Journal of Nursing Education

Major Article 

Scholarly Publication Practices of Doctor of Nursing Practice-Prepared Nurses

Marion E. Broome, PhD, RN, FAAN; Mary E. Riner, PhD, RN; Eman S. Allam, PhD, MSc

Abstract

Doctor of Nursing Practice (DNP) graduates are expected to contribute to nursing knowledge through empirically based studies testing the effectiveness of practice approaches that ultimately benefit patients and health care systems. This article describes publication practices of DNP graduates in the scholarly literature. Published studies (2005 to 2012) with at least one author with a DNP degree were identified. The search yielded 300 articles in 59 journals; 175 met the inclusion criteria and were included in this study. A codebook, consisting of 15 major categories, was used to extract relevant information. Original clinical investigations were the most frequent, followed by practice-focused patient and provider studies. The number of studies published in peer-reviewed journals with DNP-prepared authors increased over time. We recommend greater integration of translational science models into DNP curricula to achieve the goal of publishing scholarly products that use evidence to improve either practice or patient outcomes. [J Nurs Educ. 2013;52(8):429–434.]

Dr. Broome is Dean and Distinguished Professor, and Dr. Riner is Associate Dean for Global Affairs and Coordinator for the Doctor of Nursing Practice Program, Indiana University School of Nursing, Indianapolis, Indiana; and Dr. Allam is Researcher, National Research Centre, Cairo, Egypt.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Marion E. Broome, PhD, RN, FAAN, Dean and Distinguished Professor, Indiana University School of Nursing, 1111 Middle Drive, NU 132, Indianapolis, IN 46202; e-mail: mbroome@iupui.edu.

Received: November 29, 2012
Accepted: April 10, 2013
Posted Online: July 18, 2013

Abstract

Doctor of Nursing Practice (DNP) graduates are expected to contribute to nursing knowledge through empirically based studies testing the effectiveness of practice approaches that ultimately benefit patients and health care systems. This article describes publication practices of DNP graduates in the scholarly literature. Published studies (2005 to 2012) with at least one author with a DNP degree were identified. The search yielded 300 articles in 59 journals; 175 met the inclusion criteria and were included in this study. A codebook, consisting of 15 major categories, was used to extract relevant information. Original clinical investigations were the most frequent, followed by practice-focused patient and provider studies. The number of studies published in peer-reviewed journals with DNP-prepared authors increased over time. We recommend greater integration of translational science models into DNP curricula to achieve the goal of publishing scholarly products that use evidence to improve either practice or patient outcomes. [J Nurs Educ. 2013;52(8):429–434.]

Dr. Broome is Dean and Distinguished Professor, and Dr. Riner is Associate Dean for Global Affairs and Coordinator for the Doctor of Nursing Practice Program, Indiana University School of Nursing, Indianapolis, Indiana; and Dr. Allam is Researcher, National Research Centre, Cairo, Egypt.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Marion E. Broome, PhD, RN, FAAN, Dean and Distinguished Professor, Indiana University School of Nursing, 1111 Middle Drive, NU 132, Indianapolis, IN 46202; e-mail: mbroome@iupui.edu.

Received: November 29, 2012
Accepted: April 10, 2013
Posted Online: July 18, 2013

The American Association of Colleges of Nursing (AACN) calls for Doctor of Nursing Practice (DNP) graduates to engage in a synthesis project based on their educational experience and one that lays the groundwork for future scholarship (AACN, 2006). Because the DNP degree involves mastery of advanced practice, the intent of the AACN is that validation of this mastery should occur through practice-relevant scholarly papers and presentations that use evidence to improve either practice or patient outcomes.

Because DNP programs started in the early 2000s, there has been sufficient time for graduates to contribute to the body of nursing knowledge; however, the dissemination of projects that reflect strategies to change health care systems to improve care and patient outcomes is needed. Studies conducted by DNP-prepared nurses, if published, contribute to building empirically based knowledge, corroborating or disconfirming theories, testing the effectiveness of practice approaches, and ultimately benefitting patients and health care systems. Without this study dissemination, nursing and our communities of interest (other researchers, practitioners, policy makers, and the consumers of nursing services) will not benefit from the scholarship being conducted by graduates of this relatively new practice doctorate.

