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.
Keywords: ethics, Doctor of Nursing Practice, DNP, ethical principles, nursing education, doctoral education
In the Vol. 10, No. 3 issue of the Online Journal of Issues in Nursing (OJIN) entitled "The Doctor of Nursing Practice (DNP): Need for More Dialogue," Glazer (2005, Overview and Summary section, para. 8) identifies seven "challenging questions" that readers may ponder about the DNP degree. In this column we offer another challenging question: "Is the Doctor of Nursing Practice ethical?" In recent years the pros and the cons of the DNP have been discussed in the literature (e.g., Dracup, Cronenwett, Meleis, & Benner, 2005; Mundinger, 2005), by faculty in nursing programs, by staff nurses, and by nurse members of various professional organizations. This discussion has been precipitated by a position statement published in 2004 by the American Association of Colleges of Nursing (AACN) that is entitled AACN Position Statement on the Practice Doctorate in Nursing.
Yet, this discussion so far is mostly silent in one critical area, ethics, which is the cornerstone of the nursing profession. Thus, we begin what we anticipate will be an ongoing ethical debate about the DNP. We frame this debate around four ethical principles associated with the DNP: (a) social responsibility, (b) respect for persons, (c) do no harm, and (d) justice as fairness.
The ethical principle of social responsibility focuses on social issues that affect the greater good of society. This principle is foundational to how nurses ought to think and act when recommending significant changes in nursing such as the DNP, which affects not only nurses but also the greater society. Fortunately in nursing we have a foundational document—the American Nurses Association’s (ANA) 2003 Nursing’s Social Policy Statement—that makes explicit the ethical principle of social responsibility. According to this document, a social contract exists between society and nursing whereby society grants nursing its authority to practice in return for nursing’s commitment to society regarding matters related to health and the public good. Thus, our mandate to exist and to serve comes from society and not from within our ranks.
We raise three questions about the ethical principle of social responsibility and its relationship to the DNP:
- Why has not a nursing foundational framework related to social responsibility been articulated for the DNP?
- Why has the ANA’s (2003) Nursing’s Social Policy Statement seemingly been ignored in writings about the DNP?
- Would the AACN’s (2004) position statement on the DNP have a different focus if it were grounded in Nursing’s Social Policy Statement?
Regarding questions one and two, we do not know why a nursing foundational framework and Nursing’s Social Policy Statement seemingly were not used by AACN or by other authors writing about the DNP. Were they taken for granted or forgotten, or considered unimportant, irrelevant, or outdated? The answers are not clear. However, some of the authors in the OJIN topic did note nursing’s relationship with society. For example, O’Sullivan, Carter, Marion, Pohl, and Werner (2005) briefly noted that "continued expansion in breadth and depth of the master’s programs is no longer socially responsible" (Impetus for Change section, para. 1). Flinter (2005) briefly noted that social good relates historically to the development of the nurse practitioner and the community health center movements. We argue that brief notations about social good are not enough and that a well delineated philosophy about nursing, social good, and health as they relate to DNP programs would strengthen, or at least broaden, any discussions about the DNP.
Regarding question three, we believe that the AACN’s (2004) Position Statement would have a different focus if it were grounded in Nursing’s Social Policy Statement. Whereas the primary focus of the 2004 AACN Position Statement on the Practice Doctorate in Nursing is on advanced practice nurses (APN) and the preparation of them, the primary focus of Nursing’s Social Policy Statement is on the recipients of nursing care. For the AACN focus, the important questions are: (a) How does one define APN? (b) How does one define the DNP? (c) What are the appropriate curricula and other requirements needed to confer the DNP? For the social policy focus, however, the important questions are: (a) How does one define the recipients of nursing care? (b) How does one determine the health care needs of these recipients? (c) How does one deliver the necessary nursing care to meet these needs? We believe that one cannot address the DNP without also addressing the recipients of nursing care and how DNP nurses would deliver care to them. Thus, we recommend that increased thought be given to the recipients of nursing care and the social responsibility due them by DNP nurses. The degree to which the ethical principle of social responsibility is met by DNP nurses is also the degree to which this aspect of the DNP will be ethical or not.
Respect for Persons
The principle of respect for persons is defined in provision one of the American Nurses Association’s (ANA) 2001 Code of Ethics for Nurses with Interpretive Statements: "The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems" (p. 7). Regarding the recipients of care, the ANA (2001) Code addresses respect for persons as considering "the needs and values of all persons"... (p. 7); as considering "an individual’s lifestyle, value system and religious beliefs..." (p. 7); as honoring persons "irrespective of the nature of the health problem" (p. 7); and as honoring persons’ "right to self-determination" (p. 8). If nurses practice with the preceding principles as priorities, the ethical principle of respect for persons as recipients of care will be honored. But respect for the recipients of care is only half of the story.
