Understanding the Doctor of Nursing Practice (DNP): Evolution ...

Understanding the Doctor of Nursing Practice (DNP): Evolution, Perceived
Benefits and Challenges

Background

Controversy regarding educational requirements for entry into professional practice is not
new to nursing and has long been a subject of intense debate and conflict, both inside and
outside of the profession. Education for entry into advanced practice has followed a
similar pattern with most state boards of nursing and national certifying bodies only
recently requiring graduate level preparation for advanced practice.

In 2004, the American Association of Colleges of Nursing (AACN) published a position
statement advocating that by 2015, entry into practice change once again—from the
Master’s degree to the Doctor of Nursing Practice (DNP) degree. It is believed that
enhanced educational preparation will lead to degree parity with other health care
professions and assist graduates to assume leadership roles in clinical practice, clinical
teaching, and policy development.

As the issue of the DNP as entry into advanced practice evolves, there continues to be
many questions that are yet unanswered. The following information is intended to inform
you of the background, perceived benefits and challenges of the DNP.

Entry into Practice

At the advanced practice level, state boards of nursing vary widely regarding education
requirements for practice. Based on a survey of individual state boards of nursing and
examination of online materials by AACN as documented on October 20, 2006:

• 19 states require a Master’s degree for nurses to practice in an APN role;
• 24 states require a graduate degree, or minimum of a Master’s degree, for APN
authorization to practice;
• 8 states have no language in their state laws regarding educational requirements.

For APNs, state regulation and national certification have become almost synonymous.
In many states, national certification is used as a substitute for regulation for APN
licensure. A majority of state boards of nursing require national certification for APN
authorization to practice.

These inconsistencies have added to the public’s confusion and forced the profession to
defend its lack of congruency with varying requirements for professional practice.

Terminal Degrees for the Profession

• The Master of Science degree offers post-baccalaureate preparation for nurses
seeking advanced practice roles, to include nurse practitioners, midwives, clinical
nurse specialists, and nurse anesthetists.

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• The doctoral degree, specifically the practice doctorate, is being advocated (by
AACN and others) as one terminal degree for the profession of nursing due to
modern trends in education and health care. There is still a great deal of
confusion about the various types of educational preparation for the practice
doctorate, and varying titles that go with those degrees.

Historical Perspective of Doctoral Education in Nursing

• Doctor of Education (EdD) was started in the early 1900s when pioneer nurses of
doctoral education studied in schools of education and were awarded the EdD
degree. The major emphasis was on education and leadership as opposed to
clinical practice. The education doctorate currently prepares nursing leaders to
become expert educators and specialists in curricular change.
• Doctor of Nursing Science (DNSc) was originated by 1970 with an emphasis on
advanced clinical practice in an effort to move nursing onto equal grounds with
other disciplines. The DNSc is grounded in clinical competence and proficiency
but requires students to demonstrate ability to perform scholarly research.
• Doctor of Philosophy (PhD) programs proliferated around the same time as the
DNSc and were designed to advance the science of the discipline of nursing
through research. The PhD has been recognized as the highest distinction in
scholarship and academic achievement across all disciplines.
• Doctor of Nursing (ND) emerged in 1979 to prepare college graduates as nurses
at a level similar to other health professional doctoral programs, such as medicine,
veterinary medicine, dentistry, optometry, and others. Unlike the DNSc, the ND
focused exclusively on preparing the clinical leader.
• Doctorate of Nursing Practice (DrNP) focuses on advanced clinical expertise and
is geared toward nurse practitioners. The purpose of this degree is to prepare
nurse practitioners for independent primary care roles in a variety of settings.
• Doctor of Nursing Practice (DNP) concentrates on direct care, specifically
research utilization, for improved delivery of care, patient outcomes and clinical
systems management. It has been recommended as the standard for entry to
advanced practice, including nurse practitioners, nurse midwives, nurse
anesthetists, and clinical nurse specialists, by the year 2015 by AACN.


Understanding the DNP: The 4W’s

In order to understand the relevance and impact of the DNP movement, we must
address the most basic questions.

• Why?
o Parity with other disciplines: Other disciplines such as audiology,
dentistry, medicine, pharmacy, physical therapy, and psychology have
established a practice doctorate as the standard entry into practice.
NPs and other APNs could potentially be left behind with Master’s
preparation only.

