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The Practice Doctorate in Nursing: An Idea Whose Time Has Come

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Elizabeth R. Lenz, PhD, RN, FAAN

Abstract

The practice-focused doctorate is an important alternative to research-focused doctorates in nursing. The goal of this article is to provide the reader with an understanding of the nature and potential benefits of the practice doctorate. After discussing the background of this doctoral degree and the development of the degree by the American Association of Colleges of Nursing (AACN) Task Force on the Practice Doctorate in Nursing, the article will describe patterns in practice-focused doctoral education and issues considered by the task force in developing the position paper on the practice doctorate in nursing. A look ahead provides an update on current steps being taken by AACN and others toward implementing the task force’s recommendations.

Citation: Lenz, E.R. (September 30, 2005). "The Practice Doctorate in Nursing: An Idea Whose Time Has Come". OJIN: The Online Journal of Issues in Nursing. Vol. 10 No. 3, Manuscript 1.

DOI: 10.3912/OJIN.Vol10No03Man01

Key words: clinical doctorate, clinical education, doctoral nursing education, leadership, practice doctorate, trends

During the past five years interest in a practice doctorate in nursing has been building at a tremendous rate. Viewed as a viable alternative to the research-focused doctorate in nursing for those who aim to attain the highest levels of excellence in practice, the practice-focused doctorate has been a topic of frequent discussion at professional meetings and is increasingly being addressed in professional journals. A major catalyst for the current level of interest has been the American Association of Colleges of Nursing (AACN) position paper on the practice doctorate. This position paper was the result of two years of work by a task force, which gathered information about existing practice-focused doctoral programs in nursing, hosted multiple sessions to obtain input from stakeholders about the advisability of recommending such programs, grappled with many issues, and ultimately made decisions that the task force realized would be controversial. The goal of this article is to provide the reader with an understanding of the nature and potential benefits of the practice doctorate. After discussing the background of this doctoral degree and the development of the position paper by the American Association of Colleges of Nursing Task Force on the Practice Doctorate in Nursing, the article will describe patterns in practice-focused doctoral education and issues considered by the task force in developing the position paper on the practice doctorate in nursing. Finally a look ahead provides an update on current steps being taken by AACN and others toward implementing the task force’s recommendations.

Background

Certainly a practice doctorate in nursing is not a new idea. Nearly 20 years ago Schlotfeldt (1978) and her colleagues operationalized the dream of making the doctorate the entry-level degree in nursing when the first practice-focused Doctor of Nursing (ND) program opened at what is now Case Western Reserve University (CWRU). Eclipsed in priority and popularity by the research-focused PhD, by 2000 the ND was offered by only four institutions (CWRU, Rush University, the University of Colorado, and the University of South Carolina). Its original conceptualization as an analog to the MD had blurred and changed to an advanced practice focus. Nevertheless, the ND made an important contribution to the discipline by providing a practice-focused degree that represented a type of doctoral preparation that is distinctly different from the research-focused academic doctorate (PhD) or nursing’s professional research-focused degree (the Doctor of Nursing Science – DNS, DSN or DNSc).

The idea that the two types of programs are distinctly different and should not be evaluated by identical criteria is consistent with the recommendations of a task force of the AACN that reviewed and recommended the indicators of quality for research-focused nursing doctoral programs (AACN, 2001). By that time the idea that the nursing discipline should offer both research- and practice-focused doctoral degrees had resurfaced actively, and was beginning to stimulate considerable discussion and activity. Three additional schools of nursing were then planning, and later opened, practice-focused doctoral programs: The University of Tennessee Memphis, The University of Kentucky, and Columbia University.


...Trends suggested an increasing need for insightful and visionary nursing leadership in practice...[for] a place at the table in high level health care management and policy decisions.

Several trends and events in the practice arena and in nursing and health professions education are detailed in this section. Practice trends include the increasing complexity of health care and the resulting requirement for increased knowledge for advanced practice; education trends include the trend toward practice doctorates in the health professions, the increase in credit requirements at the master’s level in nursing, and the tremendous need for nursing faculty who are well prepared for clinical teaching.

Regarding the practice arena, in addition to the ever-spiraling complexity and sophistication of health care, particularly in acute care settings, several studies and reports documented problems with health care delivery and patient safety (e.g., Institute of Medicine, 1999, 2001, 2003). These trends suggested an increasing need for insightful and visionary nursing leadership in practice with the educational credentials necessary to be accorded a place at the table in high level health care management and policy decisions.

