In 2004, the American Association of Colleges of Nursing (AACN) endorsed the Doctor of Nursing Practice (DNP) degree as the single-entry degree for advanced practice nurses (APNs) (AACN, 2004). In their endorsement of the DNP, the AACN (2004) identified several benefits of the new degree, including (a) advanced competencies for increasing complex clinical, faculty, and leadership roles; (b) “enhanced knowledge to improve nursing practice and patient outcomes; (c) advanced leadership skills” (p. 7); (d) parity with other health professionals; (e) increased faculty for clinical instruction; and (f) improved image. This endorsement led to the rapid expansion of DNP programs across the country, from 20 in 2006 (AACN, 2012b) to 229 at the time of this article’s publication, with more than 100 additional programs in the planning stages (AACN, 2013). In a time of health care reform with associated complexity that requires a high-level skills set, many leaders and professional organizations support the AACN’s position on the minimal level of preparation for APNs (National Organization of Nurse Practitioner Faculties, 2004, 2008). However, others raise serious concerns about this DNP mandate, given the shortage of primary care providers and the need to provide health care access to approximately 33 million more people who will have insurance when the new reform bill is fully implemented (Cronenwett et al., 2011).
Although the AACN’s The Essentials of Doctoral Education for Advanced Nursing Practice (2006) clearly state that the DNP is a practice-focused doctorate that should prepare clinicians for leadership in evidence-based practice (EBP), much confusion exists about academic curricula for the DNP, in comparison with the PhD degree, and the roles DNP graduates should assume in academic and health care settings. Therefore, the purposes of this article are to (a) resolve the confusion in the academic preparation of the DNP versus the PhD student, (b) discuss current roles of the DNP-prepared versus the PhD-prepared graduate, and (c) distinguish the roles of DNP and PhD nurses in knowledge discovery, translation of evidence into practice, and dissemination of scholarship.
Importance of Doctoral Preparation in Improving Americans’ Health Care and Health
Although the United States spends approximately $3.1 trillion annually on health care, which accounts for 17.7% of our gross domestic economic output (Chernew, Baicker, & Hsu, 2010), it ranks 37th in performance on health outcomes according to the World Health Organization (2000). These health care expenditures are 50% to 100% higher than those of other industrialized countries (World Health Organization, 2000). Wasteful health care spending costs the health care system $1.2 trillion annually, and half of American hospitals are functioning in deficit (American Hospital Association, 2007). In addition, preventable medical errors add $77 billion to total outpatient health care costs (Porter & Teisberg, 2006). Further, many practices within health care continue to be based on tradition versus the best evidence-based practices. Although the U.S. Preventive Services Task Force has long published evidence-based prevention recommendations on various health topics that are often viewed as the gold standard, these evidence-based guidelines and other evidence-based clinical preventive services by providers are underutilized, resulting in wasteful health care spending and, more importantly, loss of life-years for Americans (Melnyk, Grossman, et al., 2012). Fragmentation of care in our health care system is another huge problem (Carter, 2010). It is now not unusual for a typical Medicare patient to see two primary care providers and five specialists working in four medical practices (Thorpe, Ogden, & Galactionova, 2010). Our health care system cannot sustain these rising health care costs, wasteful spending, and lack of evidence-based practices without a collapse of the entire system.
As a result of a challenged health care system, the overall health of the American people is declining. Behavior, such as smoking, overeating, lack of physical activity, nonadherence to medications, and suicidal gestures, is the number one killer of Americans. Overweight and obesity will soon surpass tobacco as the number one cause of preventable death and disease in the United States (Stewart, Cutler, & Rosen, 2009). With the rapid increase in the prevalence of overweight and obesity, the Centers for Disease Control and Prevention predict that one of three Americans will have diabetes by 2050 (Boyle, Thompson, Gregg, Barker, & Williamson, 2010). According to the Medicare Payment Advisory Commission, approximately 75% of the total U.S. health care spending is allocated to the treatment of chronic diseases (Carter, 2010). For Medicare, chronic diseases account for 96% of total spending, with approximately one quarter of a rapidly aging population of older Americans having four or more chronic conditions (Wipf & Langner, 2006). Successful treatment of chronic diseases prevents morbidity and mortality. However, less than 22.7% of Americans have been told they have hypertension, and less than half of those diagnosed have been treated to effective levels. Americans also have rapidly climbing rates of mental health disorders. The National Institute of Mental Health (2009) reported that 26.2% of Americans who are 18 years and older have a diagnosable mental health disorder within a given year, with 6% of these individuals having a serious mental health disorder. Unfortunately, less than 25% of those affected by mental health disorders receive any treatment (National Institute of Mental Health, 2009). Furthermore, evidence is accumulating to support that individuals with chronic diseases and comorbid mental health disorders have higher rates of complications, outpatient visits, and hospitalizations, leading to greater health care costs (Hutter, Schnurr, & Baumeister, 2010).