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o NPs and other APNs currently complete Master’s programs that
require far more credit hours for completion than most Master’s degree
programs in other disciplines. Professional students today expect to
gain higher degree recognition, and nursing may lose prospective
students to other disciplines where they can achieve a higher terminal
degree for clinical practice for an equivalent amount of time and other
costs.
o The current shortage of nursing faculty is impeding the progress to
expand nursing educational programs to address practice shortages in
most healthcare arenas to include acute and critical care, public health
nursing, and home care nursing. Predictions are that this faculty
shortage will continue to rise significantly. Clinical teaching
necessitates advanced clinical expertise.
o Despite the high number of credit hours in current advanced practice
Master’s degree programs, nurse educators feel an urgency to pack
content into the curriculum and yet must make difficult choices about
what to include and exclude. Still, the increasing complexity of
healthcare systems requires additional leadership and management
content for advanced practice nurses.
o With the rapid expansion of healthcare knowledge, APNs need more
skills in utilization rather than acquisition. We can no longer train
students to memorize all content but rather provide skills necessary to
access and synthesize information quickly using critical thinking to
improve patient outcomes.
o The DNP will also provide a terminal degree and advanced
educational credential for those who do not want a research-focused
degree.
• What?
o The Master’s degree is currently the degree for specialized advanced
nursing practice. With development of DNP programs, this new
degree may become the preferred preparation for specialty nursing
practice.
o As educational institutions transition from the Master’s to DNP degree
for advanced practice specialty preparation, a variety of pathways are
planned, but one constant is true for all of these models. The DNP is a
graduate degree and is built upon the generalist foundation acquired
through a baccalaureate or Master’s degree in nursing.
o AACN proposes that the terminal degree options in nursing fall into
two primary education pathways: baccalaureate or Master’s to DNP or
baccalaureate or Master’s to PhD.
o The DNP graduate is expected to have an expanded knowledge base in
eight essential areas, that have been outlined and defined in a
document published by AACN in October 2006 titled “The Essentials
of Doctoral Education for Advanced Nursing Practice”, these include
the “Masters Essentials” plus the the following:
Scientific underpinnings for practice

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Organizations and Systems leadership for quality improvement
and systems thinking
Clinical scholarship and analytical methods for evidence-based
practice
Information systems and patient care technology for the
improvement and transformation of health care
Health care policy for advocacy in health care
Interprofessional collaboration for improving patient and
population health outcomes
Clinical prevention and population health for improving the
nation’s health
Advanced nursing practice
• Increased clinical hours to 1000 hours minimum post
baccalaureate in order to achieve DNP competencies
via end of program practice immersion experiences
• Where?
o The sense of positive momentum is mirrored in data collected
regarding DNP program planning and development. According to
AACN data:
In Spring 2005, there were 8 DNP programs admitting students
and 80 had DNP programs under consideration;
By February 2006, 11 institutions had DNP programs and were
admitting students, 5 had graduated students, and 190
institutions were developing programs;
As of January 2007, 25 institutions are admitting students in
DNP or DrNP programs.
• When?
o Choosing when to pursue a practice doctorate in nursing is an
individual choice, dependent on one’s career trajectory.
o The innovators will want this degree as soon as possible. These might
be new candidates for nursing, seeking the opportunity for the highest
degree, or they might be master’s prepared APNs seeking new
opportunities.
o The average person will likely wait awhile to assess the movement and
study the program options.
o The skeptic won’t see an advantage initially and some may not be in a
position to pursue this degree.
o NPs and NP faculty need to be thoughtful about career goals and
institutional issues in making the decision on when the practice
doctorate makes sense. Some individuals who are nearing the end of
their careers will not likely continue their education at this level since
the years left to practice may be few compared to the time required to
complete the degree

Perceived Benefits of the DNP

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o Enhanced knowledge to improve practice
o Enhanced leadership skills to strength practice and health care delivery
o Enhanced status of the profession
o May provide higher reimbursement for services
o Improved patient care outcomes

The Future of the Master’s Degree

AACNs (2004) Position Statement on the Practice Doctorate in Nursing endorses the
transition from specialty nursing practice education at the master’s level to the DNP by
the target goal of 2015. AACN recommendations include:

o Programs designed to prepare nurses for advanced practice nursing will begin the
transition to the practice doctorate for nurses who initially want to obtain the
DNP, as well as nurses with master’s degrees who want to return to obtain the
practice doctorate;.
o Master’s programs will continue to be offered and will prepare nurses for
advanced generalist practice;
o Specialty focused Master’s programs will be phased out as transition to the DNP
occurs;
o The practice doctorate will be the graduate degree for advanced nursing practice
preparation, including but not limited to the four current APN roles: clinical
nurse specialist, nurse midwife, nurse anesthetist, and nurse practitioner.