Much of the early discussion about educational preparation for advanced practice nursing has focused on nurse practitioners. Mundinger and colleagues (Mundinger, 2005; Mundinger, Cook, Lenz, Piacentini, & Smith, 2000) at Columbia University mounted a powerful argument that although master’s-prepared nurse practitioners (NPs) practice effectively and achieve primary care patient outcomes that are equivalent to those of MDs (Mundinger, Kane, Lenz, Totten, Tsai, Cleary, et al., 2000), doctoral education is the optimal level of preparation to provide cross-site, full-scope practice in primary care. In order to ascertain the extent to which actively practicing NPs perceived gaps in their formal education and to identify potential areas for curricular emphasis, Columbia University researchers conducted a national mailed survey. Results from 2303 NPs revealed that although formal education provided the basis for their skills in patient diagnosis and management (in a majority of cases supplemented by subsequent on-the-job training), gaps existed in relation to cross-site practice, credentialing, use of information technology, evidence as a basis for practice, policy, synthesis and application of knowledge at a high level, and multiple aspects of practice management. Although they expressed a desire for more education about these topics, few anticipated obtaining more formal education; because they did not believe existing research-focused doctoral programs to be particularly relevant (Lenz, Mundinger, Clark, Hopkins & Lin, 2000). These findings about perceived gaps in knowledge and the need for additional education are consistent with themes from focus group sessions conducted by the National Organization of Nurse Practitioner Faculties (NONPF) (Marion, personal communication, 2003).


...it became increasingly apparent that a major trend in other health disciplines was underway to move the terminal degree to the doctoral level.

With respect to education, several patterns converged. First, it became increasingly apparent that a major trend in other health disciplines was underway to move the terminal practice degree to the doctoral level. In some cases the doctorate had been newly established as the educational level that will be required for entry into practice (for example, the PharmD in pharmacy, DPT in physical therapy, and AuD in audiology). Nursing remained one of the few health-related disciplines for which a doctorate is not regarded as the highest and desired practice credential.

Secondly, it became increasingly apparent that nursing may be under-credentialing its advanced practice graduates. As the knowledge requirements for advanced practice nursing in today’s complex clinical environment have increased steadily, the credit requirements for master’s programs and the clinical hour requirements for credentialing have also increased (the phenomenon is often termed "credit creep") to the point where they far surpass master’s credit requirements in many other disciplines. They are equivalent to or surpass requirements for doctoral programs in other fields, even clinical disciplines. It is not uncommon for master’s programs that prepare nurse practitioners to require in excess of 50 semester credits of didactic courses and clinical practica. An alternative strategy that has been used to keep the credit requirements to a reasonable number is to under-credit clinical practica, allowing credit hour to practicum clock hour ratios to increase well beyond the traditional 1:3 or 1:4. At the same time that credit hour requirements have been escalating, the number of nurse practitioner programs has also escalated, with programs sometimes opening with insufficient numbers of qualified faculty and other resources; concerns about their quality have mounted.

A trend in nursing education that has served to increase the demand for doctorally prepared nurses with expertise in nursing practice is the tremendous shortage of faculty. As was predicted by Berlin (2002) faculty shortages, which are already seriously compromising the discipline’s ability to respond to the shortage of bedside nurses, are expected to worsen as more and more faculty reach retirement age. Unfortunately, the enrollments in and graduations from PhD programs in nursing have remained quite steady, so are insufficient to replace the number of faculty who are scheduled to retire in the near future. A practice-focused doctorate appeals to a sizable number of master’s-prepared, experienced, and expert clinicians who desire the doctoral credential that many universities recommend or require for their faculty, but who do not wish to pursue a research-focused doctoral degree.

AACN Task Force on the Practice Doctorate in Nursing

Stimulated both by the recommendation by its task force on indicators of quality in doctoral programs that practice-focused doctoral programs be examined separately, and also by the growing interest in practice doctorates, the AACN Board of Directors in March, 2002, established a task force to examine trends in practice-focused doctoral education and make recommendations about the need for and nature of such programs in nursing. The membership of the task force included representatives from universities that already offered or were planning to offer the practice doctorate, from universities that did not yet offer this type of degree, from a specialty professional organization, and from nursing service administration. The task force was given the following charge: Describe patterns in existing practice-focused doctoral programs; clarify the purpose of practice doctorate, particularly as differentiated from the research doctorate; identify preferred goals, titles, and tracks; identify and make recommendations about key issues; and prepare a position paper.

