Journal of Nursing Education

Major Article 

Impact of Doctor of Nursing Practice Education in Shaping Health Care Systems for the Future

Jacqueline Dunbar-Jacob, PhD, RN, FAAN; Donna G. Nativio, PhD, CRNP, FAAN; Heba Khalil, BSN, RN

Abstract

The approval of the Doctor of Nursing Practice (DNP) by the American Association of Colleges of Nursing in 2004 and publication of The Essentials of Doctoral Education for Advanced Nursing Practice in 2006 promised significant benefit to nursing and to shaping health care systems. Currently, 229 DNP programs exist and more are planned. This article provides an overview of program types, graduates, and postgraduation placement, using Pennsylvania as an exemplar, to describe the potential impact of DNP education in health care systems. Nurse educators need to consider whether our current directions enable us to realize opportunities for shaping health care systems or whether we need to make course corrections. [J Nurs Educ. 2013;52(8):423–427.]

Dr. Dunbar-Jacob is Dean and Professor of Nursing, Dr. Nativio is Associate Professor of Nursing and Director of the Doctor of Nursing Practice Program, and Ms. Khalil is predoctoral fellow in nursing, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania.

Dr. Dunbar-Jacob received support from the Committee on Institutional Cooperation.

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

Address correspondence to Jacqueline Dunbar-Jacob, PhD, RN, FAAN, Dean and Professor of Nursing, University of Pittsburgh School of Nursing, 3500 Victoria Street, Pittsburgh, PA 15261; e-mail: dunbar@pitt.edu.

Received: January 24, 2013
Accepted: April 03, 2012
Posted Online: July 19, 2013

Abstract

The approval of the Doctor of Nursing Practice (DNP) by the American Association of Colleges of Nursing in 2004 and publication of The Essentials of Doctoral Education for Advanced Nursing Practice in 2006 promised significant benefit to nursing and to shaping health care systems. Currently, 229 DNP programs exist and more are planned. This article provides an overview of program types, graduates, and postgraduation placement, using Pennsylvania as an exemplar, to describe the potential impact of DNP education in health care systems. Nurse educators need to consider whether our current directions enable us to realize opportunities for shaping health care systems or whether we need to make course corrections. [J Nurs Educ. 2013;52(8):423–427.]

Dr. Dunbar-Jacob is Dean and Professor of Nursing, Dr. Nativio is Associate Professor of Nursing and Director of the Doctor of Nursing Practice Program, and Ms. Khalil is predoctoral fellow in nursing, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania.

Dr. Dunbar-Jacob received support from the Committee on Institutional Cooperation.

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

Address correspondence to Jacqueline Dunbar-Jacob, PhD, RN, FAAN, Dean and Professor of Nursing, University of Pittsburgh School of Nursing, 3500 Victoria Street, Pittsburgh, PA 15261; e-mail: dunbar@pitt.edu.

Received: January 24, 2013
Accepted: April 03, 2012
Posted Online: July 19, 2013

Prior to discussion of the potential impact of the Doctor of Nursing Practice (DNP), one must consider the context of the development and expectations for this level of nursing education. The now 10-year-old landmark Institute of Medicine reports addressing medical error recommended improved education for nurses. The Institute of Medicine committees made recommendations for new models of health care delivery and health professions education to address those errors and the increasing complexity of health care (Committee on Quality of Health Care in America, 2001; Greiner & Knebel, 2003; Kohn, Corrigan, & Donaldson, 2003). These reports called for several improvements that demand greater skill and knowledge from nurses. The recommended improvements included systems redesign, an increased emphasis on safety and quality improvement, use of evidence-based practice with an ability to find and evaluate ever-growing bodies of evidence, the delivery of patient-centered care, the increasing use of technologies and informatics for health care delivery and evaluation, the ability to develop patients’ self-management skills, and an emphasis on interdisciplinary team-based care and education. The recommendations exceeded the skills and knowledge routinely offered in master’s degree education.

