Advancing practice inquiry: Research foundations of the practice doctorate in nursing

Advancing practice inquiry: Research foundations of the practice doctorate in nursing Diane Magyary, ARNP, PhD JoAnne D. Whitney, RN, PhD, CWCN, FAAN Marie Annette Brown, ARNP, PhD, FAAN

The University of Washington Doctor of Nursing Practice program entails 3 curricular dimensions: advanced practice, leadership, and practice inquiry. In this article, the practice inquiry dimension is discussed and defined as a type of clinical investigation that closely aligns with the realities and complexities of everyday practice by advanced practice nurses (APNs). The advancement of APNs’ practice inquiry competencies is timely for its interfaces with the national scientific agenda’s emphasis on translating science to clinical practice, health care delivery systems and policy. A framework for conceptualizing a practice inquiry curriculum and competencies is proposed. In addition, the divergent and convergent comparisons with Doctor of Philosophy (PhD) nursing programs are discussed, with emphasis placed on potential collaborative clinical research endeavors.

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he health of the nation and the delivery of health care are in a crisis.1–3 Widespread disparity in the safety and quality of health care has been documented across urban and rural communities and throughout the private and public health care systems such as hospitals, community clinics, and public health departments.4 The response to the health care crisis will require a fundamental change in how health status, health care delivery, and health care reimbursement are conceptualized and managed based on scientific evidence.1,5 The reformulation of health care necessitates concomitant changes in the educational process of health care professionals. The emergence of Doctorate of Nursing Practice (DNP) programs is timely and

Diane Magyary is a Professor, Psychosocial and Community Health Department at the University of Washington School of Nursing, Seattle, WA. JoAnne D. Whitney is a Professor, Biobehavioral Nursing and Health Systems at the University of Washington School of Nursing, Seattle, WA. Marie Annette Brown is a Professor, Family and Child Nursing at the University of Washington School of Nursing, Seattle, WA. Reprint requests: Dr. Diane L. Magyary, University of Washington, Psychosocial and Community Health, Seattle WA 98195-7263 E-mail: [email protected] Nurs Outlook 2006;54:139-151. 0029-6554/06/$–see front matter Copyright © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2006.03.004

situated to shape the anticipated reformulation of health and health care delivery, assuring equitable access to quality health care. The future socialization and education of advanced practice nurses (APNs) need to reflect innovative ways to conceptualize, deliver and evaluate health care— honoring the substantive core of nursing science, theory and practice. The national dialogue to move the education of APNs to a practice doctorate offers an exciting opportunity for the nursing profession to enhance the bridge between science and practice. As nurses become more advanced and sophisticated in their clinical knowledge and competencies, they will, on a parallel level, be required to become more sophisticated in approaching their practice with a reflective and inquisitive orientation; addressing clinical questions derived from the full array of preventative, acute and chronic health care practice patterns, service models and policy formulation. Health care professionals are challenged and held accountable in achieving a safe, effective, patientcentered, timely, efficient and equitable health care system for the 21st century.1 Through this accountability process, APNs are positioned to be vital players in how basic scientific knowledge and technological advancements are translated to the routines of daily practice and health care delivery systems. They will ultimately contribute substantively to transforming health care for the 21st century. On January 24th, 2005, the University of Washington School of Nursing voted to offer a practice-oriented doctoral degree. The documents Proposal to Establish a Practice Doctorate in Nursing at the University of Washington6 and Conceptual Underpinnings of the DNP Program and Curriculum7 delineate the 3 main curriculum components (advanced practice, practice inquiry, and leadership) and outline the rationale, program objectives and curricular threads for each of the 3 components. The curricular component (practice inquiry) is addressed in this article, whereas the other dimensions (advanced practice and leadership) are addressed in the referenced companion articles.8 –10 In this article, the authors address the critical importance of the dimension of practice inquiry and its opportune interface with national research agendas and initiatives. Practice inquiry refers to the type of clinical M

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(National Institute of Child Health and Human Development),19 and Translating Research into Practice (Agency for Healthcare Research and Quality).13 The National Institute of Nursing Research (NINR) has aligned efforts with many of these initiatives such as the NIH Roadmap.20

investigations that interface closely with everyday practice by advanced practice nurses (APN). A practice inquiry conceptual framework and curriculum are proposed. In addition, salient practice inquiry competencies are identified that are realistic and consistent with graduates of a practice-intensive doctoral program and the desire to focus primarily on practice upon graduation. The divergent and convergent comparisons with PhD programs are discussed, with emphasis placed on potential collaborative clinical research endeavors jointly carried out by PhD- and DNP-prepared nurses. Finally, a DNP curricular evaluation plan is briefly addressed. In this article, the word “practice” encompasses the provision of health care services, programs and service systems to individuals, families or populations, as well as health care policies that dictate service parameters.