All of these pervasive problems in the nation’s health care system and the declining health of Americans call for an increasing number of well-educated APNs who have the EBP knowledge and skills to improve the quality of health care and enhance population health, as well as positively impact organizational and health policy. In addition, PhD-prepared nurses are greatly needed to conduct rigorous studies, including randomized controlled trials and comparative effective experiments, to generate the best evidence to guide practice in real-world practice settings. Further, DNPs and PhDs must work together with other interprofessional colleagues to rapidly and effectively translate evidence-based interventions supported by research into clinical settings for the ultimate purpose of improving health care quality and patient outcomes.
Resolving Confusion in Academic Curricula That Prepare PhD and DNP Graduates
In the landmark document The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine [IOM], 2010), the IOM recommended increased education for nurses, specifically increasing the number of nurses with baccalaureate degrees, but also doubling the number of nurses with doctoral education to “add to the cadre of nurse faculty and researchers, with attention to increasing diversity” (p. 4). For decades, doctoral education in nursing has focused on the PhD, with an emphasis on the generation of evidence through rigorous research to provide a sound knowledge base for nursing (Edwardson, 2010). Therefore, academic curricula in PhD programs have appropriately focused courses and dissertation work on the rigorous process of how to conduct research.
Although much confusion in the academic preparation and roles of the PhD versus DNP still exists throughout the United States, PhD and DNP programs have two clearly distinct end points: (a) the PhD degree prepares researchers and scholars to generate external evidence (i.e., evidence generated through rigorous research) to extend science and theory and guide practice, and (b) the DNP prepares expert clinicians to generate internal evidence (i.e., evidence generated through outcomes management, quality improvement, and EBP projects) and to translate evidence produced through rigorous research into practice to improve health care quality, patient outcomes, and organizational or health policy (Figure). The DNP Essentials (AACN, 2006) consists of eight substantive areas, including: (a) scientific underpinnings for practice, (b) organizational and systems leadership for quality improvement and systems thinking, (c) clinical scholarship and analytical methods for EBP, (d) information systems and technology for the improvement and transformation of health care, (e) health care policy for advocacy in health care, (f) interprofessional collaboration for improving patient and population health outcomes, (g) clinical prevention and population health for improving the nation’s health, and (h) advanced nursing practice (Hawkins & Nezat, 2009). Although the DNP Essentials document gives clear guidance on the expectation and content areas necessary for DNP curricula, there is much variation in how DNPs are academically prepared (Dracup, Cronenwett, Meleis, & Benner, 2005). In the planning of the new DNP degree, several colleges across the country have taken substantial content and research courses from their PhD programs and integrated them into DNP curricula. Further, some DNP programs require students to conduct rigorous research as part of their DNP capstone projects instead of focusing the capstone project on the translation of research findings into clinical practice or policy to positively influence health care and patient and policy outcomes. Requiring original research as part of a practice doctorate is contrary to the intent of the DNP (AACN, 2006). The confusion in academia about how to best prepare DNPs and the fact that some programs are preparing these students to conduct rigorous research instead of preparing them to be expert evidence-based clinicians, leaders, and mentors is leading to confusion regarding the role of DNPs in the health care system. As an example, postings can be found online for DNPs to assume roles as researchers in health care systems. Recent publications also have emphasized the role of DNPs as practitioner–researchers (Vincent, Johnson, Velasquez, & Rigney, 2010).