An examination of the interdisciplinary health care environment reveals numerous colleagues who hold professional doctorates, often as a requirement for entry to the profession. Medicine, dentistry, physical therapy, pharmacy, and other disciplines require the practice doctorate for licensure. For some disciplines, the doctoral degree is required for licensure in specific areas of practice; for example, clinical or counseling psychology requires the PhD or the PsyD. For some others, either the professional master’s or doctorate is acceptable for entry into the profession (e.g., occupational therapy MS or DOT).

In 2004, the membership of the American Association of Colleges of Nursing (AACN) considered a position statement on the practice doctorate in nursing, prepared by a task force within the organization. The membership endorsed that statement, including the recommendation that the “practice doctorate be the graduate degree for advanced practice preparation” and that this goal would be achieved by 2015 (AACN, 2004, p. 8). The American Association of Nurse Anesthetists endorsed doctoral education for entry to practice by 2025 (American Association of Nurse Anesthetists, 2007), and the current draft of the accreditation standards specifies that “students accepted into accredited entry-level programs on January 1, 2022, must graduate with doctoral degrees” (Council on Accreditation of Nurse Anesthesia Educational Programs, 2013, p. 2). In 2006, the AACN endorsed The Essentials of Doctoral Education for Advanced Nursing Practice with a curriculum model designed to build on the generalist foundation of the baccalaureate in nursing or the entry-level master’s in nursing (MSN) (AACN, 2006).

The Essentials (AACN, 2006) comprises eight foundational competencies, as well as specific specialty competencies, consisting of an enriched clinical experience of at least 1,000 hours. This increase in clinical hours is consistent with other clinical disciplines at the doctoral level. For example, the Pennsylvania Code requires applicants for the Doctor of Physical Therapy license to have a minimum of 800 supervised clinical hours, whereas the applicant for the clinical PhD or PsyD in psychology is required to accrue 1,200 hours in an approved internship, followed by at least 1,750 hours of supervised experience at the postdoctoral level (Commonwealth of Pennsylvania, 2013a, 2013b).

This new model in nursing education would afford a number of benefits to nursing. Nursing leaders expect that the DNP would develop advanced competencies, enhance nursing knowledge, enhance leadership skills, develop parity with other health care professionals, improve the image of nursing, provide advanced credentials, attract individuals to nursing, and increase the supply of faculty for clinical instruction. Further, in its 2005 report, Advancing the Nation’s Health Needs, the National Research Council noted that “the need for doctorally-prepared practitioners and clinical faculty would be met if nursing could develop a new nonresearch clinical doctorate, similar to the MD and PharmD” (p. 74). Thus, the expectations for the impact of the practice doctorate are high.

Influence of Educational Programs

The interpretation of the Essentials and employer practices by educational programs will ultimately determine whether the DNP achieves the proposed objectives. With 6 years of experience since the adoption of the DNP Essentials, it is now a reasonable time to examine the nature of these programs and the place of graduates in the health care workforce. At the time of publication, 229 DNP programs exist in the United States, and more than 100 are in development (AACN, 2013). Programs are available in 41 states, with Pennsylvania leading the nation in the number of programs with 15. An examination of the Pennsylvania programs will provide examples of the types of programs and health care placements for assessment of the potential impact of DNP programs.

Pennsylvania’s first DNP program debuted in 2006, with programs opening at various times over the past 7 years. These programs were initially available at doctoral (PhD) institutions and private master’s-level institutions. State master’s-level institutions were not able to offer doctoral degrees. However, in 2012, the Pennsylvania governor signed the Commonwealth Higher Education Modernization Act, which permits master’s-level state universities to offer applied or professional doctorates. It is likely that this opportunity will reduce the barrier to movement toward the DNP among institutions that previously could offer only the baccalaureate or master’s degree. Thus, it is expected that the numbers of programs will grow and the diversity of institutions offering the degree will broaden.

Method of Information Collection

To describe the Pennsylvania programs, we first identified programs listed on the AACN Web site (AACN, 2013). At the time of this information collection, 14 programs were identified. Since then, one more program has opened. We then examined each program’s Web site to identify its admission criteria, specialty, and curriculum. Subsequently, we contacted each program’s director by e-mail with a brief survey asking for the number of graduates (as of June 2012) and the placement of those graduates according to role (faculty, advanced practice registered nurse [APRN], administrator, or other) and type of setting (acute care, primary care, long-term care, educational institution, or other). Eight programs reported graduates. Several programs had not yet graduated students.

