Ethics: Is the Doctor of Nursing Practice Ethical?

Mary Cipriano Silva, PhD, RN, FAAN

Mary Cipriano Silva, PhD, RN, FAAN

Email: msilva@gmu.edu

Mary Silva, RN, PhD, FAAN, received her BSN and MS from the Ohio State University and her PhD from the University of Maryland. She also completed post-doctoral study at Georgetown University in health care ethics. Since 1974, she has been a prolific writer about health care ethics in general and ethics in nursing administration in particular. She was a member of the ANA Code of Ethics Project Task Force. The Task Force, along with ANA staff guidance, wrote the 2001 Code of Ethics for Nurses with Interpretive Statements, which won an AJN "Book of the Year Award." Dr. Silva is Professor Emerita of Nursing at George Mason University in Fairfax, VA.
Ruth Ludwick, RN, PhD, C, is a Professor at Kent State University, College of Nursing (CON) and directs the Office of International Initiatives at the CON. She is an Associate Editor and a member of the founding editorial board of the Online Journal of Issues in Nursing (OJIN). She serves as coordinator for the OJIN Ethics Column and coordinator of the links for each topic. Ruth teaches across the curriculum and is certified in gerontological nursing. She is widely published and presents nationally and internationally on research related to gerontology and college teaching. She recently completed a 1 year study funded by the National Institute of Aging and began a 2 ½ year study funded by the Institute of Museum and Library Services. Of particular interest to her is the research she has done across disciplines and with colleagues in N. Ireland, Australia, and Scotland related to the factorial survey method.

Article

Keywords:ethics,DoctorofNursingPractice,DNP,ethicalprinciples,nursingeducation,doctoraleducation

IntheVol.10,No.3issueoftheOnlineJournalofIssuesinNursing(OJIN)entitled"TheDoctorofNursingPractice(DNP):NeedforMoreDialogue,"Glazer(2005,OverviewandSummarysection,para.8)identifiesseven"challengingquestions"thatreadersmayponderabouttheDNPdegree.Inthiscolumnweofferanotherchallengingquestion:"IstheDoctorofNursingPracticeethical?"InrecentyearstheprosandtheconsoftheDNPhavebeendiscussedintheliterature(e.g.,Dracup,Cronenwett,Meleis,&Benner,2005;Mundinger,2005),byfacultyinnursingprograms,bystaffnurses,andbynursemembersofvariousprofessionalorganizations.Thisdiscussionhasbeenprecipitatedbyapositionstatementpublishedin2004bytheAmericanAssociationofCollegesofNursing(AACN)thatisentitledAACNPositionStatementonthePracticeDoctorateinNursing.

Yet,thisdiscussionsofarismostlysilentinonecriticalarea,ethics,whichisthecornerstoneofthenursingprofession.Thus,webeginwhatweanticipatewillbeanongoingethicaldebateabouttheDNP.WeframethisdebatearoundfourethicalprinciplesassociatedwiththeDNP:(a)socialresponsibility,(b)respectforpersons,(c)donoharm,and(d)justiceasfairness.

EthicalPrinciples

SocialResponsibility

Theethicalprincipleofsocialresponsibilityfocusesonsocialissuesthataffectthegreatergoodofsociety.ThisprincipleisfoundationaltohownursesoughttothinkandactwhenrecommendingsignificantchangesinnursingsuchastheDNP,whichaffectsnotonlynursesbutalsothegreatersociety.Fortunatelyinnursingwehaveafoundationaldocument—theAmericanNursesAssociation’s(ANA)2003Nursing’sSocialPolicyStatement—thatmakesexplicittheethicalprincipleofsocialresponsibility.Accordingtothisdocument,asocialcontractexistsbetweensocietyandnursingwherebysocietygrantsnursingitsauthoritytopracticeinreturnfornursing’scommitmenttosocietyregardingmattersrelatedtohealthandthepublicgood.Thus,ourmandatetoexistandtoservecomesfromsocietyandnotfromwithinourranks.