Will all APNs have to get a DNP?

o There is no intent to disenfranchise practicing APNs. Master’s degree
programs in nursing have been remarkably successful in preparing APNs to
delivery quality health care as well as nurse administrators to lead and manage
health care systems.
o If all APN master’s degree programs were entirely replaced by practice doctorate
degrees, regulation, including state by state licensure, accreditation of programs,
and certification of graduates would need extensive changes. “Grandfathering”
would need consideration in each regulatory arena for a smoother transition.

Options for Obtaining the DNP

o Post Master’s entry
o Early in the transition period, many students entering the DNP program
will have a Master’s degree.
o DNP curriculum will be designed to include higher level and expanded
content based on prior education, experience, and specialization.
o Post Baccalaureate entry
o Candidates who enter the program with a baccalaureate degree in nursing
or another field would require a more comprehensive program of study
including more extensive content and clinical experiences related to all

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curriculum components defined in the DNP Essentials including specialty
competencies and content.

Questions and Challenges

o Titling?
o Titling is a concern expressed by many NPs who believe that creating a new
title will only add to confusion. The recommendation put forth by AACN
addresses this issue by directing that one title—the DNP—be used to
represent practice-focused doctorate programs and that other titles now in
existence be phased out. Although virtually all programs have complied,
some programs have decided to retain the DrNP title.

o Patient and public confusion?

o Some are concerned, particularly MDs, that the public and patients will be
confused when advanced practice nurses become doctorally prepared. The
fact is, the title of doctor is common to many disciplines and is not the domain
of any one group of professionals. In all likelihood, APNs will retain their
specialist titles after completing a doctoral program. For example, nurse
practitioners will continue to be called nurse practitioners. However, DNPs
would be expected to clearly display their credentials to insure that patients
understand their preparation as a provider.

o Transitioning for advanced practice?

o Transition to the DNP remains a controversial issue. It is important to
remember that this shift to the practice doctorate is an education-driven
initiative. At this time, boards of nursing and certification agencies continue
to require the Master’s degree as a prerequisite to licensure or certification at
the advanced level. Second, it is simply impractical to imagine that
educational institutions are prepared to retro-educate more than 100,000
advanced practice nurses.
o As academic programs begin the transition to the DNP, educators must
continue to focus on maintaining current graduation levels so that a shortage
of APNs is not exacerbated.

o Accreditation of programs?

o The CCNE (Commission on Collegiate Nursing Education) has agreed to
initiate an accreditation process for DNP programs based on The Essentials of
Doctoral Education for Advanced Nursing Practice endorsed by AACN in
October 2006. Outcome competencies for nurse practitioners have been
developed by the National Organization of Nurse Practitioner Faculties
(NONPF) and were also published in October 2006. At the present, there is
no national consensus on what the curriculum should look like and schools

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with DNP programs vary across their curricula, however, the DNP Essentials
are the foundational outcome competencies deemed essential for graduates of
a DNP program.

o Legislation and licensure?

o A concern raised by practicing NPs is how boards of nursing would transition
to the DNP as the recognized entry level of NP education and what effect it
would have on NPs with Master’s degrees. Currently, the AACN is working
with all relevant stakeholders to recommend viable solutions. At this time,
there is no plan by regulatory bodies to require that all currently practicing
NPs obtain a practice doctorate; neither is there any certification agency that
requires the practice doctorate as an eligibility requirement.

o Job market for the DNP?

o Frequently raised concerns about the practice doctorate are the issues of who
will hire NPs with practice doctorate degrees and of whether the pay they
receive would be worth the additional education. Research by Dr. Linda
Aikens and Dr. Carole Estabrooks and others have established a clear link
between higher levels of nursing education and better patient outcomes. What
is expected is that clinicians prepared with a DNP will have the ability to
demonstrate their worth based on the additional leadership, economic, and
policy knowledge and skills they will acquire in DNP programs. Studies
tracking patient outcomes also hold promise as evidence of improved patient
outcomes, such as better control of hypertension or diabetes, is data that can
be shared with employers to demonstrate that clinicians can not only generate
revenue but can improve the health of clients. With sufficient data, a practice
could advertise positive patient outcomes as well, which may generate more
revenue with new clients.

Choosing what is best for you

Ask yourself the following questions:
Where are you going with your career?
How do you think the practice doctorate will impact on your practice and status?
Do you believe that this is an opportunity to enhance your skill and knowledge?
Would you consider pursuing the practice doctorate?
Is your focus on clinical practice or research?

For more information about the DNP

AACN website
– http://www.aacn.nche.edu/DNP/index.htm
NONPF website
– http://www.aacn.nche.edu/DNP/index.htm

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