2001) related that "all emergency nurses are natural leaders ... however, not all emergency nurses see themselves as leaders" (p. 1). Moreover, certain leadership styles have been reported to improve staff-nurse turnover in the emergency department. Raup (2008) noted that a transformational leadership style, defined as "behaviors categorized as charismatic, encouraging, educational, and communicative" (p. 404), resulted in reduced staff turnover within this setting. Interestingly, transformational leadership behaviors are reflective of the leadership styles reinforced in a DNP program (Table 5).
CONCLUSION
The advent of the DNP degree has been a source of confusion within the nursing community. This article distinguished the DNP from the PhD in an attempt to clarify this confusion. Competencies for the DNP were identified and linked to expectations of nursing organizations and the IOM. In addition, examples of the specific roles of DNP graduates were described as well as pertinent issues related to the DNP degree. After reading this article, it is expected that nurses will be able to speak more cogently about the DNP degree and the issues surrounding this degree for APNS in emergency care.
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