The activities undertaken by the task force included interviewing administrators, faculty, and graduates of five existing and two planned practice-focused doctoral programs and holding open discussion sessions at several AACN meetings. These meetings included conferences on doctoral education in nursing in 2003 and 2004, a conference on master’s education in 2003, and AACN semi-annual meetings in 2003 and 2004. In addition, AACN co-hosted with NONPF an invitational stakeholders’ meeting to which all major nursing organizations were invited to send representatives. It also hosted a reaction panel comprised of representatives from key stakeholder organizations, such as major employers, e.g., The Department of Veterans’ Affairs, American Organization of Nurse Executives, and Association of Academic Health Centers; physician educators, e.g., Association of American Medical Colleges; and policy makers and influencers, e.g., the Council of Graduate Schools and the National Quality Forum.

No formal marketing surveys were carried out by the task force because of time constraints. However, the aforementioned meetings provided informal indicators of marketplace receptivity, as did the groundswell of interest in the topic at meetings sponsored by AACN, NONPF, and several other specialty organizations. In addition, the results of a recent survey of potential employers of DNP graduates by the University of Kentucky indicated enthusiasm for the benefits of employing nurses prepared with the practice-focused doctorate.

The task force drafted a position paper on the practice-focused doctorate in nursing, which was approved by the AACN membership in October, 2004. The text of this position paper can be found on the AACN Web site: www.aacn.nche.edu/DNP/DNPPositionStatement.htm Throughout its investigation of practice-focused doctorates and deliberations about the position to be taken, the task force tackled a number of issues that were known to be controversial. The approach was to secure information and input from multiple sources, to weigh the information carefully before crafting a position, and then to request reactions and suggestions from stakeholders. These reactions and suggestions were taken into account in making final revisions.

Patterns in Practice-Focused Doctoral Education

The survey of existing programs by the AACN task force included all institutions that at that time offered practice-focused doctorates or had formally begun planning a practice-focused doctoral program. The phone interviews were conducted between May and September, 2002. The interviews revealed distinct differences between research- and practice-focused doctoral programs in nursing which still differentiate the two types of doctoral degrees. It is important to recognize that all of the institutions surveyed offered a research-focused doctoral programs in addition to the practice-focused program, so were very well able to articulate the differences between the two types of programs. When contrasted with research-focused programs, practice-focused programs tend to include more emphasis on practice, less emphasis on theory and meta-theory, and less extensive research methodology content. However, research methods content was noted to be essential for both types of doctoral graduates.

The research-related expectations of graduates differ, in that the research-focused programs generally state that their graduates are producers of research, i.e., expected to design and carry out major programs of research. On the other hand, practice-focused programs expect their graduates to be expert evaluators and consumers of research, prepared to evaluate evidence for application in practice. They are also expected to design and conduct practice-related research projects, such as those designed to evaluate clinical interventions.


...contrasted with research-focused programs, practice-focused programs tend to include more emphasis on practice, less emphasis on theory and meta-theory...[h]owever, research methods content was noted to be essential for both types of doctoral graduates.

Practice-focused doctoral programs generally include a residency or intense integrative clinical experience. In lieu of a knowledge-generating dissertation, the student in a practice-focused program is generally required to carry out a clinical, application-oriented "capstone project" that is related to the clinical residency. Depending on program requirements and the student’s area of emphasis, such a project might include the development of a program of intervention, or an analysis of a health care policy, or a discussion of patient care provided.

The survey revealed two distinct foci in practice-focused programs (or tracks): clinical and executive/administrative. Programs with clinical emphases including both those addressing hands-on patient care (including the advanced practice nursing roles of nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist), and also those addressing the care of aggregates, including clinical populations. Some programs were limited to one domain, whereas several included both clinical and administrative foci as different tracks.

An analysis of the curricula and content addressed in the existing, practice-focused doctoral programs revealed both commonalities and differences among the programs. Several content areas were addressed – albeit to varying degrees – in all of the programs. For example, all programs included content regarding advanced clinical practice and clinical populations; at least some research methodology, particularly as it concerns application of research findings to practice; critical thinking; health care organization and management; use of computer technology; and the scientific underpinnings for practice from nursing and related disciplines. Depending on the specific focus(foci) of the program and the level of preparation of entering students – i.e., whether admission was limited to whose already prepared as advanced practice nurses – some of these content areas could receive considerably more attention than others. Nevertheless, such content areas were considered to be relevant for both hands-on and administrative/executive practice domains, so were potential core content for all practice-focused doctoral programs.