National DNP forums, both at conferences and online, always include some extensive conversations about the inquiry or capstone project that is expected to demonstrate the students’ ability to conduct and evaluate evidence-based projects in health systems. Although the Sigma Theta Tau International Virginia Henderson International Library has established a central repository of DNP scholarship products, it is not complete in terms of peer-reviewed papers. Therefore, we decided that the most feasible way to assess the focus and quality of these projects, as well as to assess the dissemination practices of the DNP graduates, was through a review of the published journal literature using standard indexes that were supplemented with hand searches of journal tables of contents. The purpose of our study was to review and analyze trends in the published literature over the past decade and to describe scholarship dissemination practices of graduates of DNP programs. It is through such an analysis that the discipline can gauge how effectively the inquiry or capstone projects are meeting the intent of DNP programs.

Method

Search Strategy and Codebook

Several criteria were used to select the articles for this analysis, including (a) those having at least one author with a DNP degree, (b) those published between 2005 and 2012, (c) those published in English-language journals, (d) those published in peer-reviewed journals listed in the ISI (now known as Thomson Reuters) Web of Science 2009 rankings for nursing journals, and (e) those published in journals for a predominantly United States audience. All journal issues published between 2005 and 2012 were searched. These years were selected based on the earliest possible publication of a DNP-prepared author, as the first DNP program began in 2004. The rationale for choosing from the 2009 ISI rankings of nursing journals was that the journals on this list were well established, they were judged by Thomson Reuters (formerly ISI) Web of Science panels as scholarly, they were assumed to have some comparable level of quality, and they were most likely to be read by nurses with advanced degrees (Polit & Northam, 2011). A final rationale was that the systematic reviews, based on the accessible literature from major bibliographic databases, have yielded results similar to those from more comprehensive searches (Egger, Juni, Bartlett, Holenstein, & Sterne, 2003). The decision to restrict the search to those journals primarily read by U.S. audiences was based on an assumption that authors with a DNP degree would most likely submit manuscripts to journals based in the United States. The application of these journal screening criteria resulted in 59 journals being searched.

The titles of published original articles in the table of contents for each issue of every journal was then searched by hand for at least one author with the DNP degree. This labor-intensive search was conducted because MEDLINE search strategies do not allow for a search by author degree (i.e., DNP). This initial search yielded 300 titles of articles published. Using the titles, each of the published articles were judged to be (a) data based, (b) not data based, or (c) not sure. After both the first and second authors (M.E.B. and M.E.R., respectively) reviewed the 300 titles, the abstracts were printed for those articles that suggested data or evidence were included or those that were in the “not sure” category. Then they each independently reviewed abstracts for one half of the 300 articles and used the codebook (described below) to extract and document information from the abstracts. If sufficient information was not available in the abstract, the full article was then printed.

The codebook for information extraction was developed by the authors using an iterative process (i.e., examination of codebooks from previous systematic reviews). The codebook consisted of 15 different fields, such as order of the DNP authorship, whether the article was original research or practice or education focused, and whether it included practice guideline testing. The fields are described in Table 1. Because the contents of an article could be coded in several different categories, the percentages described in our findings do not total 100%. For instance, articles that reported on a clinical intervention could have been original research or an educational survey.

Codebook for Information Extracted From the Articles Reviewed

Table 1:

Codebook for Information Extracted From the Articles Reviewed

Procedure

The two authors independently reviewed the data extracted from the abstracts or full publications (when necessary) and then validated the coding with each other for those articles about which they were unsure. One hundred twenty-five of the abstracts were judged to lack sufficient data or evidence about the topic and were not used in the final analysis. These abstracts included opinion papers (e.g., “March Madness”); a “how to” description of a nursing activity (e.g., medication calculation); a description of a new clinical innovation or topic (e.g., influenza vaccine); a review of the literature on a specific topic (e.g., preoperative fasting, evidence and practice); or a skill-building description or how to engage in evidence-based practice activities (e.g., critical appraisal). One hundred seventy-five article abstracts remained, from which information was extracted. A complete list of the included articles can be found in Table A (available in the online version of this article). A third author (E.A.) then reviewed the appropriateness (criteria match) of all 175 articles selected and reviewed the coding for accuracy and congruency across the two initial reviewers.

