The development and implementation of a quality Doctor of Nursing Practice (DNP) program requires resources to support a learning environment that prepares graduates as experts in nursing practice and organizational leadership. The crucial elements of an academic infrastructure include financial resources, personnel, space, and equipment to support the unique needs of a practice-focused nursing doctorate (American Association of Colleges of Nursing [AACN], 2006). Beyond these basic organizational structures, the redesign of graduate nursing education to the DNP necessitates transformation of the academic environment to integrate teaching, practice, and practice-focused scholarship into the academic environment of schools and colleges that offer the program. This article presents a comprehensive analysis of the specific resources needed to support the planning, the implementation, and, ultimately, the sustaining of a quality DNP program.
The transformational curricular change required to ensure that DNP graduates achieve the advanced competencies defined in the Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006) necessitates that considerable funding be directed toward curriculum design and faculty recruitment and development. Faculty need focused time to conceptualize doctoral-level education for advanced practice. This may require that they be released from some portion of regular teaching activities to devote their attention to curriculum development. Alternatively, salary supplementation can be provided to faculty with academic-year appointments to support curriculum development during the summer months. Recognizing that faculty may not have the expertise in curriculum design to create an innovative, integrated program to meet the competencies outlined in the Essentials document, resources may need to be allocated for a curriculum consultant, including consultant fees and travel costs.
A crucial resource to implementing a quality DNP program is a cadre of faculty with practice and intellectual perspectives representing the specialty areas for which graduates are being prepared (AACN, 2006). Those who teach in the DNP program must represent diverse backgrounds and include both doctoral-prepared, research-focused and practice-focused faculty. Faculty teaching in a practice specialty area need to be credentialed for that population-focused area and should actively practice in their field of specialization. Those programs that prepare graduates for organizational leadership and administrative roles will need to have faculty with experience in health system improvement and program evaluation, as well as faculty engaged in quality improvement initiatives. The level of involvement of research-focused faculty in DNP program teaching needs to be weighed carefully to ensure that it does not compromise the school’s or college’s research programs and grant funding.
Resources to support additional faculty positions may need to be acquired. In many instances, salaries for practice-focused, doctoral-prepared faculty will need to be augmented beyond established faculty salaries to be competitive with practice settings. For faculty to maintain their practice expertise and specialty credential, resources to support their ongoing engagement in practice must be considered in planning for a DNP program. In addition, the funding to support active clinical scholarship activities of faculty teaching in the DNP program is essential. Recruitment of qualified faculty will require dedicated resources, including advertising, interviewing costs, and search committee time.
To offer a quality DNP program, faculty preparation to deliver a practice doctorate curriculum is vital. Resources need to be allocated to provide faculty development in pedagogy, as many practice-focused faculty who are new to academia will not have this expertise. If courses are delivered over the Inter-net, education specific to teaching in the online environment will be essential. Specific training in simulation will need to be provided. In addition, dedicated time will be needed for all faculty teaching in the DNP program to become knowledgeable of the competencies essential to DNP preparation and the strategies needed to support students’ achievement of these expectations.
The academic environments in which DNP programs are offered must provide a learning environment in which students have access to substantial nursing practice expertise, with opportunities to engage with advanced-practice clinicians, nurse executives, informaticists, or health policy makers (AACN, 2006). Funding must be sufficient to provide the faculty, the clinical settings, and the academic infrastructure to create such academic milieus. Resource considerations for implementation of a superior DNP program include an adequate number of qualified faculty, clinical resources, faculty practice, information technology, physical infrastructure, and staff and administrative support.
Delivery of courses in the DNP program requires that faculty resources be deployed to maximize the efficient use of research-focused and practice-focused faculty. Where possible, classes for DNP and PhD students should be combined, thus fostering intraprofessional collaboration, while taking advantage of available faculty. In institutions that offer a Clinical Nurse Leader graduate program, courses focused on leadership, health policy, and finance can be incorporated in both the DNP and Clinical Nurse Leader curricula. Didactic courses can be taught by either research-focused or practice-focused faculty, whereas faculty whose practice credential is specific to the specialty must deliver practice specialization courses. When courses are offered in an online format, a class size of no more than 30 students will allow faculty to create a vibrant, interactive learning environment. Clinical courses in specific specialization areas require practice-focused faculty who are credentialed in the practice specialty. Resource considerations for implementing these learning experiences are substantial, as accreditation standards for nurse practitioner programs recommend an on-site faculty-to-student ratio (direct supervision) of 1:1 if faculty are seeing their own patients and 1:2 if faculty are not seeing patients. A ratio of 1:6 is recommended for clinical experiences using preceptors (indirect supervision), where a faculty member coordinates the clinical experience, interacts with the preceptor, and evaluates the student. Faculty-to-student ratios for programs preparing graduates for leadership and management roles are less prescriptive, with practice-based experiences being predominantly delivered using preceptors. Generally, one faculty member for every 10 to 15 student–preceptor dyads will provide a learning environment that facilitates seminars and group discussions that build on the practice-based experiences with preceptors.