WeraisethreequestionsabouttheethicalprincipleofsocialresponsibilityanditsrelationshiptotheDNP:

WhyhasnotanursingfoundationalframeworkrelatedtosocialresponsibilitybeenarticulatedfortheDNP?
WhyhastheANA’s(2003)Nursing’sSocialPolicyStatementseeminglybeenignoredinwritingsabouttheDNP?
WouldtheAACN’s(2004)positionstatementontheDNPhaveadifferentfocusifitweregroundedinNursing’sSocialPolicyStatement?

Regardingquestionsoneandtwo,wedonotknowwhyanursingfoundationalframeworkandNursing’sSocialPolicyStatementseeminglywerenotusedbyAACNorbyotherauthorswritingabouttheDNP.Weretheytakenforgrantedorforgotten,orconsideredunimportant,irrelevant,oroutdated?Theanswersarenotclear.However,someoftheauthorsintheOJINtopicdidnotenursing’srelationshipwithsociety.Forexample,O’Sullivan,Carter,Marion,Pohl,andWerner(2005)brieflynotedthat"continuedexpansioninbreadthanddepthofthemaster’sprogramsisnolongersociallyresponsible"(ImpetusforChangesection,para.1).Flinter(2005)brieflynotedthatsocialgoodrelateshistoricallytothedevelopmentofthenursepractitionerandthecommunityhealthcentermovements.Wearguethatbriefnotationsaboutsocialgoodarenotenoughandthatawelldelineatedphilosophyaboutnursing,socialgood,andhealthastheyrelatetoDNPprogramswouldstrengthen,oratleastbroaden,anydiscussionsabouttheDNP.

Regardingquestionthree,webelievethattheAACN’s(2004)PositionStatementwouldhaveadifferentfocusifitweregroundedinNursing’sSocialPolicyStatement.Whereastheprimaryfocusofthe2004AACNPositionStatementonthePracticeDoctorateinNursingisonadvancedpracticenurses(APN)andthepreparationofthem,theprimaryfocusofNursing’sSocialPolicyStatementisontherecipientsofnursingcare.FortheAACNfocus,theimportantquestionsare:(a)HowdoesonedefineAPN?(b)HowdoesonedefinetheDNP?(c)WhataretheappropriatecurriculaandotherrequirementsneededtoconfertheDNP?Forthesocialpolicyfocus,however,theimportantquestionsare:(a)Howdoesonedefinetherecipientsofnursingcare?(b)Howdoesonedeterminethehealthcareneedsoftheserecipients?(c)Howdoesonedeliverthenecessarynursingcaretomeettheseneeds?WebelievethatonecannotaddresstheDNPwithoutalsoaddressingtherecipientsofnursingcareandhowDNPnurseswoulddelivercaretothem.Thus,werecommendthatincreasedthoughtbegiventotherecipientsofnursingcareandthesocialresponsibilityduethembyDNPnurses.ThedegreetowhichtheethicalprincipleofsocialresponsibilityismetbyDNPnursesisalsothedegreetowhichthisaspectoftheDNPwillbeethicalornot.

RespectforPersons

TheprincipleofrespectforpersonsisdefinedinprovisiononeoftheAmericanNursesAssociation’s(ANA)2001CodeofEthicsforNurseswithInterpretiveStatements:"Thenurse,inallprofessionalrelationships,practiceswithcompassionandrespectfortheinherentdignity,worthanduniquenessofeveryindividual,unrestrictedbyconsiderationsofsocialoreconomicstatus,personalattributes,orthenatureofhealthproblems"(p.7).Regardingtherecipientsofcare,theANA(2001)Codeaddressesrespectforpersonsasconsidering"theneedsandvaluesofallpersons"...(p.7);asconsidering"anindividual’slifestyle,valuesystemandreligiousbeliefs..."(p.7);ashonoringpersons"irrespectiveofthenatureofthehealthproblem"(p.7);andashonoringpersons’"righttoself-determination"(p.8).Ifnursespracticewiththeprecedingprinciplesaspriorities,theethicalprincipleofrespectforpersonsasrecipientsofcarewillbehonored.Butrespectfortherecipientsofcareisonlyhalfofthestory.