Results

The overall characteristics of the 175 articles used in our final analyses and coding are shown in Table 2. The journals in which the articles were published varied in terms of their primary editorial purpose and, consequently, their primary audience. Nearly 80% of the articles were in journals that published predominantly practice-focused topics (Figure 1). This was followed by journals that predominantly published research or empirical articles, followed by those that published policy, education, and theory articles. The number of publications has increased over time as the DNP programs have matured and the number of graduates has grown. In fact, since 2007, the number of publications with at least one DNP author has increased sixfold (Figure 2).

Characteristics of the Articles Reviewed (N = 175)

Table 2:

Characteristics of the Articles Reviewed (N = 175)

Description of the included journals by category (n = 59).

Figure 1.

Description of the included journals by category (n = 59).

Classification of the reviewed articles by year of publication.

Figure 2.

Classification of the reviewed articles by year of publication.

Characteristics of the Publications

In the majority of articles (n = 132, 75%), a DNP-prepared individual was the first author. Seventy-six (43%) of the authors were from multiple settings (practice and academe) or held a joint appointment in a school of nursing and a health care agency. Thirty-four of the articles listed coauthors from other disciplines, such as medicine and psychology. Only seven articles involved projects conducted in international settings outside of the United States.

Focus

Of the 175 articles, some were coded in multiple categories. Sixteen (9%) articles were literature reviews. The remaining articles varied between practice focus (n = 65; 37%), in which the data reported were from nurses or other health providers; patient focused (n = 85; 48.6%), in which the data was about or taken from patients; and in 23 (13%) articles, data were collected about the implementation of an organization or system intervention. One hundred thirteen (65%) of the articles described a clinical intervention and another 17 (10%) reported the development or testing of practice guidelines. Twenty-two (13%) articles involved information technology or informatics interventions, whereas articles collecting data about an educational intervention numbered 21 (12%). In 13 (7%) of the remaining articles, a survey was sent to a cohort of individuals about nursing practice or education.

Discussion

Our review found that DNP-prepared nurses are contributing to the body of nursing knowledge. In addition to being the first author of the majority of articles reviewed, DNP-prepared nurses are publishing with interdisciplinary colleagues and colleagues in practice and academia. The studies that collected data evaluating the effectiveness of an intervention with either nurses or patients were most the prevalent. The second most prevalent type of studies were self-report surveys of nurses or patients. Interprofessional collaboration is one of the essentials of DNP education identified by the AACN (2006) and is considered an important aspect in improving quality and safety (Interprofessional Education Collaborative, 2011); thus, it is encouraging to see these coauthorship patterns. Gaps were noted in the reviewed publications, particularly as related to the dearth of policy-relevant and informatics studies.

In the sense that nursing scholarship is intended to build the scientific body of knowledge used in practice, we found evidence of this in our review. The most frequent type of DNP-generated publication was the clinical intervention study that sought to produce new nursing knowledge. Examples of issues addressed included implementing a medication administration system that uses bar codes (Rack, Wolf, & Dudjak, 2012), developing a staff intervention for preventing catheter-associated urinary tract infections (Andreessen, Wilde, & Herendeen, 2012), and establishing quality improvement in an anticoagulation clinic (Carver, Studeny, Gress, & Wood, 2012). Rack et al. (2012) analyzed RN workarounds in an academic medical center using bar code technology for medication administration and included significant considerations that may minimize the development of these workarounds in practice. Carver et al. (2012) described a protocol for managing heart valve patients with subtherapeutic international normalized ratio tests and suggested that the new protocol provides significant improvements in patient care.