A Look at the Issues Considered

As the task force gathered information about existing programs and began to solicit input from various stakeholders about the practice doctorate, it became readily apparent that there were a number of complex issues to be considered and stances to be taken. The issues that the task force debated, sometimes at considerable length, are described below. In each case the stance taken in the position paper and the rationale for that stance is described. The issues that were considered included: (a) how to define practice for the purpose of defining the scope of the practice doctorate; (b) the degree title to be used; (c) whether the benefits to be derived if the practice doctorate were implemented on a large scale would warrant the effort and potential disruption that would be involved; (d) the recommended curricular structure and major content areas of practice doctoral programs, and (e) whether to recommend the practice doctorate as the advanced practice degree (i.e. the desired level of preparation for all advanced nursing practice) or as an advanced, post-master’s credential to be attained by only a portion of advanced practice nurses.

Definition of Practice

The task force deliberated "long and hard" about the way in which practice would be defined for the purposes of the position paper on the practice-focused doctorate. Ultimately, we chose to define practice more broadly than direct, hands-on care, so as also to include management of care for individuals and populations, administration of nursing and health care organizations, and health policy formulation and evaluation. The choice to use an inclusive approach was based, in part, on a long-standing conceptualization of nursing practice as having two related domains: the direct and the indirect, with the latter defined as activities that are carried out in support of the provision of direct care. Nursing practice was defined as:

...any form of nursing intervention that influences health care outcomes for individuals or populations, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations, and the development and implementation of health policy. Preparation at the practice doctorate level includes advanced preparation in nursing, based on nursing science, and is at the highest level of nursing practice (AACN, 2004, p. 3).

The decision to define nursing practice more inclusively than hands-on care was also based on recognition that the authority and responsibility to make decisions that influence nursing and health care, and ultimately patient outcomes, often reside at the system level, i.e., with nursing administrators and policy makers. Many of the key stakeholders from whom input was secured by the task force spoke to the advisability of preparing such decision makers and leaders at the doctoral level and in the discipline of nursing. The curricular implication of this broadly scoped definition of practice is that it includes, but does not limit, practice-focused doctoral programs to preparation for the traditional hands-on advanced practice nursing roles of nurse practitioner, clinical nurse specialist, nurse midwife, and nurse anesthetist. Although this decision remains controversial (see Mundinger, 2005), it received overwhelming support among audiences polled by the AACN task force.

Practice Doctorate Status and Title


As conceptualized by the task force, the practice doctorate represents the highest level of preparation...it is not an entry level degree.

The task force concluded that the practice-focused doctorate was needed in nursing, was a valid terminal degree, and should be recognized as a viable and robust alternative to (but definitely not a substitute for) the research-focused doctorate. The two types of programs should be considered to be distinct and complementary, both contributing in important ways to the future of the profession and to health care in general. All of the institutions that currently offer the practice-focused doctorate also offer research-focused doctoral programs. Although there may be some overlap in core content, the purposes, objectives, and requirements of the two types of programs are clearly different. The experience reported by these institutions is that research- and practice-focused programs do not compete for students. Instead, they provide complimentary alternatives into which students appropriately self-select.

As conceptualized by the task force, the practice doctorate represents the highest level of preparation for advanced nursing practice in a specialized practice area; it is not an entry level degree. In order to be respected as a credible terminal degree, the programs that offer the practice-focused doctorate must be demanding and rigorous, and must include content and requirements and expect terminal behaviors that clearly are beyond the level of current master’s degree programs. To minimize confusion both within and outside the discipline, it was recommended that one degree title, Doctor of Nursing Practice (DNP), be used for all practice-focused doctorates, and that the Doctor of Nursing (ND) degree be phased out. The four ND programs are in fact at various stages in the process of formalizing changes in degree title to the DNP.

Benefits


The availability of the practice-oriented doctorate...should help to attract highly able individuals to the field...

