About One DNP

I earned my "terminal practice" degree in nursing from the University of Tennessee Health Sciences Center in a journey of excitement and challenge. It inspired me to advocate for an all encompassing clinical credential rather than continuing the hodgepodge of nonsensical initials. I hope these entries will provide entertainment and insight into the Doctor of Nursing Practice experience, which will soon be the entry standard for all advanced practice nurses.

Sunday, August 29, 2010

Dr. Nurse

This is a paper I wrote a couple of years ago on the history and implications of the DNP.
Dr. Nurse:
Development and Implications of the Clinical Nursing Doctorate
In 2004, the American Association of Colleges of Nursing (AACN) endorsed the Doctorate of Nursing Practice (DNP) degree for entry into advanced practice nursing with full implementation by the year 2015 (Montoya & Kimball, 2007). The decision prompted debate among nurses, physicians, allied health professionals, and consumers concerning the need and usefulness of this clinical doctorate (Chase & Pruitt, 2006). Issues in question include scope of practice, role in healthcare education, economic implications, and impact on the healthcare system. The DNP is a natural progression of the nursing profession allows nurses to attain professional parity, improve patient care based on evidenced based practice and specialization, and influence policy for the enhancement of systems and organizations.
The first clinical doctorate for nurses was developed by Case Western University in 1979 in response to a desire for an advanced clinically focused degree (Royeen & Lavin, 2007). Prior to this time, nurses seeking a higher level of education were limited to research-focused doctor of philosophy (PhD) programs or educational doctorate (EdD). Following Case Western’s example, other universities across the United Sates began to form their own clinical doctorate program, but the degrees varied widely in both curriculum and title. One of the goals of the AACN is to transition the present clinical doctorate programs to the DNP, which allows for a clearly defined curriculum requirements and basis for scope of practice (AACN, 2006).
Another goal of the DNP is to answer the growing trend in other healthcare disciplines that offer or require a clinical doctorate for entry to practice. Established professional doctorates include medical (MD), veterinary (DVM), and dental (DDS). In the past decade, audiologists, nutritionists, occupational therapists, and physical therapists have adopted the clinical doctorate. Laboratory science, nuclear medicine, and physician assistant programs are in development (Royeen & Lavin, 2007). The DNP credential provides professional parity that allows for improved interprofessional communication and collaboration among doctors, psychologists, pharmacists, and other doctoral prepared healthcare professionals.
Several of the AACN goals concern improvement of patient care both through the individual practitioner and system delivery (AACN, 2006). Professionals and consumers are not satisfied to accept tradition as a rational for performing duties. Evidenced based practice, health promotion, development of health care policy for patient advocacy, and transforming healthcare delivery systems through patient care technology and systems are areas in which the DNP serves to improve patient health and outcomes. Clinical expertise in assessment, categorization of disease, and treatment strategy is gained through clinical practice (Burman, Stepans, & Jansa, 2002). This knowledge and experience can be used to evaluate and improve on existing organizational structures and system thinking.
The DNP fills a number of needs that have appeared as a result of a changing healthcare system and population shifts. Longer life spans require healthcare providers to manage multiple and complex illnesses with cultural competence, interdisciplinary collaboration, and advanced knowledge of informatics (Royeen & Lavin, 2007). The DNP graduate in private or collaborative practice as a nurse practitioner is a cost-effective solution to the current shortage in primary care left by physicians moving toward highly specialized and acute clinical areas offering higher levels of reimbursement (Montoya & Kimball, 2007). Consumer knowledge and access to information demands well-educated clinicians current with pharmaceuticals, testing, and medical procedures. In their investigation of clinical decision making with nurse practitioners, Burman, Stephans, Jansa, and Steiner (2002), reveled a tendency to rely on intuition more than scientific method and evidenced based practice in assessment, diagnosis, and treatment of clients. The additional exposure to evidenced based practice that the DNP offers to advanced practice prepares nurses for client inquiry and rational for decision-making. Increased sophistication of technology and expansion of knowledge creates a divide between knowledge and practice that may be rectified by DNP graduates in the role of clinical nurse educators (Montoya & Kimball, 2007). Demands for change in the operation of the healthcare system require policy changes in individual units and hospitals as well as on state and national political levels. DNP graduates with a focus in administration are positioned to influence change due to their direct daily interactions within these systems and knowledge of theories central to and outside of nursing practice.