However, it was somewhat surprising that this clinical intervention study design, which resulted in the generation of new knowledge, was prevalent when the majority of DNP curricula did not emphasize research methods, according to our own review of curricula available online. It is possible that DNP graduates were working with faculty mentors who were more experienced and comfortable with knowledge discovery research methods, rather than evidence-based practice application or translation study designs. If so, to what extent does DNP curricula immerse students in research methods and statistics to ensure they have a foundation for continuing their scholarship based on original research throughout their careers? Is it not the intent of DNP preparation to enable graduates to shape practice using knowledge translation methods and designs? If so, do all current DNP program curricula include sufficient practice-based investigation methods to ensure that graduates continue to engage in practice scholarship into the future? A related question that is also important is, “Was it the clinical intervention studies that were primarily well-enough designed, conducted, and written to merit publication in peer-reviewed journals?” We assume so, as we chose journals in nursing with the highest impact factors, but we did not use a quality assessment measure; therefore, this is something that should be considered as the field continues its dialogue about DNP outcomes related to scholarship.

Although preparation of nurse educators was and is not an intended outcome of DNP education according to the AACN’s (2006) Essentials document, several articles examining educational topics in either academic or practice settings were found. For example, these included clinical teaching studies that focused on student satisfaction and self-confidence after a simulation intervention (Alfes, 2011), issues around classroom participation systems (Smith & Rosenkoetter, 2009), and the impact of mindfulness meditation on safety (Brady, O’Connor, Burgermeister, & Hanson, 2012). Alfes (2011) evaluated and compared the effectiveness of simulation versus a traditional skills laboratory method in promoting self-confidence and satisfaction with learning among beginning nursing students. The findings revealed a significant positive relationship between self-confidence and satisfaction, and, thus, a recommendation of implementing simulation throughout the curricula was set. Brady et al. (2012) examined the impact of the mindfulness-based stress reduction program on managing work stress and improving patient outcomes and indicated that the program assisted staff in decreasing their stress levels and improved their self-care, which resulted in improved patient care.

Several practice or education surveys were conducted outside of the institutions where the study authors’ earned their degrees. Examples of these included consumer perspectives on nurse practitioners and independent practice (Brown, 2007), psychological empowerment and structural empowerment among nurse practitioners (Stewart, McNulty, Griffin, & Fitzpatrick, 2010), and clinical experiences for DNP students (Wolf, Budd, & Bhattacharya, 2011). Stewart et al. (2010) studied the relationship of psychological empowerment and structural empowerment in nurse practitioner practice, and their results indicated that nurse practitioners significantly value their work and find meaning in what they do. As an implication for practice, they specified that the relationships between psychological empowerment and structural empowerment have been linked to work effectiveness, quality patient care, cost effectiveness, and retention, and the study results support the implication that it is of critical importance for the organization or practice setting to facilitate both psychological and structural empowerment to the nurse practitioner to ensure successful practice. Wolf et al. (2011) investigated the number of clinical hours required in post-master’s programs and the types of clinical experiences provided and showed that the programs included differed in their clinical hour requirements, which ranged from 0 to 1,000. In comparison of schools with only DNP programs, those that had both DNP and PhD programs were more likely to require additional clinical hours if the applicants had less than 1,000 hours prior to admission.

Organizational system studies in this sample examined topics such as the association between relationship-based care and patient satisfaction (Cropley, 2012), evaluation of the professional practice (Ditomassi, 2012), and transformational leadership practices (Clavelle, Drenkard, Tullai-McGuinness, & Fitzpatrick, 2012). This focus on systems phenomena is a positive area of scholarship and one that is a reflection of the organizational and system leadership development that is an intended outcome for the clinical doctorate. DNP-prepared nurses must be able to develop and evaluate care delivery approaches for patient populations and lead quality improvement and safety initiatives in health care systems.

Recommendations

Based on the analysis of publication practices, we suggest several recommendations that those who develop, refine, and revise DNP curricula may want to consider. These recommendations include (a) continuing the strong interdisciplinary work; (b) placing a greater emphasis on translational research methods; (c) using multiple site and multistudent projects that make more effective use of faculty time, increase sample sizes, encourage team-based models, and encourage greater development and testing of protocols; (d) focusing on developing a way to catalog the scholarly inquiry or capstone projects, as well as a greater push to disseminate these scholarly products in mainstream, peer-reviewed journals; and (e) integrating journal publishing guidelines into writing standards for the scholarship article.