The practice doctorate was viewed as a viable and necessary alternative to the research-focused doctorate because of the many benefits that the availability of high-level preparation in nursing practice was anticipated to provide to the profession, to health care in general, and to the individuals earning the degree. Although the ANCC task force found no formal studies of the accomplishments of nurses with practice doctorates, and several of the programs were too new to have graduates, it was believed that the nursing profession will benefit both clinically and educationally from the addition of more nurses with practice doctorates. In an era in which virtually all health care professions have moved to the doctorate as the terminal practice degree, parity for nursing is not simply a matter of status. Instead, it is increasingly the credential that is needed for credibility in leadership positions. The task force concluded, based upon comments from the administrative experts with whom the task force met, that nurses who have earned the doctoral degree with a practice focus will be more likely than their master’s-prepared counterparts to be accorded a place at the table in institutional and health system decision making. The result should be improved ability to effect needed change in nursing practice, health care, and health policy. The availability of a practice-oriented doctorate as a "destination" should help to attract highly able individuals to the field, which will, in turn, benefit from their intelligence, insight, and leadership skills.


The practice doctorate should provide ideal preparation and credentialing for clinical teaching.

It is appropriate that experts in practice play a central role in educating the nurses of the future. Currently, much of the clinical instruction of undergraduate students is carried out by master’s prepared individuals who may not qualify for full faculty status because they have not earned a terminal degree in the discipline. The practice doctorate should provide ideal preparation and credentialing for clinical teaching. With the practice doctorate as an option the attractiveness of academic careers may increase and result in the ability to attract expert clinicians who enjoy teaching, but lack sufficient interest in research to pursue the PhD credential.

The availability of skilled clinicians and administrators with advanced practice preparation at the doctoral level will benefit health care in general, as well as the individual patients to whom they provide care. Such individuals will be exceptionally well prepared to design, deliver, and direct evidence-based practice; to develop improved practice guidelines; to develop practice innovations; and to evaluate the effectiveness of complex interventions. These individuals will be at the forefront of efforts that will improve health care outcomes and patient safety and increase efficiency. Mundinger (2005) predicts that "these clinicians will change health care and profoundly improve the nation’s image of nursing" (p. 174).


Importantly, the availability of practice-focused doctoral programs will allow a better fit of educational preparation to individuals' career goals.

Finally, individual nurses will benefit from the availability of practice-focused doctoral programs. The curricula will provide advanced competencies for improved management of complex patients and patient populations, and for providing leadership in the practice arena. Given the complexity and sophistication of the content that has to be mastered for advanced nursing practice in today’s health care system and the high number of credits that are required to achieve expected competencies, the doctorate will provide a better match of degree requirements to the credential earned, while also allowing the inclusion of important content that simply cannot be fit into master’s programs.

Importantly, the availability of practice-focused doctoral programs will allow a better fit of educational preparation to individuals’ career goals. Currently many nurses are dissuaded from pursuing doctoral education because they do not envision research-focused careers, but would prefer to attain additional practice expertise. Others enter PhD programs despite their lack of interest in and commitment to research, because there simply are so few options. The disconnect between the educational program and student goals results not only in dissatisfied students and faculty, but also in an incredible waste of scarce resources for both the student and the institution.

Curricular Elements

In order to differentiate practice-focused from research-focused doctoral programs, and practice doctorates from master’s programs, and to make the degree understandable to patients, potential employers, and the public, it is advisable to achieve as much standardization as possible among practice-focused doctoral programs. The balance is to give the degree meaning, while allowing for some variability across institutions and specialties. To that end, an agreed-upon set of core objectives, curricular components, and content areas should be included in all programs. Core competencies should be expected of anyone holding the degree. The curricular model, therefore, should ideally combine a core of courses and experiences to address the competencies expected of all degree graduates. The core should be accompanied by a specialty component comprised of content and objectives that are specific to the specialty and most likely influenced by certifying bodies external to the institution. NONPF, for example, is developing doctoral-level competencies for nurse practitioners.

One of the clearest differences between the practice doctorate and the research doctorate is the lack of a dissertation requirement in the former. Instead of a dissertation, which is the hallmark of research-focused doctoral education, practice-focused programs are characterized by an extensive and integrative practice experience, often termed a residency or "capstone" experience. Tailored to the specialty and interests of the individual student, this practice experience is up to a year in length, and may be even longer for individuals who lack a background of practice experience. A practice-related written product of some kind is expected, and should be defensible when subjected to peer, professional, and possibly public scrutiny. Examples include a portfolio of case studies analyzing patient care provided, an empirical evaluation of a program of intervention, a publishable policy analysis, a business plan for a major clinical project, a publishable analysis of best practices for the care of a particular patient population, or clinical guidelines based on the analysis of published research and other evidence.