The ANA (2001) Code also discusses the principle of respect for persons as it relates to colleagues and others:
The nurse maintains compassionate and caring relationships with colleagues and others.... This standard of conduct precludes any and all prejudicial actions, any form of harassment or threatening behavior, or disregard for the effect of one’s actions on others. (p. 9)
The ethical principle of respect for persons as colleagues also precludes inattention, sarcasm, interruptions, put downs, feigned listening, selective listening, ignoring, and the like, especially when differences of opinion occur. Regarding this point, we raise the following question: When such differences of opinion do occur, how should the principle of respect for persons be honored? To address this question, we examine some pro and con statements about the DNP found in the Vol. 10, No. 3 issue of OJIN.
Pro: "The move to the practice doctorate is no longer in question for advanced practice nursing and particularly for NPs of the future" (O’Sullivan et al., 2005, Conclusion section, para. 1).
Con: "Specifically the proposed DNP as the terminal degree for clinical nurse specialists (CNSs) presents a troublesome use of resources" (Fulton & Lyon, 2005, Impact on Educational Resources section, para. 4).
Pro: "This [move to the practice doctorate] is an exciting time in the history of nursing education. NPs will at last be on parity with the other health professions and can continue to demand a place at the policy table" (O’Sullivan et al., 2005, Conclusion section, para. 1).
Con: "The time involved in all these dialogues, debates, approvals, and changes [related to the DNP] is time taken away from the more vital discussion about the quality of care in the healthcare system" (Meleis & Dracup, 2005, Timing section, para. 4).
Pro: "The membership of the task force [AACN Task Force on the Practice Doctorate in Nursing] 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" (Lenz, 2005, AACN Task Force on the Practice Doctorate in Nursing section, para. 1).
Con: "It is imperative that the entire nursing community―all stakeholders―participate in meaningful dialogue about the practice doctorate specifically and the future of nursing education in general. Previous discussion forums about the DNP sponsored by the AACN have been limited . . ." (Fulton & Lyon, 2005, Conclusion section, para. 1).
The preceding quotes demonstrate honest, respectful, and compelling differences of opinions among colleagues and, as such, are in accord with the ethical principle of respect for persons. In fact, the ANA (2001) Code of Ethics for Nurses with Interpretive Statements notes that "sound ethical decision-making requires the respectful and open exchange of views [italics added] between and among all individuals with relevant interests" (p. 19). When the preceding does not happen, then real or potential problems with respect for persons occur. To resolve problems of disrespect for colleagues as persons, we suggest careful, thoughtful, attentive listening to them without interruption or annoyance because their ideas are different from our own. The degree to which the ethical principle of respect for persons is met by colleagues, especially those colleagues most invested in the DNP, is also the degree to which this aspect of the DNP will be ethical or not.
Do No Harm
According to Beauchamp and Childress (2001), the principle of do no harm includes protecting persons from harm, not harming them, and providing benefits to them. Such preclusion of harm is also supported by the ANA (2001) Code of Ethics for Nurses. Specifically, two provisions of the Code primarily focus on the do no harm principle. Provision 2 states that "the nurse’s primary commitment is to the patient, whether an individual, family, group, or community" (p. 4). Provision 3 states that "the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient" (p. 4). Thus, the question we raise is this: How might the 2004 AACN Position Statement on the Practice Doctorate in Nursing harm or potentially harm patients?
Harm might occur, for example, when inadequate data exist to merit DNP programs. Most ethical decision-making frameworks stress the need for accurate, current, and adequate information gathering before an ethical decision can be made. The reason is simple: These data are vital to sound decision making and, thus, a prerequisite to quality of ethical outcomes.
According to the 2004 AACN Position Statement on the Practice Doctorate in Nursing, the Task Force conducted pertinent literature reviews, spoke to key persons and groups involved with current DNP programs, formed collaborative relationships, and provided for open discussion about the DNP at three AACN sponsored events. Despite these AACN efforts, in 2005, the National Association of Clinical Nurse Specialists (NACNS) expressed several concerns about the Position Statement in their White Paper on the Nursing Practice Doctorate. These concerns focused on the "nursing profession" (p. 2), "education" (pp. 2-3), "patient safety" (p. 3), "economic issues" (pp. 3-4), "development of the DNP" (p. 4), "nurse practice acts" (p. 4), and "ongoing/implementation concerns" (p. 4).
The NACNS also were concerned about data gaps. Here are three examples:
- "There are no studies showing that doctorally-prepared advanced practice nurses have better outcomes than master’s-prepared advanced practice nurses" (p. 2).
- "It is unclear how the proposed DNP will contribute to increased patient safety as there have been no studies done to support this premise" (p. 3).
- "It is not known if DNP-prepared advanced practice nurses will be affordable to employers and third party reimbursers" (p. 3).
Some of these preceding data concerns also have been addressed by several OJIN authors (e.g., Cartwright & Reed, 2005; Fulton & Lyon, 2005; Meleis & Dracup, 2005) in the Vol. 10, No. 3 issue on the DNP. Therefore, we recommend continued purposeful data gathering and synthesis throughout the planning, implementing, and evaluating stages of the DNP. The degree to which the ethical principle of do no harm is met by nurses responsible for these stages of the DNP is also the degree to which this aspect of the DNP will be ethical or not.