The scholarship of the clinical DNP has been compared with Boyer’s model of scholarship (Milton, 2005). From this perspective, we expected to find more articles using translational science models in guideline testing studies. A perusal of online DNP curricula found that several DNP programs (e.g., University of Washington, University of Michigan, Indiana University, Johns Hopkins University) have included translational science course-work in their curricula. Translational science models are not new to nursing and should continue to be embraced within nursing education and practice as a field of scholarship ripe for nursing to advance (Mitchell, Fisher, Hastings, Silverman, & Wallen, 2010).

Publication of Scholarship Projects

It is important for DNP programs to prepare students for scholarly publication. The Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines ( http://squire-statement.org/about) provide a systematic way to conceptualize practice improvement studies and to disseminate the findings. Stein (2010) recommended the use of these guidelines for DNP clinical practice projects as a way to disseminate project evaluations. These guidelines have been adopted by journal editors for quality improvement manuscripts.

Central Repository

Currently, there is no central repository of published work by DNP-prepared nurses. This limits nursing’s ability to identify the contributions of this relatively new academic degree to the health care enterprise and to health knowledge. Substantial resources have been devoted to developing DNP programs in a variety of education institutions, and a rapidly growing number of students have completed such programs and obtained the degree. Yet, how will nursing as a collective be able to describe the contribution of the clinical practice doctorate without a mechanism to collect the scholarship produced? Although some universities have repositories, such as ScholarWorks, not all do. We suggest that national and international nursing organizations consider establishing a publicly available, searchable repository of DNP scholarship papers.

Conclusions

We reviewed 175 articles that included DNP-prepared nurse authors to identify characteristics and trends of the scholarship being published. The studies showed a positive trend of DNP-prepared nurses engaging in interdisciplinary scholarship with colleagues in practice and those with a mix of academic degrees. The predominance of first authors with the DNP degree reflects the emerging leadership role in practice scholarship. DNP-prepared nurses are engaging in a wide range of clinical investigations using a range of research methods. However, we were surprised by the lack of widespread use of translational science models; therefore, programs may want to consider incorporating these into their curricula in the future. With the stated intent of the DNP Essentials (AACN, 2006) to prepare nurses with clinical practice doctorates, it is important to ensure that curricula adequately prepares graduates with the conceptual models, design methods, statistical analysis, and writing experience to continue contributing to nursing knowledge.