Although it was beyond the scope of the task force’s charge to recommend specific content, our analysis of the existing programs and the needs of the health care system and the profession yielded recommendations about content areas that should be considered for inclusion in all programs. These include: (a) scientific underpinnings for practice, including emerging areas of science; (b) organizational and systems contexts for care and management; (c) research and analytic methodologies needed to evaluate, apply, and generate evidence; (d) informatics and the use of information technology; (e) health policy analysis and evaluation; and (f) interdisciplinary collaboration. Finally, it was recommended that all programs include at least one area of advanced nursing practice in which students would specialize. We were not specific about the nature of the specialty area(s), recognizing that in some programs specialties might be designed around specific ANP roles, such as nurse anesthetist or pediatric nurse practitioner, while in others the specialties might be based on clinical populations, rather than roles per se.

Current master’s programs are arguably too credit-heavy; however, academic and professional credibility requires that the practice doctorate not simply be a renaming of what currently is being offered at the master’s level. With regard to both core and specialty content, it is essential that the level of sophistication and complexity of the content provided and the competencies to be demonstrated by graduates be higher and the scope more inclusive. It must be clear that the nurse with a practice doctorate has "attained a greater depth and breadth of knowledge and practice" (Mundinger, 2005, p. 173) than an advanced practice nurse with a master’s degree.

Because they prepare nurses for an advanced level of practice that directly or indirectly impacts patients and patient care, practice-focused doctoral programs must be subject to professional accreditation and governmental regulation. To the extent that the graduates are to be certified for a particular level and scope of practice, these programs may also need approval by specialty organizations. The accreditation and approval processes are essentially analogous to those currently in place for master’s programs that prepare for specialized practice. However, the requirement of accreditation further differentiates practice - from research-focused doctoral programs.

Preparation for Advanced Practice

Probably the most controversial of the decisions made by the task force was the recommendation to upgrade the degree requirement for advanced nursing practice from the master’s to the practice doctorate. The reason for this stance was the firm belief that the doctorate is the appropriate degree to reflect the extent and level of difficulty and sophistication of preparation required for specialized, advanced practice in today’s health care system. The intent of this recommendation was in no way to devalue or make obsolete the master’s credential that is currently the accepted preparation for advanced practice nursing. Rather, it was designed to underscore the complexity of knowledge that must be mastered in order to practice at the highest level. The intent was to be forward-looking and to set a high standard, with the full realization that the shift to the doctorate as the preferred preparation for advanced nursing practice will be difficult, requiring a transition period of approximately ten years. Although a dual-level system will undoubtedly be in existence for a considerable period of time, the goal is to move to the doctorate as the sole advanced practice degree.


Probably the most controversial of the decisions made by the task force was the recommendation to upgrade the degree requirement for advanced nursing practice...

Currently the majority of DNP programs have focused attention on a phased-in approach that begins with the post-master’s level of education. With the exception of the former ND programs, which tend to have multiple entry points, most practice-focused programs presently admit only students who have already earned master’s degrees. Such students generally bring to their doctoral education a wealth of practice experience. Although the doctoral program objectives and expected competencies build upon this level of preparation, they are designed clearly to extend beyond it.

Ultimately it is anticipated that there will be multiple entry points and routes to the practice doctorate as illustrated by Marion, O’Sullivan, Crabtree, Price, and Fontana (2005). For some students who are advanced practice nurses with extensive experience in complex practice arenas, the transition to the doctorate can ideally be streamlined in a way that acknowledges and provides efficiently for validation of terminal competencies. However, since most institutions set minimum credit and residency requirements at the doctoral level, it is unrealistic to expect that a high quality program could be any less than a year in length. The nurse entering the program without master’s preparation or with limited advanced practice experience will require more time to achieve the desired level of competency.