Justice as Fairness
The ethical principle of justice means giving persons what they are due or owed. Herein we are focusing on justice as fairness as it relates to access to and distribution of scarce resources. The 2001 ANA Code of Ethics for Nurses with Interpretive Statements notes both access and distribution:
The nurse has a responsibility to be aware not only of specific health needs of individual patients but also of broader health concerns such as world hunger, environmental pollution, lack of access to health care [italics added], violation of human rights, and inequitable distribution of nursing and health care resources [italics added]. (p. 23)
Regarding the DNP and the ethical principle of justice as fairness, we raise this question: How is justice as fair access to and fair distribution of scarce resources addressed by AACN (2004 AACN Position Statement on the Practice Doctorate in Nursing), by NACNS (2005 NACNS White Paper on the Nursing Practice Doctorate), and by OJIN (Vol. 10, No. 3 issue on the DNP)?
In the background section of the 2004 AACN Position Statement on the Practice Doctorate in Nursing, the authors cite the Institute of Medicine’s (2001) report that "calls on all health care organizations and professional groups to promote health care that is safe, effective, client-centered, timely, efficient, and equitable [italics added]" (p. 6). The AACN authors, however, did not define equitable. Likewise, in recommendation 1, of the 2004 AACN Position Statement, the authors specified the need for an "increased supply of faculty for clinical instruction" (p. 8), but they did not make explicit how the increased supply of nurse faculty relates to justice as fairness.
According to the 2005 NACNS White Paper on the Nursing Practice Doctorate, "Some existing CNS programs, as well as other advanced nursing programs, may need to close because they are not permitted by state statue to offer doctoral education [such as the DNP] or may lack the fiscal or faculty resources" (p. 3). The NACNS White Paper also addresses another degree issue: "Potential nurse scientists may opt for the DNP as opposed to traditional PhD programs, thus the DNP could compete against the PhD for scarce resources, reducing the number of nurse scientists..." (p. 2). Like the AACN authors, the NACNS authors did not make explicit the relationship between scarce resources and justice as fairness.
The following three OJIN articles on the DNP, like the preceding documents, also do not make explicit how scarce resources relate to justice as fairness. Lenz (2005) addressed the issue of under-credentialing of APN. By this she meant that the knowledge and skills required of APN have become increasingly complex. Consequently, the credits required for an advanced practice master’s degree in nursing often surpass the credits of other disciplines. Is this fair? Are other options available? Lenz supports the DNP as the other option. But will justice be served if students do not have fair access to DNP programs?
O’Sullivan et al. (2005) also supported Lenz’s (2005) concern about the continued length of master’s programs for APN. In addition, they addressed the issue of workforce shortages; that is, the demand for health care providers is greater than the supply. Providers then become scarce resources. How are these scarce resources to be distributed? Although O’Sullivan et al. see the DNP as a way to increase workforce shortages, they did not discuss the underlying ethical principle of justice as fair distribution.
Cartwright and Reed (2005), respectively, a university president and a senior administrator at a large public institution, are well aware of the problems of scarce resources; however, they appear less aware of the underlying ethics of justice as fair access to and fair distribution of these resources. They (2005) stated, "Of particular importance are overcoming policy concerns that relate to the allocation of limited public funds for doctoral education…." (Abstract section, para. 1). They also note that in Ohio money for doctoral education was recently capped because the state believed that undergraduate education was underfunded and doctoral education was overfunded.
The preceding discussion about the DNP and justice highlights examples of how the ethical principle of justice as fair access to and fair distribution of scarce resources are implicit, rather than explicit, in the 2004 AACN Position Statement, in the 2005 NACNS White Paper, and in the Vol. 10, No. 3 issue of OJIN. While acknowledging that the ethics of justice are embedded in these documents, we call for a fuller and more active discussion and debate that makes the ethics of justice explicit. Discussion and debate are important because if scarce resources are viewed only in explicit financial terms, ethical outcomes may be neglected. The degree to which the ethical principle of justice as fairness is met regarding the DNP is also the degree to which this aspect of the DNP will be ethical or not.
Summary and Conclusion
While a healthy debate has been started about the pros and the cons of the DNP, the ethics related to this new degree rarely have been noted and certainly not fully debated. To start this debate, we discussed four ethical principles associated with the DNP: (a) social responsibility, (b) respect for persons, (c) do no harm, and (d) justice as fairness. During our discussion of these issues, we have raised the question of whether or not the DNP was ethical. In our minds, the DNP is presently in a malleable state and, thus, opportunities still exist for key decisionmakers in nursing to ground the degree in ethics and to make the ethics explicit, or for key decisionmakers in nursing to discuss the degree and write about it without regard for or conscious awareness of ethics. Ultimately, the degree to which the DNP meets ethical principles, as well as other ethical considerations, is the degree to which the DNP will be ethical. The decision is up to us collectively as faculty, staff, and members of professional associations to ethically examine and decide, "Is the DNP ethical?"
Mary Cipriano Silva, PhD, RN, FAAN
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, PhD, RN.C, CNS
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.
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© 2006 Online Journal of Issues in Nursing
Article published March 20, 2006