Description of Pennsylvania Programs

The programs in Pennsylvania, similar to programs across the country, offer both onsite and online options and consist of both baccalaureate-entry and master’s-entry levels. The weighting of programs favors the MSN to the DNP by far. Fourteen programs offer this option, compared with four programs that offer the BSN-to-DNP. According to the AACN’s DNP Essentials document (2006), the preferred educational pathway is expected to progress from the professional entry degree (baccalaureate or master’s entry) to the DNP; however, in this early stage of DNP education, the majority of programs are enhancing the MSN with the DNP. This leads to a more mature and experienced DNP population than one would expect from a BSN-to-DNP population.

MSN-to-DNP Programs. The MSN-to-DNP programs within the state vary significantly. For example, the program lengths range from 27 to 50 credits. This reflects the institutions’ variation in doctoral requirements, rather than variation in the master’s-level credits of the applicant. The specialty areas for MSN-to-DNP programs include leadership and administration (n = 14), nurse practitioner (n = 5), clinical nurse specialist (n = 2), nurse anesthetist (n = 2), education (n = 1), clinical scholar (n = 1), and none specified (n = 4). It should be noted that each program may offer more than one specialty area; for example, the University of Pittsburgh program offers four specialties, with subspecialties offered within the nurse practitioner specialty.

Programs differ in the manner in which they address the master’s education of applicants. This difference ranges from programs that have a fixed curriculum—that is, independent of the master’s specialty education—to programs that build on the master’s program to enrich specialty education at the DNP level. For example, one university offers a DNP program that consists of seven specific courses and a 500-hour, self-directed clinical capstone project. In contrast, another university admits master’s graduates into a specialty DNP program, which complements their master’s degree. Previous master’s-level course work and clinical practica are mapped onto a specialty BSN-to-DNP curriculum of 81 or more credits (the minimum requirement for a doctoral degree at the institution). Post-master’s students complete the remaining course work and the additional practicum hours for a total of 1,000 clinical hours. The students graduate with a specialty DNP, which appears on both the transcript and the diploma. For example, the transcript and diploma may read “Doctor of Nursing Practice, Nursing Administration” or “Doctor of Nursing Practice, Nurse Practitioner, Pediatrics.” In this instance, curricula diversity prepares graduates for specific practice areas, resulting in a varied potential impact for health care.

BSN-to-DNP Programs. Four (28.6%) of the Pennsylvania programs admit BSN graduate entry to the DNP. These four programs offer specialty preparation as a nurse practitioner (n = 4), clinical nurse specialist (n = 2), and nursing administration (n = 2). The nurse practitioner specialties include Adult–Gerontology Primary Care (n = 4), Acute Care (n = 1), Family (n = 3), Neonatal (n = 1), Pediatric Primary Care (n = 1), and Psychiatric Mental Health Across the Lifespan (n = 2). The clinical nurse specialist programs offered to BSN-prepared students are Adult Medical–Surgical (acute care; n = 1) and Adult Gerontology (n = 1). Program lengths range from 58 to 93 credits, again reflecting institutional variability in requirements for doctoral education.

Program Emphasis

As of August 2012, there were 589 Pennsylvania DNP graduates according to the reports of eight programs. The majority (n = 378) were from administration programs, whereas 189 graduated from nurse practitioner programs and 22 from other programs. As noted, the majority completed post-master’s DNP education. Thus, to date, the DNP programs have not substantially increased the number of advanced practice providers, although they have contributed to a higher level of education.

For most graduates, postgraduation placement was unknown. Of the 163 for whom placement data were available, 78 (47.9%) were employed in acute care, 53 (32.5%) in academics, 24 (14.7%) in primary care, and 8 (4.9%) in other settings. If Pennsylvania, an early adoption state, is reflective of the potential impact of the DNP in the health care arena, the impact will be greatest in acute care, principally in administration, and in academics. Primary care has not yet realized the impact.