The issues and challenges raised by this recommendation are admittedly many, and it continues to be debated (Dracup, Cronenwett, Meleis, & Benner, 2005). At the individual level nurses who are already practicing as advanced practice nurses will need to decide whether to pursue the doctorate. Although compensation may not increase markedly with the added degree, even the most experienced nurse should benefit from practice-focused doctoral education, because it leads to additional competencies and an expanded world view. Both of these competencies should enrich and improve practice. An expanded repertoire of employment opportunities may become available as employers become aware of the value added by the capabilities of this level of graduate. As noted above, the opportunities for employment in academia should be excellent, given impending faculty shortages. Whether or not faculty who have earned a practice doctorate (versus the PhD) will be tenurable will depend on institutional policy and individual scholarly productivity.


An expanded repertoire of employment opportunities may become available as employers become aware of the value added by the capabilities of this level of graduate.

Institutional challenges cannot be ignored. Nearly all institutions desiring to offer the degree will face the challenge of providing faculty to teach the core and specialty courses, as well as appropriate practicum experiences. Some institutions have chosen to admit some of their own faculty in the first cohort of students, while others are precluded from doing so and are planning inter-institutional collaborations that will allow faculty from one institution to enroll at another. Some are taking advantage of programs that are offered online. The recommendation to upgrade the degree requirement for advanced practice may create some difficulties for some institutions currently offering the master’s degree in nursing, particularly smaller schools that are not chartered to offer doctoral degrees. There is interest in developing models of inter-institutional collaboration that will encourage partnerships between such schools and those that can offer the doctorate. As with any new degree program, institutional resistance to innovation may require skillful negotiation in order to secure approval. The existence of profession-wide positions and standards by AACN and other professional organizations should be helpful in this regard.

Some educators have expressed the fear that the existence of DNP programs will siphon off badly needed enrollment in PhD programs and compromise the development of the science (e.g., Dracup & Brian-Brown, 2005; Dracup, Cronenwett, Meleis & Benner, 2005). As reported in the survey of institutions that offer both research- and practice-focused doctorates, that fear has not materialized. For example, at the University of Kentucky applications to the PhD program increased after the initiation of the DNP program was announced. A likely explanation is that the two types of programs are attracting students from two distinct applicant pools, with different interests and goals.

The move to the practice doctorate as the desired credential for advanced nursing practice has been criticized as contributing to the confusion about nursing education that is experienced by the public, other health professionals, even nurses themselves. Dracup and Brian-Brown (2005) have argued that in the midst of considerable debate and disagreement about requirements for entry into practice, the master’s degree has remained a "beacon of clarity…the degree required for all advanced practice and faculty roles" (p. 279). Notwithstanding the statement is clearly debatable – given the long-standing existence of generic master’s programs and the requirement in many institutions that faculty be doctorally prepared – the practice doctorate could actually result in improved degree clarity if it is established as the only practice-focused doctorate and ultimately as the only preparation for advanced practice.

Recent Developments

The pace of program development since approval of the position paper has been remarkable, suggesting that the practice doctorate will tap an important unmet need in nursing education and practice. Programs have currently been approved in at least 10 institutions (including the four ND and one DNS programs that have already or are about to change the degree offered to the DNP), and the most recent information collected by AACN indicates that over 40 institutions are in the process of developing practice-focused doctoral programs. An accreditation process is being developed.

Two AACN task forces are currently working to develop guidelines that will be useful to institutions developing practice doctoral programs and to licensing and accrediting bodies. The AACN Essentials Task Force is developing an Essentials document that will recommend terminal competencies and content areas for all DNP programs (i.e., the core), as well as faculty qualifications, resource needs, and possible roles of graduates. This essentials document is analogous to those developed for baccalaureate and master’s education. The AACN Task Force on the Roadmap to the Doctor of Nursing Practice has been asked to "identify, assess, and make recommendations regarding academic, practice, and regulatory issues to be addressed in the implementation process. The Task Force also should assess the implications of this change for the full variety of academic organizations that currently provide master's level nursing education" (AACN, 2004). It is thus addressing issues of certification, licensure and regulation, as well as possible routes of progression to the doctorate. During fall, 2005 and winter, 2006, the groups will hold joint regional meetings in Boston, Atlanta, St. Louis, Houston, and San Diego. These meetings are designed to provide the opportunity for widespread discussion and feedback about the documents and recommendations being developed. Various specialty organizations, such as NONPF, are in the process of soliciting input about and developing doctoral-level competencies and suggested content for the specialty component of the programs.