The final DNP project represents another resource-intensive component of implementing the program. Although considerable debate exists related to the final project within the discipline, the expectation is that the student will produce a high-quality, tangible academic product based on extensive involvement in practice. With a focus on practice inquiry, the scholarly work of the project should begin early in the program and be developed and conducted through the course of the program. It is desirable for practice projects to be identified in collaboration with practice partners to reinforce their linkage with tangible practice or administrative problems. Regardless of the specific focus of the project, several faculty members will be involved in evaluating the student’s development in knowledge and expertise as the project evolves. Both research-focused and practice-focused faculty may be engaged in evaluating this immersion experience. As enrollment in the DNP programs increases, the workload demands of the final project will require that resources be allocated to employ additional faculty or that the efforts of existing faculty be reallocated from other academic programs to the DNP program.
Beyond delivering courses in the DNP program, resources must be dedicated to program administration and coordination. Accreditation criteria require that a faculty member who is certified as a nurse practitioner in the specialty area be designated to direct and provide overall leadership for programs that are preparing nurse practitioners. Although not bound by the same prescriptive accreditation requirements, a quality nurse executive–focused program benefits from leadership that is experienced in organizational or systems administration in health care delivery organizations. Workload must be adjusted to provide time for student advising, oversight of student recruitment and admissions, and ongoing monitoring and evaluation of the program. In addition, an administrative stipend may need to be provided to acknowledge the added leadership responsibilities.
Clinical resources that provide students with immersion in high-quality professional nursing practice, engagement in practice scholarship, and exposure to health care providers collaborating in interprofessional teams are fundamental to a strong DNP program. Considerable financial and human resources must be allocated to ensure that students have access to practice environments that exemplify these characteristics. Resources must be devoted to the recruitment of practicum settings that provide in-depth work experiences and meaningful opportunities for engagement within the practice environments. Access to populations that align with the specific specialty focus is essential for nurse practitioner programs. Practice-based experiences for the leadership role must be able to engage students in comprehensive, systems-level processes. As health systems become increasingly integrated, arrangements for practice experiences will involve coordination with a specific individual who facilitates student placements in a variety of settings across the health care organization. Collaboration with statewide networks, such as area health education centers, can provide a means of linking with practice settings across an entire state.
The resource commitment of practice settings to support the DNP program must be addressed throughout the implementation phase. To offset the commitment of time required of preceptors to meet the desired 1,000 or more hours per student of direct practice or leadership experience, practice affiliations must be crafted in a manner that benefits both the academic program and the practice setting. These arrangements may involve the sharing of academic resources with practice settings. Formal academic–practice partnerships can provide a collaborative structure for the sharing of resources to jointly benefit the educational and practice institutions. For example, the academic setting might offer research infrastructure support, such as data management expertise and statistical consultation, to the practice site in exchange for preceptor services. To reduce the burden on practice settings that arises from frequent rotation of new students in the practicum site, consideration should be given to maintaining students in the same setting for an extended period (e.g., 1 year). In some instances, reimbursement must be provided to the clinical site to compensate the practice for preceptor time that is devoted to mentoring the student.
Within each practice setting, a qualified preceptor must be identified for each student in the program. Considerable academic support staff time must be dedicated to the identification of preceptors who are certified in the specialty for which the nurse practitioner students are being prepared. Because practitioner preparation is currently in transition, master’s-prepared nurse practitioners, as well as those who have acquired the DNP, may serve as preceptors for DNP students. It is important that the preceptor have substantial experience in the practitioner role and that the typical functions performed in the preceptor’s practice are an appropriate match with the student’s level of learning. For programs preparing students for organizational leadership, preceptors must be engaged in executive leadership roles in a health care system. Regardless of the type of preceptor, resources must also be dedicated to the development and implementation of a system for preceptor orientation and ongoing evaluation.
The coordination of practicum experiences with practice settings requires dedicated resources from the academic institution. Faculty travel to practicum sites must be funded, and the cost can be substantial when practicum sites are distributed over a large geographic area. The coordination of clinical contracts, student placements, and preceptor assignments requires dedicated DNP program staff in the academic institution. As the size of the DNP program grows, these coordination functions will require a full-time, dedicated staff person. In addition, a computerized student enrollment management system must be created to track student matriculation and progression through the DNP program. Variations in a student’s progression through the program must be meticulously managed to anticipate teaching demands and to ensure that maximum benefit is attained from the available clinical placement sites. This involves dedicated staff time to create the system and link it with the multiple institutional databases that contain relevant student information. A well-designed enrollment management system can also serve as the foundation for projecting the anticipated revenue from tuition and forecasting future faculty needs.