The slow adoption of the BSN-to-DNP program signals a reluctance to move away from master’s specialty education to the DNP as the preferred advanced practice degree in time for a transition by 2015. Possible explanations are beliefs about graduate education, concerns about enrollment, or simply a wait-and-see approach to the transition. The post-master’s DNP programs focus primarily on leadership and administration. One may view this as a way of increasing nursing administrators’ knowledge and skills or as a method of adding leadership and systems skills to existing advanced practice qualifications. In either case, growth in the numbers of new APRNs at the DNP level is relatively slow, and added clinical education to master’s-level advanced practice preparation is significantly behind that of leadership preparation.

Early Impact of DNP Education

Health Care Systems

DNP preparation will influence how the emergence of the DNP in health care will impact the field. The DNP program brings new skills to nurse leaders in several areas. The emphasis on quality improvement will promote nurse leaders’ knowledgeable engagement in and encouragement of quality initiatives. The emphasis on collaborative team care will reinforce quality improvement at the interdisciplinary level. The evidence-based practice thread has the potential to strengthen the use of evidence in the design of nursing interventions and procedures through nurse administrators’ expectations and competence in finding, synthesizing, and applying evidence appropriately. Whether evidence-based practice in administration programs should include the identification and application of research in management and leadership is open to discussion. In addition, attention to informatics would facilitate the inclusion of nursing in electronic record design and utilization for both routine use and practice-based nursing research. Finally, new skills in systems redesign would potentially support the nursing administrator in amassing the other competencies to create improved systems for nursing practice. Thus, the potential for significant impact at the hospital level, with these new skills acquired, is great.

Academics

The second most common placement for Pennsylvania DNP graduates has been in academics, as previously noted. DNP graduates in an academic setting bring numerous strengths. First is a clinical and health systems depth of understanding, which exceeds that of MSN graduate faculty members. This knowledge is important in advanced practice students’ education, as well as that of master’s and undergraduate students. Second, the DNP also provides added competencies for students. Among these are an increased depth in quality and safety, the value and skills for team practice, and the use of evidence-based practice in patient care delivery.

DNP-prepared faculty members offer other benefits to the academic setting. First is the modeling of an advanced practice education. For faculty with a practice component to their effort, the opportunity to demonstrate or mentor students has the potential to further model the benefits of the greater depth of knowledge in practice that the DNP can impart.

Second, DNP-prepared faculty members can also foster a methodological expansion to scholarship in nursing. The design of practice innovations and management strategies, although maintaining an emphasis on utilization of evidence, requires one to use a methodology not commonly found in the sciences underlying new knowledge development. Examples include program evaluation, improvement science, implementation science, single-case designs, and other strategies to inform the design and evaluation of evidence-based programs in the local unit. With an advanced knowledge of translation of evidence into practice programs and the methodology to examine its effectiveness at the local level, DNP-prepared faculty afford an enhanced opportunity and value in collaboration with their scientific colleagues, as well as their colleagues in clinical settings.

Finally, the DNP allows university and college departments to increase the numbers of doctorally prepared faculty. In an environment in which doctoral education—either the PhD or professional doctorate—is an expectation, the DNP allows for parity with other departments and disciplines. With this equivalence comes the potential for an enhanced respect for the discipline and for the education of new entrants to nursing.

Primary Care

DNP graduates bring to primary care an enhanced understanding of the health care system, policy issues, finance, and professional leadership. Such knowledge will benefit the redesign of health care systems and prepare clinical leaders for evolving practice. For programs that offer advanced clinical education in the DNP, the primary care setting will benefit from the presence of an APRN with a depth of clinical knowledge beyond the level of master’s preparation. The APRN in primary care will be a peer with colleagues, in terms of level of education, and will have an understanding of how to promote and engage in interdisciplinary team care. As nurses assume increasing responsibility for patient care in primary care settings, the combination of increased clinical and systems knowledge, as well as the capability to apply and evaluate evidence to practice innovations, can only have a positive impact.