TheANA(2001)Codealsodiscussestheprincipleofrespectforpersonsasitrelatestocolleaguesandothers:

Thenursemaintainscompassionateandcaringrelationshipswithcolleaguesandothers....Thisstandardofconductprecludesanyandallprejudicialactions,anyformofharassmentorthreateningbehavior,ordisregardfortheeffectofone’sactionsonothers.(p.9)

Theethicalprincipleofrespectforpersonsascolleaguesalsoprecludesinattention,sarcasm,interruptions,putdowns,feignedlistening,selectivelistening,ignoring,andthelike,especiallywhendifferencesofopinionoccur.Regardingthispoint,weraisethefollowingquestion:Whensuchdifferencesofopiniondooccur,howshouldtheprincipleofrespectforpersonsbehonored?Toaddressthisquestion,weexaminesomeproandconstatementsabouttheDNPfoundintheVol.10,No.3issueofOJIN.

Pro:"ThemovetothepracticedoctorateisnolongerinquestionforadvancedpracticenursingandparticularlyforNPsofthefuture"(O’Sullivanetal.,2005,Conclusionsection,para.1).
Con:"SpecificallytheproposedDNPastheterminaldegreeforclinicalnursespecialists(CNSs)presentsatroublesomeuseofresources"(Fulton&Lyon,2005,ImpactonEducationalResourcessection,para.4).
Pro:"This[movetothepracticedoctorate]isanexcitingtimeinthehistoryofnursingeducation.NPswillatlastbeonparitywiththeotherhealthprofessionsandcancontinuetodemandaplaceatthepolicytable"(O’Sullivanetal.,2005,Conclusionsection,para.1).
Con:"Thetimeinvolvedinallthesedialogues,debates,approvals,andchanges[relatedtotheDNP]istimetakenawayfromthemorevitaldiscussionaboutthequalityofcareinthehealthcaresystem"(Meleis&Dracup,2005,Timingsection,para.4).
Pro:"Themembershipofthetaskforce[AACNTaskForceonthePracticeDoctorateinNursing]includedrepresentativesfromuniversitiesthatalreadyofferedorwereplanningtoofferthepracticedoctorate,fromuniversitiesthatdidnotyetofferthistypeofdegree,fromaspecialtyprofessionalorganization,andfromnursingserviceadministration"(Lenz,2005,AACNTaskForceonthePracticeDoctorateinNursingsection,para.1).
Con:"Itisimperativethattheentirenursingcommunity'•allstakeholders'•participateinmeaningfuldialogueaboutthepracticedoctoratespecificallyandthefutureofnursingeducationingeneral.PreviousdiscussionforumsabouttheDNPsponsoredbytheAACNhavebeenlimited..."(Fulton&Lyon,2005,Conclusionsection,para.1).

Theprecedingquotesdemonstratehonest,respectful,andcompellingdifferencesofopinionsamongcolleaguesand,assuch,areinaccordwiththeethicalprincipleofrespectforpersons.Infact,theANA(2001)CodeofEthicsforNurseswithInterpretiveStatementsnotesthat"soundethicaldecision-makingrequirestherespectfulandopenexchangeofviews[italicsadded]betweenandamongallindividualswithrelevantinterests"(p.19).Whentheprecedingdoesnothappen,thenrealorpotentialproblemswithrespectforpersonsoccur.Toresolveproblemsofdisrespectforcolleaguesaspersons,wesuggestcareful,thoughtful,attentivelisteningtothemwithoutinterruptionorannoyancebecausetheirideasaredifferentfromourown.Thedegreetowhichtheethicalprincipleofrespectforpersonsismetbycolleagues,especiallythosecolleaguesmostinvestedintheDNP,isalsothedegreetowhichthisaspectoftheDNPwillbeethicalornot.