An active faculty practice program is strategic to a vibrant DNP program. Not only does it provide an important practice setting for faculty to maintain their practitioner expertise, but it also provides a learning environment for students to experience the rapid translation of new scientific discoveries into practice. The faculty practice offers opportunities for practice-focused faculty to deliver direct patient care, as well as to implement programs of clinical scholarship, thereby integrating practice-focused scholarship into the faculty role. An important consideration in implementing a faculty practice is that it must be incorporated into the faculty workload. Therefore, the faculty practice must be configured to generate revenue, thereby offsetting the cost of faculty time that is reallocated away from teaching. Practice initiatives must be developed in ways that minimize infrastructure costs while providing billable services that produce revenue for the school or college. When a faculty practice is not a viable option in an academic setting, contractual arrangements may be negotiated with a practice setting for practitioner faculty to engage in patient care delivery. Such agreements should address faculty time commitments, access to the site for student experiences, opportunities for engagement in clinical scholarship, and compensation for the practitioner services.
A well-designed and well-managed academic infrastructure is fundamental to maintaining a quality DNP program. In those instances where some portion of the coursework is delivered in an online format, information technology support is crucial. Resources must be provided to fund the course designers and technology experts to support faculty in creating and implementing courses delivered via the Internet. Technology equipment and software license fees may generate additional expenses that must be addressed. Also, a system for accessing library resources must be designed to ensure that off-campus students can retrieve needed materials. Simulation learning experiences may take a variety of forms and will need to be incorporated into fiscal resources to support the DNP program. Dedicated space for examination rooms and reimbursement for volunteer patients, high-fidelity simulation facilities, consumable supplies, and equipment maintenance and replacement are among the items to be considered in determining the resources needed to support a DNP program. Additional staff support may be needed to coordinate the use of simulation facilities. Costs for office space for program faculty and staff, as well as classroom space, must be calculated based on the square footage cost of operating an academic building.
Administrative and staff support for the DNP program must be tailored to the unique characteristics of a practice-focused doctorate. Resources must be dedicated to coordination of the DNP program across specialty programs, support of DNP program evaluation, coordination with academic offices across campus, program marketing, human resource functions, and the accreditation self-studies and site visits. Staff support requirements are substantial and can necessitate the addition of staff positions to facilitate student recruitment and admission, course scheduling and registration, monitoring of student progression, and administration of student scholarships.
Successful resource management to ensure quality in a DNP program requires continual assessment to address the changing academic environment. Sources of revenue must be meticulously identified and projected into future academic years. Foresight must be exercised to ensure that revenue keeps pace with anticipated expenses. An enrollment management system that provides detailed projections of enrollment and program offerings is an invaluable tool in sustaining the fiscal integrity of the program.
The major source of revenue to support a DNP program is tuition. In planning for a DNP program, a tuition rate specific to the DNP program, which is sufficient to cover the cost per student to deliver the program, should be the goal. Because the overwhelming amount of resources needed to implement a DNP program must be provided by the school or college offering the program, tuition revenue should be negotiated to return the majority of tuition dollars to that unit. Additional special fees can be assessed to support the specialized resources needed to deliver the program, such as technology, laboratory consumables, and equipment maintenance and replacement. When tuition and special fees are unable to be returned to the school or college offering the program, extreme care must be taken to scale the size of the DNP program to the fiscal and human resource realities of the institution. The focus of the DNP program may need to be limited to a single specialty that articulates with already existing master’s or PhD offerings, thus maximizing the use of already available human and infrastructure resources.
Meeting Resource Challenges
In the current time of unprecedented change, nurse educators are challenged to prepare nurses for comprehensive, advanced practice and leadership in transforming the health care system. The DNP provides graduates with the practice competencies essential to achieving high-quality, accessible care characterized by continuous improvement and a culture of practice scholarship. However, the resource challenges inherent in planning, implementing, and sustaining a quality DNP program are formidable. To address these challenges, schools and colleges should limit the number of specialization programs offered to be consistent with their fiscal and human resources. Partnering with other academic institutions may offer an avenue to expand specialization offerings, while conserving on the fiscal resources and faculty needed to deliver the program. Core courses should be structured to maximize the enrollment of students from all specialization areas and avoid duplication of content. Engaging both practice-focused and research-focused faculty in teaching the DNP program will maximize the available personnel needed to deliver the program, while promoting intraprofessional dialogue that cultivates advancement in the practice and science of nursing. Maintaining students in the same practice site for a more extended period may be explored as a means of reducing the administrative effort devoted to student placement.
Essential to the development and implementation of a quality DNP program is a meticulous plan to ensure that the academic infrastructure exists to prepare graduates with the core competencies for advanced practice and organizational leadership. The required resources extend beyond those typically needed for master’s-level nursing programs. The greater depth and focus of the DNP core competencies requires a comprehensive plan for addressing the costs of the program in regard to the improved outcomes achieved by DNP graduates.
- American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. Washington, DC: Author. doi:10.3928/01484834-20101230-03 [CrossRef]