Main focus of the Doctor of Nursing Practice (DNP) degree versus the Doctor of Philosophy (PhD) degree. Note. EBP = evidence-based practice.
Yet, other DNP programs have focused on preparing educators, which, again, was not the original intent of the DNP. For example, Danzey et al. (2011) reported that DNP programs that offer education concentrations or educational leadership options provide experienced master’s-prepared nurses with formal preparation in educational theory, testing, evaluation, curriculum development, and a capstone educational practicum. They contend that graduates of these education-focused DNP programs are prepared to develop, implement, and evaluate nursing curriculum, as well as be involved in the scholarship of teaching. However, this educational focus in DNP programs is not in alignment with the original intention of the practice doctorate (AACN, 2006).
A contributing factor to the confusion in clearly differentiating the curricula and roles of the PhD versus the DNP is that many professors with PhD degrees, who are rigorous researchers, with limited understanding of EBP, are designing and teaching in DNP programs. For example, in a survey of advanced practice nurse educators, although the majority reported they were teaching EBP in their advanced practice nursing curriculums, the open-ended feedback from these educators on the survey revealed that the assignments given to students that were intended to teach EBP were truly designed to build rigorous research skills (Melnyk, Fineout-Overholt, Feinstein, Sadler, & Green-Hernandez, 2008). Confusion also exists among faculty regarding the difference between EBP and translational research. As a result, some DNP students are being advised to conduct rigorous studies, including translational research, which is the rigorous conduct of research geared to studying the barriers and facilitators to the uptake of research findings into practice or experimental studies that evaluate the best strategies for implementing findings from research into clinical practice to improve care and outcomes versus using the evidence that has been generated through research to improve practice (Melnyk & Morrison-Beedy, 2012a). Therefore, faculty must be clear on what constitutes EBP versus research, as well as the distinct curricula and final work (i.e., PhD dissertation versus DNP capstone project) necessary to prepare students in PhD and DNP programs to take on differentiated, yet collaborative, roles in health care systems. The AACN’s document, The Essentials of Doctoral Education for Advanced Nursing Practice (2006), clearly indicates that a DNP project should be a practice application demonstrating a synthesis of a student’s work, creating a basis for future scholarship. For practice doctorates, a dissertation or other original research is contrary to the intent of the DNP (AACN, 2006). For example, a PhD dissertation might focus on pilot testing a new cognitive–behavioral skills-building program to decrease depressive symptoms in young adults through a two-group, randomized controlled trial, whereas an appropriate capstone project for a DNP student would be to determine the most effective intervention for this problem that has been demonstrated through rigorous research (e.g., cognitive–behavioral therapy) and implement it in practice to improve patient outcomes. Any time a research-based intervention is moved into clinical practice, the monitoring of a few key outcomes (e.g., depression, emergency department utilization) is important to demonstrate that the intervention works in the real world, where extraneous factors cannot be controlled as they may have been in a randomized controlled trial.
In lieu of health care reform, both PhD and DNP students must incorporate the measurement of “so-what outcome factors” in their dissertations and DNP capstone projects. So-what outcome factors are those outcomes that are critically important to the current health care system, such as medical complications, length of hospital stay, rehospitalizations, and costs. Key questions that doctoral students need to ask when they embark on a research study or quality improvement, outcomes management, and EBP project include (a) “So what” is the prevalence of the problem and is it modifiable? (b) “So what” will the end outcome of the study or project be after it is completed? (c) “So what” difference will the study make in improving health or health care quality, costs, and, most importantly, patient, family, or community outcomes? (d) “So what” will others do with the outcomes of the study or project? (Melnyk & Morrison-Beedy, 2012b). Given that research often takes decades to be translated into real-world clinical settings, inclusion of these “so-what outcome factors” in both research by PhD students and quality improvement and outcomes management programs by DNP students will accelerate its uptake into clinical practice settings and improve the ability to make practice changes important for improving health care quality, reliability, and safety. As one example, over two decades of research and funding from the National Institutes of Health and the National Institute of Nursing Research supported the efficacy of the COPE (Creating Opportunities for Parent Empowerment) program for parents of hospitalized children, critically ill children, and premature infants in decreasing parental stress, depression, and anxiety, as well as improving child outcomes (Melnyk, 2009; Melnyk et al., 2004; Melnyk et al., 2006). However, neonatal intensive care units did not begin to implement COPE until the publication of a cost-effectiveness analysis that showed that COPE decreased the length of stay by 4 days for the premature infants of parents who received the COPE program and 8 days for infants younger than 32 weeks whose parents received the COPE program (Melnyk & Feinstein, 2009). This is an excellent example of how the measurement of a “so what outcome factor” was critical for the uptake of this research-based intervention program into real-world practice settings across the country.