DoNoHarm

AccordingtoBeauchampandChildress(2001),theprincipleofdonoharmincludesprotectingpersonsfromharm,notharmingthem,andprovidingbenefitstothem.SuchpreclusionofharmisalsosupportedbytheANA(2001)CodeofEthicsforNurses.Specifically,twoprovisionsoftheCodeprimarilyfocusonthedonoharmprinciple.Provision2statesthat"thenurse’sprimarycommitmentistothepatient,whetheranindividual,family,group,orcommunity"(p.4).Provision3statesthat"thenursepromotes,advocatesfor,andstrivestoprotectthehealth,safety,andrightsofthepatient"(p.4).Thus,thequestionweraiseisthis:Howmightthe2004AACNPositionStatementonthePracticeDoctorateinNursingharmorpotentiallyharmpatients?

Harmmightoccur,forexample,wheninadequatedataexisttomeritDNPprograms.Mostethicaldecision-makingframeworksstresstheneedforaccurate,current,andadequateinformationgatheringbeforeanethicaldecisioncanbemade.Thereasonissimple:Thesedataarevitaltosounddecisionmakingand,thus,aprerequisitetoqualityofethicaloutcomes.

Accordingtothe2004AACNPositionStatementonthePracticeDoctorateinNursing,theTaskForceconductedpertinentliteraturereviews,spoketokeypersonsandgroupsinvolvedwithcurrentDNPprograms,formedcollaborativerelationships,andprovidedforopendiscussionabouttheDNPatthreeAACNsponsoredevents.DespitetheseAACNefforts,in2005,theNationalAssociationofClinicalNurseSpecialists(NACNS)expressedseveralconcernsaboutthePositionStatementintheirWhitePaperontheNursingPracticeDoctorate.Theseconcernsfocusedonthe"nursingprofession"(p.2),"education"(pp.2-3),"patientsafety"(p.3),"economicissues"(pp.3-4),"developmentoftheDNP"(p.4),"nursepracticeacts"(p.4),and"ongoing/implementationconcerns"(p.4).

TheNACNSalsowereconcernedaboutdatagaps.Herearethreeexamples:

"Therearenostudiesshowingthatdoctorally-preparedadvancedpracticenurseshavebetteroutcomesthanmaster’s-preparedadvancedpracticenurses"(p.2).
"ItisunclearhowtheproposedDNPwillcontributetoincreasedpatientsafetyastherehavebeennostudiesdonetosupportthispremise"(p.3).
"ItisnotknownifDNP-preparedadvancedpracticenurseswillbeaffordabletoemployersandthirdpartyreimbursers"(p.3).

SomeoftheseprecedingdataconcernsalsohavebeenaddressedbyseveralOJINauthors(e.g.,Cartwright&Reed,2005;Fulton&Lyon,2005;Meleis&Dracup,2005)intheVol.10,No.3issueontheDNP.Therefore,werecommendcontinuedpurposefuldatagatheringandsynthesisthroughouttheplanning,implementing,andevaluatingstagesoftheDNP.ThedegreetowhichtheethicalprincipleofdonoharmismetbynursesresponsibleforthesestagesoftheDNPisalsothedegreetowhichthisaspectoftheDNPwillbeethicalornot.

JusticeasFairness

Theethicalprincipleofjusticemeansgivingpersonswhattheyaredueorowed.Hereinwearefocusingonjusticeasfairnessasitrelatestoaccesstoanddistributionofscarceresources.The2001ANACodeofEthicsforNurseswithInterpretiveStatementsnotesbothaccessanddistribution:

Thenursehasaresponsibilitytobeawarenotonlyofspecifichealthneedsofindividualpatientsbutalsoofbroaderhealthconcernssuchasworldhunger,environmentalpollution,lackofaccesstohealthcare[italicsadded],violationofhumanrights,andinequitabledistributionofnursingandhealthcareresources[italicsadded].(p.23)

RegardingtheDNPandtheethicalprincipleofjusticeasfairness,weraisethisquestion:HowisjusticeasfairaccesstoandfairdistributionofscarceresourcesaddressedbyAACN(2004AACNPositionStatementonthePracticeDoctorateinNursing),byNACNS(2005NACNSWhitePaperontheNursingPracticeDoctorate),andbyOJIN(Vol.10,No.3issueontheDNP)?