Summary

In this article the practice and educational trends that led to the resurgence of interest in the practice doctorate in nursing were reviewed. The characteristics of existing practice doctoral programs and differences between practice- and research-focused programs were explicated. Potential benefits of the degree for health care and for nursing education were detailed. Several of the issues that were taken into account in the development of the AACN position paper on the practice doctorate were described. These included the scope of the degree, the recommendations regarding a core curricular structure and content areas for inclusion, and the controversial decision to recommend that the DNP be established as the degree for advanced nursing practice.

As we look ahead many issues remain to be resolved, and many challenges remain to be tackled. There is considerable work to be done by individuals and groups in practice, educational, and regulatory arenas. However, if excitement, interest and the number of institutions moving forward to develop DNP programs are valid indicators, then truly the practice-focused doctorate in nursing is an idea whose time has come.

Note: The author gratefully acknowledges the outstanding contributions to the AACN position paper from the individuals who served as fellow members of the AACN Task Force on the Practice Doctorate: Kathleen Andreoli, Jean Bartels, Sandra Edwardson, Catherine Gilliss, Judy Honig, Lucy Marion (NONPF consultant), Lynne Pearcey, Julie Sebastian, Marita Titler, and particularly, Joan Stanley (AACN staff liaison)

Author

Elizabeth R. Lenz, PhD, RN, FAAN
E-mail: Lenz.23@osu.edu

Elizabeth Lenz is Dean and Professor at The Ohio State University College of Nursing. She received a BSN from DePauw University in 1964, an MS from Boston College in 1967, and a PhD from the University of Delaware in 1976. Dr. Lenz is a leading expert in doctoral nursing education, having directed research-focused doctoral programs at the University of Maryland and Columbia University. Between 2001 and 2004 she chaired the AACN Task Force on the Practice Doctorate in Nursing, and currently serves as a member of the AACN Task Force on Essentials of Nursing Education for the Doctor of Nursing Practice.

References

American Association of Colleges of Nursing (2001). Indicators of quality in research-focused doctoral programs in nursing. Washington, D.C.: AACN.

American Association of Colleges of Nursing (2004a). AACN Position Statement on the Practice Doctorate in Nursing. Washington, DC: AACN, accessed 7/20/05 at www.aacn.nche.edu/DNP/DNPPositionStatement.htm.

American Association of Colleges of Nursing (2004b). The Task Force on the Roadmap to the Doctor of Nursing Practice. Accessed 7/20/05 at www.aacn.nche.edu/ContactUs/DNPRoadmapTskFrc.htm.

Berlin, L.E., & Sechrist, K.R. (2002). The shortage of doctorally prepared nursing faculty: A dire situation. Nursing Outlook, 50: 50-56.

Dracup, K. & Brian-Brown, C.W. (2005). The practice doctorate: MRI or total body scan? American Journal of Critical Care, 14: 278-281.

Dracup, K., Cronenwett, L., Meleis, A.I., & Benner, P.E. (2005). Reflections on the doctorate of nursing practice. Nursing Outlook, 53: 177-182.

Lenz, E.R., Mundinger, M.O., Hopkins, S., Clark, J. & Lin, S. (September, 2002). Patterns of nurse practitioner practice: Results from a national survey. Presented at State of the Science Conference, Washington, D.C.

Marion, L.N., O’Sullivan, A.L., Crabtree, M.K., Price, M., & Fontana, S.A. (2005). Curriculum models for the practice doctorate in nursing. Topics in Advanced Practice Nursing eJournal, 5:1 Available: www.medscape.com/viewarticle/500742

Mundinger, M.O. (2005). Who’s who in nursing: Bringing clarity to the doctor of nursing practice. Nursing Outlook, 53: 173-176.

Mundinger, M.O., Cook, S.S., Lenz. E.R., Piacentini, K., & Smith, J. (2000). Assuring quality and access in advanced practice nursing: A challenge to nurse educators. Journal of Professional Nursing, 16(6): 322-329.

Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A.M., Tsai, W., Cleary, P.D., et al. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA: Journal of the American Medical Association, 283: 59-68.

Institute of Medicine. (1999). To err is human: Building a safer health system. Washington, DC: National Academies Press.

Institute of Medicine. (2001). Crossing the quality chasm. Washington, DC: National Academies Press.

Institute of Medicine. (2003). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: The National Academies Press.

Schlotfeldt, R.M. (1978). The professional doctorate: Rationale and characteristics. Nursing Outlook, 26: 302-311.


© 2005 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2005


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