It must be remembered that faculty cannot teach what they themselves do not know if they were prepared as rigorous researchers and did not learn EBP. Ongoing knowledge and skills building in EBP for faculty is essential if they are going to teach DNP curricula because a heavy emphasis in DNP programs should be EBP so DNP graduates can become experts and mentors in evidence-based care, well-equipped with the knowledge and skills to change practice based on the best evidence. In terms of academic curriculum, having PhD and DNP students come together for some of their academic curriculum is important for them to gain a clear understanding of their unique roles and how they can work together in teams to solve real-world practice and policy problems.
Roles of the PhD and DNP Graduates in Real-World Settings
Information from the AACN (2012a) about DNP-prepared individuals is clear regarding the components of the role, stating that:
The DNP focuses on providing leadership for evidence-based practice. This requires competence in translating research in practice, evaluating evidence, applying research in decision-making, and implementing viable clinical innovations to change practice. Considerable emphasis is placed on a population perspective, how to obtain assessment data on populations or cohorts, how to use data to make programmatic decisions and program evaluation. If a DNP desires a more formal research role, additional preparation will likely be required—similar to [an] MD completing a PhD.
Further, The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006) contends that:
Individuals who finish DNPs will seek to engage in roles as educators, but the focus of the DNP needs to be advanced practice specialization, not the process of teaching. The basic DNP education does not prepare graduates for a teaching role any more than the PhD. Teaching/learning principles are incorporated into the DNP as it is related to patient education.
DNP graduates will likely seek practice leadership roles in a variety of settings, which might include the management of quality initiatives, executive positions in health care organizations, director positions within clinical programs, and faculty positions responsible for clinical program delivery and clinical teaching (AACN, 2006). Conversely, PhD graduates will most likely seek roles in academia, health care, and academic settings in which conducting research is a substantial component of their role. Despite the clarity of the DNP role by the AACN, there remains confusion in real-world academic and practice settings. For example, some advertisements are posted for DNPs to assume researcher positions in hospitals and academic medical centers. Further, it is reported that “DNP educators” are contributing to nursing education in academic leadership roles, such as dean or director (Danzey et al., 2011).
In a program evaluation with 11 students who recently completed the DNP program at a research I midwestern university, seven of the students (63.6%) said their role changed after completing the DNP, and nine graduates (81.8%) stated their salary did not change despite the fact that a recent salary survey reported that DNP-prepared NPs earned $8,576 more annually than master’s-prepared NPs (“Complete 2011 National Salary Report,” 2011). All but one of these graduates stated that the DNP changed the way they fulfill their role, and all of the 11 graduates said they were pleased with their decision to obtain the DNP. Specifically, two of these graduates obtained higher level administrative positions, two moved from clinical to academic positions (with one of these assuming a tenure-track position at a nonresearch-intensive university), and two reported being placed on higher level committees after completion of their DNP degree. The responses to the question, “Has the DNP changed the way you fulfill your role?” included (a) “I am more confident in my abilities,” (b) “I broadened my perspective on my role in health care,” (c) “I find myself approaching system issues with a different perspective than 3 years ago,” (d) “I see the big picture now,” and (e) “I have a framework that supports my professional practice.” One graduate said, “I think the greatest challenge before us with our newly minted DNPs is defining our contributions and developing our roles. No one really has a clue what to do with us, including us.” Another graduate said, “My hospital system is slow to recognize the DNP degree.”