Inthebackgroundsectionofthe2004AACNPositionStatementonthePracticeDoctorateinNursing,theauthorscitetheInstituteofMedicine’s(2001)reportthat"callsonallhealthcareorganizationsandprofessionalgroupstopromotehealthcarethatissafe,effective,client-centered,timely,efficient,andequitable[italicsadded]"(p.6).TheAACNauthors,however,didnotdefineequitable.Likewise,inrecommendation1,ofthe2004AACNPositionStatement,theauthorsspecifiedtheneedforan"increasedsupplyoffacultyforclinicalinstruction"(p.8),buttheydidnotmakeexplicithowtheincreasedsupplyofnursefacultyrelatestojusticeasfairness.

Accordingtothe2005NACNSWhitePaperontheNursingPracticeDoctorate,"SomeexistingCNSprograms,aswellasotheradvancednursingprograms,mayneedtoclosebecausetheyarenotpermittedbystatestatuetoofferdoctoraleducation[suchastheDNP]ormaylackthefiscalorfacultyresources"(p.3).TheNACNSWhitePaperalsoaddressesanotherdegreeissue:"PotentialnursescientistsmayoptfortheDNPasopposedtotraditionalPhDprograms,thustheDNPcouldcompeteagainstthePhDforscarceresources,reducingthenumberofnursescientists..."(p.2).LiketheAACNauthors,theNACNSauthorsdidnotmakeexplicittherelationshipbetweenscarceresourcesandjusticeasfairness.

ThefollowingthreeOJINarticlesontheDNP,liketheprecedingdocuments,alsodonotmakeexplicithowscarceresourcesrelatetojusticeasfairness.Lenz(2005)addressedtheissueofunder-credentialingofAPN.BythisshemeantthattheknowledgeandskillsrequiredofAPNhavebecomeincreasinglycomplex.Consequently,thecreditsrequiredforanadvancedpracticemaster’sdegreeinnursingoftensurpassthecreditsofotherdisciplines.Isthisfair?Areotheroptionsavailable?LenzsupportstheDNPastheotheroption.ButwilljusticebeservedifstudentsdonothavefairaccesstoDNPprograms?

O’Sullivanetal.(2005)alsosupportedLenz’s(2005)concernaboutthecontinuedlengthofmaster’sprogramsforAPN.Inaddition,theyaddressedtheissueofworkforceshortages;thatis,thedemandforhealthcareprovidersisgreaterthanthesupply.Providersthenbecomescarceresources.Howarethesescarceresourcestobedistributed?AlthoughO’Sullivanetal.seetheDNPasawaytoincreaseworkforceshortages,theydidnotdiscusstheunderlyingethicalprincipleofjusticeasfairdistribution.

CartwrightandReed(2005),respectively,auniversitypresidentandasenioradministratoratalargepublicinstitution,arewellawareoftheproblemsofscarceresources;however,theyappearlessawareoftheunderlyingethicsofjusticeasfairaccesstoandfairdistributionoftheseresources.They(2005)stated,"Ofparticularimportanceareovercomingpolicyconcernsthatrelatetotheallocationoflimitedpublicfundsfordoctoraleducation…."(Abstractsection,para.1).TheyalsonotethatinOhiomoneyfordoctoraleducationwasrecentlycappedbecausethestatebelievedthatundergraduateeducationwasunderfundedanddoctoraleducationwasoverfunded.

TheprecedingdiscussionabouttheDNPandjusticehighlightsexamplesofhowtheethicalprincipleofjusticeasfairaccesstoandfairdistributionofscarceresourcesareimplicit,ratherthanexplicit,inthe2004AACNPositionStatement,inthe2005NACNSWhitePaper,andintheVol.10,No.3issueofOJIN.Whileacknowledgingthattheethicsofjusticeareembeddedinthesedocuments,wecallforafullerandmoreactivediscussionanddebatethatmakestheethicsofjusticeexplicit.Discussionanddebateareimportantbecauseifscarceresourcesareviewedonlyinexplicitfinancialterms,ethicaloutcomesmaybeneglected.ThedegreetowhichtheethicalprincipleofjusticeasfairnessismetregardingtheDNPisalsothedegreetowhichthisaspectoftheDNPwillbeethicalornot.