The presence of DNP-prepared APRNs in primary care will expand educational opportunities. In the short term, the DNP-prepared APRNs can mentor the MSN-prepared APRNs within the system. Equally as important is the opportunity for enhanced precepted education for nursing students in primary care.

The impact of the DNP in primary care will be a function of the type of education that builds on master’s-level education. As noted previously, most early programs are post-master’s programs and emphasize systems knowledge rather than additional advanced clinical education associated with direct patient care. As our examination of the Pennsylvania data found, the proportion of DNP graduates entering primary care remains small (approximately 14%). Thus, the short-term influence of DNP education in primary care is likely to be less than that in acute care and academics.

Short-Term Impact in Other Areas

The DNP has the potential to impact other areas in health care. One of those areas is the financing of health care through administrative positions in the health insurance industry. We are already seeing this happen. Other opportunities arise in policy regarding long-term care and home care, in addition to other avenues. Increased advanced practice opportunities in long-term care have arisen, including direct care on a daily basis, prevention of hospitalization, and prevention of hospital readmissions. The potential for numerous other areas exists.

Long-Term Impact of DNP Education

The DNP may likely add multiple contributions to the health care system, from systems redesign to evidence-based practice innovations. The long-term impact will depend on the type and quality of education programs, as well as on how the health care systems adopt the DNP graduate. Several questions arise as we examine the potential of the DNP in shaping the health care systems of the future.

The original intent of the DNP educational preparation was “to prepare experts in specialized advanced nursing practice… focus(ed) heavily on practice that is innovative and evidence-based” (AACN, 2006, p. 3). The recommendation suggested for DNP preparation for APRNs was based on “the expansion of scientific knowledge required for safe nursing practice and growing concerns regarding the quality of patient care delivery and outcomes” (AACN, 2006, p. 4). Further, the Essentials document states that “the curricula must be individualized for candidates based upon their prior education and experience” (AACN, 2006, p. 7).

As we have seen, the nature of the existing programs varies considerably in terms of emphasis, depth, attention to prior education of graduates, and BSN-to-DNP versus MSN-to-DNP. As noted, many of these early programs emphasize leadership, administration, and health systems. Fewer programs appear to stress the clinical component of advanced practice. Fewer programs are available for BSN-to-DNP education. As we examine the emphasis and educational trajectory of programs, we need to consider where we, as a profession, want the DNP to have the most influence. One important consideration is the direction of the DNP—do we want the DNP to continue the education of some or all MSN graduates, or do we want to build single, integrated programs?

Challenges in building DNP programs include the identification of qualified faculty for each specialty, qualified capstone advisors, and qualified clinical preceptors. A further challenge is the simultaneous education of master’s cohorts and DNP cohorts. At the authors’ institution, we have addressed these challenges by requiring faculty to obtain a doctoral degree, developing critical academic–service partnerships in mentoring students for practicum and capstone projects, and discontinuing MSN advanced practice specialty programs, while focusing on the BSN-to-DNP and MSN-to-DNP programs. High-quality DNP academics and DNP clinicians are crucial to help meet these challenges. Each educational program must assess its challenges and strategies for addressing those challenges. How we proceed will determine the impact of our programs on the future of the health care system.

Indeed, the preparation of the DNP will influence the perception of health care systems regarding the added value of DNP education. If graduates of such programs bring increased depth of knowledge and skill to the clinical arena, the DNP will likely flourish. If graduates bring little more than what is offered by master’s-level education, the DNP will not be an attractive addition to the clinical arena. Thus, the quality of the preparation of the DNP will influence the adoption of the DNP practitioner and administrator by health care systems.

The potential of DNP education is the enhancement of both acute and primary care practice, redesign and evidence-based management of health care systems, enrichment of the academic environment, strengthening of academic–service educational partnerships, and the furtherance of interprofessional collaborations in an environment of educational parity. The opportunities are extensive. As we review our educational directions for the DNP, it is important to ask the following questions: Are we able to realize those opportunities? Will we reach the goal of requiring the DNP for APRNs by 2015?

References

10.3928/01484834-20130719-03

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