Regarding the role of PhD and DNP graduates in knowledge discovery, PhDs should be the best generators of external evidence from rigorous research, whereas DNPs should be the best generators of “internal evidence” from quality improvement, outcomes management, and EBP projects (Table). Concerning knowledge translation, PhD graduates should know how to work with health care systems and clinicians on the translation of their research findings into practice to improve quality of care and patient outcomes to reduce the long research-practice gap, whereas DNP graduates should be expert clinicians who consistently implement evidence-based care and are the best translators of research evidence and evidence-based guidelines into real-world settings to improve health care quality and patient outcomes, as well as to reduce costs. As such, they must be aware of the most common EBP barriers that exist in health care systems, including misperceptions about the lack of time; organizational culture; resistance by managers, leaders, and peers; and strategies to facilitate EBP (e.g., EBP mentors, knowledge- and skills-building sessions, tools, and resources) (Beckette et al., 2011; Majid et al., 2011; Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). DNP graduates should work to implement and sustain EBP through working with clinicians to learn EBP knowledge and skills, developing evidence-based policies and procedures, conducting outcomes management and quality improvement projects, and creating EBP cultures and environments that support EBP to sustain these efforts. PhD and DNP graduates must work together to transform the current health care system, with DNPs bringing real-world clinical problems to PhD graduates who need rigorous research and external evidence for improved practice change. Both DNP and PhD graduates need to disseminate their work through publications, presentations, policy briefs, and the media, but it must be remembered that evidence has supported that dissemination alone does not typically result in practice changes (Melnyk & Fineout-Overholt, 2011).
The Role of Doctor of Nursing Practice (DNP) and Doctor of Philosophy (PhD) Graduates in Knowledge Discovery, Knowledge Translation, and Dissemination
Future Implications for Research, Academia, and Health Care Settings: A Call to Action
Research on the outcomes of DNP graduates versus master’sprepared APNs is necessary to demonstrate the impact of their role on the health care system, policy, and patient or population outcomes. In addition, studies are needed on the overall impact of different doctorates on outcomes and whether roles are being fulfilled as intended. The best strategies for teaching DNPs also need to be documented through research and program evaluation. Further, PhD students need to be more prepared in how to conduct intervention studies and comparative effectiveness research because the field needs more Level 1 (i.e., systematic reviews of randomized controlled trials) and Level 2 research (i.e., randomized controlled trials) to guide our clinical practices (Melnyk & Fineout-Overholt, 2011). Wellness also needs to be role modeled by faculty and incorporated into our curricula for all students because if we do not teach wellness, we cannot expect our students and patients to be well and stay well. In addition, nursing faculty must be educated on the clear differentiations of the PhD versus the DNP and be provided with education and skills-building workshops on EBP, as well as what comprises appropriate DNP capstone projects.
The education of administrators in health care systems also is needed to assist them in understanding the roles of DNP and PhD program graduates and the value they can add to improving the quality of care and patient and population outcomes. Position descriptions must reflect a higher level of functioning for APNs with clinical doctorates. Health care systems with clinical ladders need to incorporate the higher level of role functioning with the DNP, and salaries must be commensurate with a doctorate. Finally, legislation must be changed to require the doctorate as minimum level of preparation for advanced practice.
PhD and DNP roles in academic and service settings are both vitally important in improving the complex health care problems that currently exist in the United States and in preparing the next generation of highly competent direct care and advanced practice nurses. Clearer understanding of and research related to the preparation and roles of the PhD and DNP will result in improved nursing education, as well as enhanced outcomes for the health care system and the health of Americans.
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The Role of Doctor of Nursing Practice (DNP) and Doctor of Philosophy (PhD) Graduates in Knowledge Discovery, Knowledge Translation, and Dissemination
|PhD graduates should be the best generators of external evidence through rigorous research.|
|DNP graduates should be the best generators of internal evidence through quality improvement, outcomes management, and evidence-based practice projects.|
|PhD graduates should know how to work with health care systems and clinicians on the translation of their research findings into practice to improve quality of care and patient outcomes to reduce the long research–practice time gap.|
|DNP graduates should be the best translators of research evidence and evidence-based guidelines into real-world settings to improve health care quality and patient outcomes, as well as to influence policy and reduce costs.|
|PhD graduates and DNP graduates must work together to improve health, health care, and policy through knowledge discovery, translation, and dissemination.|
|Both PhD graduates and DNP graduates need to disseminate their work through publications, presentations, policy briefs, and the media.|