SummaryandConclusion

WhileahealthydebatehasbeenstartedabouttheprosandtheconsoftheDNP,theethicsrelatedtothisnewdegreerarelyhavebeennotedandcertainlynotfullydebated.Tostartthisdebate,wediscussedfourethicalprinciplesassociatedwiththeDNP:(a)socialresponsibility,(b)respectforpersons,(c)donoharm,and(d)justiceasfairness.Duringourdiscussionoftheseissues,wehaveraisedthequestionofwhetherornottheDNPwasethical.Inourminds,theDNPispresentlyinamalleablestateand,thus,opportunitiesstillexistforkeydecisionmakersinnursingtogroundthedegreeinethicsandtomaketheethicsexplicit,orforkeydecisionmakersinnursingtodiscussthedegreeandwriteaboutitwithoutregardfororconsciousawarenessofethics.Ultimately,thedegreetowhichtheDNPmeetsethicalprinciples,aswellasotherethicalconsiderations,isthedegreetowhichtheDNPwillbeethical.Thedecisionisuptouscollectivelyasfaculty,staff,andmembersofprofessionalassociationstoethicallyexamineanddecide,"IstheDNPethical?"

LettertotheEditorbyRiedel,Sander,andMiller-Wenning(12/09)
- withreplybyAuthors
LettertotheEditorbyLohman(6/09)
LettertotheEditorbyDetlefsen-(11/06)

MaryCiprianoSilva,PhD,RN,FAAN
E-mail:msilva@gmu.edu

E-Mail:Ojinethics@kent.edu

RuthLudwick,RN,PhD,C,isaProfessoratKentStateUniversity,CollegeofNursing(CON)anddirectstheOfficeofInternationalInitiativesattheCON.SheisanAssociateEditorandamemberofthefoundingeditorialboardoftheOnlineJournalofIssuesinNursing(OJIN).SheservesascoordinatorfortheOJINEthicsColumnandcoordinatorofthelinksforeachtopic.Ruthteachesacrossthecurriculumandiscertifiedingerontologicalnursing.Sheiswidelypublishedandpresentsnationallyandinternationallyonresearchrelatedtogerontologyandcollegeteaching.Sherecentlycompleteda1yearstudyfundedbytheNationalInstituteofAgingandbegana2½yearstudyfundedbytheInstituteofMuseumandLibraryServices.OfparticularinteresttoheristheresearchshehasdoneacrossdisciplinesandwithcolleaguesinN.Ireland,Australia,andScotlandrelatedtothefactorialsurveymethod.

References

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Meleis,A.I.,&Dracup,K.(2005,September30).ThecaseagainsttheDNP:History,timing,substance,andmarginalization.OnlineJournalofIssuesinNursing,10(3),Article2.RetrievedOctober15,2005,www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume102005/No3Sept05/tpc28_216026.aspx

Mundinger,M.O.(2005).Who’swhoinnursing:Bringingclaritytothedoctorofnursingpractice.NursingOutlook,53,173-176.

NationalAssociationofClinicalNurseSpecialists.(2005,April).Whitepaperonthenursingpracticedoctorate.http://nacns.org/nacns_dnpwhitepaper2.pdf

O’Sullivan,A.L.,Carter,M.,Marion,L.,Pohl,J.,&Werner,K.E.(2005,September30).Movingforwardtogether:Thepracticedoctorateinnursing.OnlineJournalofIssuesinNursing,10(3),Article4.RetrievedOctober15,2005,www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume102005/No3Sept05/tpc28_416028.aspx

March 20, 2006

Citation: Silva, M., Ludwick R., (March 20, 2006). "Ethics: Is the Doctor of Nursing Practice Ethical?" OJIN: The Online Journal of Issues in Nursing. Vol. 11 No. 2.