Collaborative Partnership-Building Each of the translational science-to-practice initiatives calls for dramatic cultural, organizational, and strategic changes in how clinical and translational research is conducted and eventually implemented to improve the health care of this nation and the world.11,17–20 The challenge of interfacing science with practice is complex and requires creative and multifaceted solutions generated by investigative teams of collaborators who offer diverse perspectives and expertise, often reflective of an interdisciplinary perspective. The terms “partnerships,” “alliances,” “networks,” and “collaboration” are frequently used when describing the emerging vision for conducting clinical and translation investigations. The various national institutes and federal agencies have jointly sponsored efforts to enhance infrastructure capacity for conducting practice research through collaborative partnership-building.11,17–20 Often, these collaborative partnerships bring together the collective efforts of academic-based researchers with key community-based stakeholders including clinicians, administrators, patients, and policy analysts.21–23 Clinicians and administrators are critically positioned to integrate and evaluate the latest scientific developments with the complexities and realities of clinical practice and service system delivery models.16,24 A growing consensus exists that collaborative efforts enhance the effective translation of science to practice in a timely, sustainable, and effective way.25,26 Different collaborative frameworks and structures are appropriate for different types of investigations, plus collaborative process skills become vital to coalesce divergent interests, perspectives, and expertise to advance clinical and translational research. Organizational support and resources are vital to assure successful collaborative investigative endeavors.27

National agenda and initiatives Translation of Science to Clinical Practice, Health Care Delivery Systems and Policy The past 2 decades have been characterized by a proliferation of scientific discoveries and technological advancements. And yet, a substantial disparity exists between what is scientifically known and what is actually incorporated into the daily routines of clinical practice and health care service management.1,11 Subsequently, the disparity between scientific knowledge and clinical practice results in wide variations in the quality, safety, accessibility, and cost of health care.1,12 Estimates indicate that often 1 or 2 decades are required before research findings are translated into sustainable improvements in health care, especially in communitybased outpatient settings.13 Patients with chronic health conditions are especially vulnerable for not receiving the quality of care in accordance with standards of practice.13,14 Disparities in health care are particularly visible in inner urban and rural poor communities as well as minority populations.4 Just in the last decade, substantial theoretical, empirical, and fiscal emphasis has been placed on how to accelerate the translation of basic and clinical scientific advancements to routine practice settings so that rapid adoption is sustained and evaluated over time. From 2000 –2005, the Institute of Medicine Clinical Research Roundtable (CRR) engaged a broad audience in solution-focused discussions on how to move scientific knowledge and technological innovations along a “research to practice continuum” that ultimately improves the health of our nation and the world.15,16 In addition, prominent federal initiatives have been issued to address translational challenges such as the Re-Engineering the Clinical Research Enterprise (National Institute of Health [NIH] Roadmap),17 Translating Behavioral Science into Action (National Institute of Mental Health),18 Biobehavioral Development: From Cells to Selves 140

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Educational Implications The emphasis on translating science to practice and the emphasis on collegial collaboration requires educating a “workforce” to appreciate and successfully engage in these types of investigative endeavors. Sung et al16 noted that “developing an adequate clinical research workforce remains a challenge across the spectrum of all types of health care professionals.” Initiatives to build an adequately educated workforce have primarily promoted the career pathways of scientists devoted to clinical research.16,21,22 However, the trend to expand investments in educating clinical scientists needs to have a complementary educational investment O