Proponents of adoption of the DNP as an entry to advanced practice nursing site professional parity and interdisciplinary collaboration, improved competence, and broader base of knowledge, and skills as advantages (Royeen & Lavin, 2007). It is in the interest of the nursing profession to provide advanced clinical preparation in light of the increasing number of healthcare practice doctorates adopting this strategy. It prepares the advanced practice nurse for leadership in the field through experience, brings expert clinicians to education, and provides an alternative to research and educational based doctorates for those that wish to continue in direct care. The hallmark of the DNP is specialization within the larger domain of nursing practice, making the transition from a general practice RN to a specialized DNP a natural progression (AACN, 2006).
Opponents observe this degree does not expand the practice role and increases the current shortage in nursing education due to lack of faculty trained in clinical doctorate teaching (Chase & Pruitt, 2006). Many regard the DNP as a self-serving educational inflation that is expensive without equitable compensation (Royeen & Lavin, 2007). Additionally, the use of the initials DNP imply that the graduate is a nurse practitioner and a title inclusive of education and leadership roles should be adopted. The American Medical Association (AMA) has voiced concern over clinical doctorates in relation to patient confusion, safety and trust. The AMA suggests the DNP is misleading for patients and specifically objects use of the terms doctor and resident in the clinical setting for healthcare professionals not related to medicine or osteopathy (AMA, 2006).
Many similar objections were brought forth and overcome during the conceptualization of the pharmacy doctorate (PharmD) prior to the adoption of the degree as an entry to practice (Montoya & Kimball, 2007). The current MSN programs require more hours than other masters degrees and the DNP adds a significant amount of didactic and clinical education to the pre-established masters programs. The title granted should match the work accomplished. Recognition of doctoral level work does serve the individual but more importantly makes the public aware of the preparation and dedication required to earn their trust as healthcare professionals. Confusion over initials will wane with consumer education, establishment of one degree name for all nursing clinical doctorates, and identification tags required in most healthcare facilities. The term doctor is not the sole possession of those who practice a particular profession but rather is for the social and professional use of those who attain a certain level of education be it research, education, or practice focused.
There remains a concern within the nursing profession over the use of DNP graduates as a substitute for PhDs in nursing education. The DNP is intended for direct practice in the field and is not designed to prepare a faculty member for an academic career in a research extensive or intensive institution (Royeen & Lavin, 2007). Universities with less of a research focus may find themselves relying on both the DNP and PhD prepared nurses to fill the educational shortage. The DNP graduate may be employed in clinical instruction, institutions with a focus on associate or practical nursing degrees, and practitioner focused DNP programs while PhD gradates would continue to serve in the classroom on a BSN and educational or administrative focused DNP. Delineation of teaching duties will likely be resolved on an institutional level with ongoing debate over which degree produces the superior educator.
The research article used in the discussion of nurse practitioner practice was a qualitative design using a constant comparative analysis method (Burman, Stephans, Jansa, & Steiner, 2002). According to the levels of evidence recommendations presented in the Nursing 601 lecture, this is a level four design. Evidence was obtained through clinician interview to investigate clinical decision-making and resulted in a grade B recommendation.
          Change in established institutions does not come without conflict both from within and outside of the system in transition, and the adoption of the DNP is no exception. The nursing profession must progress to remain relevant in an evolving healthcare system. The DNP allows advanced practice nurses to develop expertise in clinical practice, education, and administration, which will provide professional parity and patient confidence not only in title, but also in competence.
American Association of Colleges of Nursing (AACN). (2006). The essentials of doctoral education for advanced nursing practice. Retrieved August 23, 2008, from http://www.aacn.nche.edu/DNP/pdf/Essentials.pdf
American Medical Association (AMA). (2006). Resolution 211 (A-06): Need to expose and counter nurse doctoral programs (NDP) misrepresentation. Retrieved September 2, 2008, from http://www.pacnp.org/files/resolution__211_-_nursing_doctorate.pdf
Burman, M. E., Stepans, M. B., Jansa, N., Steiner, S. (2002). How do NPs make clinical decisions? [Electronic version]. Nurse Practitioner, 27(5), 57-64.
Chase, S. K., & Pruitt, R. H. (2006). The practice doctorate: Innovation or disruption? [Electronic version]. Journal of Nursing Education, 45(5), 155-162.
Montoya, I. D., & Kimball, O. M. (2007). Marketing Clinical Doctorate Programs [Electronic version]. Journal of Allied Health, 36(2), 107-112.
Royeen, C., & Lavin, M. A. (2007). A contextual and logical analysis of the clinical doctorate for health practitioners: Dilemma, delusion, or de facto? [Electronic version]. Journal of Allied Health, 36(2), 101-106.

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