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Relationships between lifestyle, health behaviors, and health status outcomes for underserved adults. J Am Acad Nurse Pract, 24(6), 364– 374. doi:10.1111/j.1745-7599.2012.00697.x [CrossRef] Andreessen, L., Wilde, M. H. & Herendeen, P. ( 2012). Preventing catheter-associated urinary tract infections in acute care: the bundle approach. J Nurs Care Qual, 27(3), 209– 217. doi:10.1097/NCQ.0b013e318248b0b1 [CrossRef] Ardizzone, L. L., Enlow, W. M., Evanina, E. Y., Schnall, R. & Currie, L. ( 2009). Impact of a patient safety curriculum for nurse anesthesia students. J Nurs Educ, 48(12), 706– 710. doi:10.3928/01484834-20091113-01 [CrossRef] Avadhani, A. & Miley, H. ( 2011). Probiotics for prevention of antibiotic-associated diarrhea and Clostridium difficile-associated disease in hospitalized adults--a meta-analysis. J Am Acad Nurse Pract, 23(6), 269– 274. doi:10.1111/j.1745-7599.2011.00617.x [CrossRef]Bartges, M. ( 2012). Pairing students in clinical assignments to develop collaboration and communication skills. Nurse Educ, 37(1), 17– 22. doi:10.1097/NNE.0b013e318238372c [CrossRef] Barth, M. M. & Jenson, C. E. ( 2006). Postoperative nursing care of gastric bypass patients. Am J Crit Care, 15(4), 378– 387; quiz 388.Beaulieu, M. J. ( 2009). Failure to rescue as a process measure to evaluate fetal safety during labor. MCN Am J Matern Child Nurs, 34(1), 18– 23. doi:10.1097/01.NMC.0000343861.64614.c9 [CrossRef] Beckstrand, R. L., Giles, V. C., Luthy, K. E., Callister, L. C. & Heaston, S. ( 2012). The last frontier: rural emergency nurses’ perceptions of end-of-life care obstacles. J Emerg Nurs, 38(5), e15– 25. doi:10.1016/j.jen.2012.01.003 [CrossRef] Beckstrand, R. L., Rasmussen, R. J., Luthy, K. E. & Heaston, S. ( 2012). Emergency nurses’ perception of department design as an obstacle to providing end-of-life care. J Emerg Nurs, 38(5), e27– 32. doi:10.1016/j.jen.2011.12.019 [CrossRef] Benton, M. J., Whyte, M. D. & Dyal, B. W. ( 2011). Sarcopenic obesity: strategies for management. Am J Nurs, 111(12), 38– 44; quiz 45– 36. doi:10.1097/01.NAJ.0000408184.21770.98 [CrossRef] Best, J. T., Frith, K., Anderson, F., Rapp, C. G., Rioux, L. & Ciccarello, C. ( 2011). Implementation of an evidence-based order set to impact initial antibiotic time intervals in adult febrile neutropenia. Oncol Nurs Forum, 38(6), 661– 668. doi:10.1188/11.ONF.661-668 [CrossRef] Bhengu, B. R., Ncama, B. P., McInerney, P. A., Wantland, D. J., Nicholas, P. K., Corless, I. B. & Ros, A. V. ( 2011). Symptoms experienced by HIV-infected Individuals on antiretroviral therapy in KwaZulu-Natal, South Africa. Appl Nurs Res, 24(1), 1– 9. doi:10.1016/j.apnr.2009.01.001 [CrossRef] Binner, M., Ross, D. & Browner, I. ( 2011). Chemotherapy-induced peripheral neuropathy: assessment of oncology nurses’ knowledge and practice. Oncol Nurs Forum, 38(4), 448– 454. doi:10.1188/11.ONF.448-454 [CrossRef] Bookbinder, M. & McHugh, M. E. 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Codebook for Information Extracted From the Articles Reviewed

FieldQuestion
First authorWas the first author Doctor of Nursing Practice-prepared?
Interdisciplinary authorsWere the authors from multiple disciplines?
Joint practice and academicsWere the authors from both academic and practice settings?
International settingDid the project involve an international setting?
Literature reviewDid the project include data from an intervention or a descriptive study?
Year publishedWhat year was the article published?
Practice focus—nursing or interdisciplinaryWere data collected about nurses or other health care professionals?
Practice focus—patientWere data collected about patients?
Were data collected to generate knowledge about the effectiveness of the intervention?Was the intervention conducted with patients or with nurses?
Practice guideline developed and testedDid the authors describe the development of a guideline and did they test it?
Practice guideline testedDid the authors test an already established guideline?
Informatics technology interventionDid the intervention involve information technology?
Clinical teaching moduleWere the data collected about an educational intervention?
Education or practice surveyWere surveys sent to a cohort of individuals outside of the authors’ home institution?
Organizational systems interventionWas the intervention designed to change a system within an organization?

Characteristics of the Articles Reviewed (N = 175)

CharacteristicNo. (%)a
Doctor of Nursing Practice-prepared first author132 (75.4)
Interdisciplinary authors34 (19.4)
Joint practice and academics76 (43.4)
International setting7 (4)
Literature review16 (9.1)
Practice—nursing focused65 (37.1)
Practice—patient focused85 (48.6)
Clinical intervention113 (64.6)
Practice guideline developed and tested17 (9.7)
Informatics technology intervention22 (12.6)
Clinical teaching module21 (12)
Education or practice survey13 (7.4)
Organizational systems intervention23 (13.1)

10.3928/01484834-20130718-02

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