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in socializing and educating practitioners and administrators to value and engage in clinical and translational investigative endeavors. The very nature and success of translational scientific endeavors require clinicians and administrators knowledgeable about ethical, conceptual, and methodological issues related to the translation of science to practice and to evaluate the translational impact on the quality of health care.16,28 –30 Clinicians who provide clinical care offer a critical perspective on the design, implementation, and evaluation of quality improvement endeavors toward translating science to practice. And yet, many clinicians across all disciplines are neither socialized to value nor educated to apply the latest methodological advancements in translational and health care quality research.1,16,30 Clinical and translational research curriculums are being increasingly introduced into graduate programs that award professional degrees.1,28,30 Zerhouni, NIH Director, acknowledges that strengthening clinical research expertise of not only academic-based researchers but also community-based clinicians and administrators lay the foundation for innovative partnerships and collaborative endeavors and broadens the number, scope and relevance of clinical and translational research initiatives.31 The PEW Health Care Professions Commission concluded its decade-long (1989 –1999) work by highlighting clinical competencies for the 21st century. Several of these competencies relate to interdisciplinary innovative efforts to translate science and evaluate the impact on quality of care and health outcomes, thereby contributing to the accountability and advancement of health care.30 Teams of providers value their collegial network sharing perspectives and expertise to creatively and proactively advance change on behalf of patients, families, and communities.

The full spectrum of clinical research Clinical Research Domains In response to the growing acknowledgement of the translational gap between science and practice, emphasis has been placed on articulating a more inclusive conceptual framework for thinking about clinical and translational research and methodologies. Recently, the National Institute of Mental Health (NIMH) jointly convened a workgroup of scientists, clinicians, policymakers, and lay advocates who generated the report Bridging Science and Service.32 Although the report focuses on mental health clinical research, the proposed conceptual framework offers generic ways of thinking about clinical research that emphasizes the dynamic and interconnected interplay among the domains of “efficacy research, effectiveness research, large-scale service system type research and practice research.”32 The proposed clinical research domains are not discrete per se, but each category emphasizes particular purposes,

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designs, and methods. Each design and method has its strengths and limitations for examining different types of clinical questions. Traditionally, funding sources such as NIH have placed priority on efficacy research that examines the cause-effect relationship between treatment and outcomes, often using complex randomized clinical trials with homogeneous samples and controlled settings.32 Recently, an increased emphasis has been placed on effectiveness research that addresses whether efficaciously proven interventions maintain their benefits when applied to diverse populations under more naturalistic settings.29,32 Theoretical models and evidence suggest that no one health or behavioral intervention is effective under all circumstances nor generalizable to all populations.1,4,5,33,34 Thus, clinically relevant questions entail subgroup analyses asking who is most likely, versus least likely, to benefit from an intervention under what type of circumstances. The third clinical research domain is service system research that typically addresses large-scale organizational, delivery, utilization, financial, and policy questions in realtion to safety, accessibility and quality care issues.32 For example, many studies that examine the relationship between in-patient nursing practice and staffing patterns and the impact on patient safety and quality of care are “service system research” that has resulted in the generation of magnet hospital criteria.35,36 The fourth domain of clinical research is practice research that captures the type of research designs and methods that are relevant and particularly germane to examine clinical questions related to the complexity of everyday clinical situations. Practice includes those features of routine care that clinicians typically employ on a routine basis. Practice research examines the differential provision of treatments or services to clinical populations within health care systems, examining clinical profiles and evaluating patterns of variations in health care accessibility, safety, quality, and outcomes—including the analysis of health disparities.32 As discussed in the Bridging Science and Service report, the purpose of practice research is not so much to isolate the causal links between interventions and outcomes or to generalize intervention effects to service settings, but to examine variations in care and evaluate methods by which evidence-based best practices and empirically supported therapeutics are introduced, modified, and adapted to the routines of clinical practice and service systems, with consideration given to provider expertise, consumer’s preferences, economic constraints, service delivery support systems, and organizational structures.32

Practice Inquiry Areas Practice Research encompasses the research inquiry areas of translational and evidence-based practice, clinM

