September 30, 2005
in response to topic The Doctor of Nursing Practice (DNP): Need for More Dialogue (Sept. 30, 2005)
I have read with interest the debate in regards to the DNP. Having studied the historical development of practice doctorates in other practice disciplines, it is clear that the topics of timing, purpose, substance, academic support, regulatory issues, economics, and other issues are not novel to nursing. Osteopathy, optometry, audiology, naturopathy, occupational therapy, physical therapy, psychology, public health, and pharmacology have traveled the path that nursing is just now beginning to tread in developing a practice doctoral degree.
A case in point is that of pharmacy. The American Pharmaceutical Association’s 1948 recommendation that the Doctor of Pharmacy (Pharm.D) be the appropriate educational preparation for clinical practice led to considerable consternation in that day. And, analogous to the current DNP debate, the rationale for the opposition to the entry-level PharmD consisted of increasing educational costs, inadequate remunerative return to the student, inadequate numbers of PhD prepared faculty, increasing consumer costs, underutilization of the pharmacist’s preparation, a reduction in overall quality as compared to a post-BS PharmD, and inadequate faculty to train students for the PharmD. Yet prescient clinical leaders persisted, recognizing that the doctoral degree provided the basis of contemporary knowledge required for professionalism, provided additional time for the student to integrate their knowledge, and eliminated a two-tiered approach to pharmacy education (Gans, 1990; LaFranco, Tannenbaum & Cannon, 1977; McLeod, 1992; Tse, 1992; Weinburg, 1986; Wurster, 1997).
What other health care disciplines have learned is the importance of all their members working together and supporting each other. My position is that a practice doctorate in no way threatens PhD-prepared faculty nor weakens nursing. Meleis and Dracup (2005) write that the MD may be a terminal degree, but it is also an entrance degree to the profession of medicine that can be followed by the PhD for advancing clinical science. This progression seems to be a perfect example for what the DNP can and should be. Their argument that we are in the midst of various health care crises such as unsafe hospital care seems to be yet another cogent argument for an outcomes-focused clinical doctorate. And finally, their argument that doctoral education should be designed to help define and develop the base of nursing knowledge again seems to align perfectly with my preparation and experience as a DNP student and now, newly minted faculty. PhD’s and professional doctorates must not compete within the profession. Together, working on the same team, these distinct emphases strengthen and enrich our profession. This is how other health professions have been functioning for decades.
Other health disciplines have already developed two degrees—the professional doctorate and the PhD. Nursing needs to immediately transition its DNS, DNSc, DrNP and other designations to the PhD and the DNP (if that is the consensus designation, I acknowledge its weaknesses) exclusively. Dr. D’Arcangelo (2006) states it well when she says "the issue is not whether or not nurses will be marginalized within the profession, but how our profession marginalizes itself by confusing the public and our colleagues in other health care disciplines with our constantly changing nomenclature."
I also fully support Flinter’s (2005) recommendation of the clinical residency. Nearly every other health profession recognizes the need to prepare their clinicians to step out of the educational cocoon with well-rounded clinical preparation and competency. Yet this is an area where most nurse practitioners—the ones who are honest, including several who have written their own letters to the editor--will admit we in nursing education have failed them. Clinical preparation for advanced practice roles is too often marginal at best. Offering quality standardized educational tracks with residencies would be the first step towards changing that.
Finally, in all the aforementioned health disciplines, a practice doctorate is meant for entry-level preparation for advanced practice. This is where we in nursing perhaps need to take a good look in the mirror, not in our politics. Could it be that since we have failed to resolve the issue of the bachelor’s degree as the entry for professional nursing, that the doctorate should then be the appropriate bar of entry to professional nursing practice? I have yet to resolve this question, but I believe it deserves to be raised and discussed just as vigorously as we are now discussing the DNP.
I acknowledge that many logistical and curricular questions remain to be resolved. Yet we must also acknowledge that our professional future depends upon each and every advanced practice graduate possessing a comprehensive quality education. My hope is that all eyes will be on the horizon ahead of us and that we will move toward it together.
Deonne J. Brown, DNP, ARNP, FNP-C
D’Arcangelo, J. S. (2006). Response by Janet S. D'Arcangelo to: "Reflections on the DNP and an Alternate Practice Doctorate Model: The Drexel Model" by H. Michael Dreher, Gloria F. Donnelly, and Rita C. Naremore (December 12, 2005). Online Journal of Issues in Nursing. Retrieved December 12, 2006, from www.nursingworld.org/MainMenuCategories/OJIN/TableofContents/Volume102005/Number3/tpc28_716031.aspx.
Flinter, M. (2005). Residency programs for primary care nurse practitioners in federally qualified health centers: A service perspective. Online Journal of Issues in Nursing, 10 (3).
Gans, J. A. (1990). Freedom of opportunity: The PharmD degree. American Pharmacy, NS30 (6), 328-331.
LaFranco, M. M., Teannenbaum, R. P., & Cannon, M. L. (1977). A rebuttal to the universal PharmD. proposal. Drug Intelligence and Clinical Pharmacy, 11 (77), 477-479.
Meleis, A. F., & Dracup, K. (2005). The case against the DNP: History, timing, substance, and marginalization. Online Journal of Issues in Nursing, 10 (3).
McLeod, D. C. (1992). All-PharmD degree alone will not significantly alter the pharmacy profession. The Annals of Pharmacotherapy, 26, 998-999.
Tse, C.S.T. (1992). How much is the Pharm.D. worth to a student? The Annals of Pharmacotherapy, 26, 1017.
Weinburg, S. (1986). What is a Pharm.D.? American Journal of Hospital Pharmacy, 43 (8), 1915-1916.
Wurster, D. E. (1997). Will the PharmD make the pharmaceutics Ph.D. an endangered species? Pharmaceutical Development and Technology, 2 (1), vii-viii.