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ical epidemiology and informatics, and quality of care.32 Translational/dissemination research and evidencebased practice have become common health care nomenclature. While there is a sense of urgency in the timely translation of evidence-based knowledge to realworld clinical settings, the scientific knowledge base for translational endeavors is still vastly underdeveloped, particularly in view of the complexities and realties of everyday practice settings.25,37,38 Dissemination research initiatives focus on generating new knowledge, technology, and implementation strategies that accelerate and sustain the integration of scientific information with everyday practice. Translational strategies have focused on health care providers, organizational cultures, health care delivery systems, policy enactment, and even consumers of health care.25,38 The emergence of the increasingly popular term “evidence-based practice” entails the active clinical process whereby best-available research evidence is integrated with clinical expertise and patient values.1,39 – 41 Best research evidence encompasses all forms of systematically acquired knowledge such as scientific studies, clinical practice guidelines and protocols, systematic reviews and evidence reports by expert panels.1,24,41,42 Clinical expertise entails the clinician’s sense of judgment, competency, and experience in considering the applicability of evidence to a particular patient.1,24,41 Patient characteristics entail factors such as values, preferences, and social-cultural context.1,24,41 The interplay among the application of best research evidence in consideration of the clinician’s expertise and patient characteristics requires further research.24 The emphasis on evidence-based practice and empirically supported therapeutics has generated a proliferation of clinical best practice guidelines and protocols available through internet access clinical resources such as National Guideline Clearinghouse43 and its companion web-site National Quality Measures Clearinghouse44 and Quality Tools.45 Systematic reviews are available through collaborative endeavors such as the Cochrane Collaboration46 and Evidence Based Practice Centers Programs.47 The proliferation of systematic reviews, evidence-based clinical guidelines, and empirically based therapeutics has only recently been accompanied by the generation of criteria for the selection, appraisal, and the judicious application of evidence to practice.24,48 –50 Evidence-based clinical guidelines cannot be applied without understanding the validity of their scientific underpinnings and their application to individual patients. Berg et al51 highlights the critical appraisal process when teaching how to translate clinical guidelines to practice; “using guidelines in education must teach not only how to choose a guideline, but when to apply it, to whom, and, importantly, when its use would be inappropriate? Too often, 142

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the translation of best practice guidelines occurs without a systematic evaluation of the cost-effectiveness on patient health outcomes, provider practice patterns, and health care utilization patterns.29,52 Emerging evidence suggests that clinical practice guidelines, coupled with supportive technology such as computer-based decision support and reminder systems, has improved patient care, especially if patient preferences and values are considered.1,53 Clinical Epidemiology and Informatics concepts and methods have proliferated with recent advancements in clinical information systems, patient registries, and electronic records. Nurses increasingly have access to technologically advanced clinical information systems that aggregate data across individual patients so that group-based clinical profiles, practice patterns, and variations can be identified, analyzed and even compared against regional and national benchmark norms and databases. Health Care Quality research, including the domain of outcome research and effectiveness, has become more salient and sophisticated over the years. The advancements in health care quality research is reflected in newly developed conceptual frameworks, scientific underpinnings, analytical methods, statistical strategies, and organizational infrastructural support to examine the effects of practice and service patterns on health outcomes.54,55 Emergent health care quality improvement models place emphasis on the meaning and analysis of the concepts “variation and disparity” analyzed within and across practice settings. Advancements in information technology allow for practice variation patterns to be identified and understood— perhaps reflective of patient complex health status, personal preferences or cultural values or, perhaps, reflective of deviation from normative standards that result in compromised care and poor health outcomes.1,54 Analytical methods, design and statistical strategies have proliferated—referenced by terminology such as minimal data sets, profiling, run charts, scorecards, dashboards, health indicators, performance measures, and comparison analyses such as benchmarking.54 Clinicians need to bring their perspectives and values to health care quality improvement research to assure the generation of meaningful data. Timing, application, and interpretation of quality improvement concepts methods and results require an interdisciplinary effort inclusive of clinicians who understand the daily process of practice.56,57 Clinicians in small private practices are even engaging in health care quality improvement efforts.58 The full spectrum of clinical research, including practice research, is being increasingly recognized, even by federal institutes that typically fund more basic and clinical trials. For example, NIMH extramural programs reorganized effective October 2004 with an increased emphasis on service and intervention reO

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search, including the dissemination and translation of research findings to practice.59 The new NIMH Division of Service and Intervention Research and the Division of Adult/ Pediatric Translational Research and Treatment Development developed foci that are broad and inclusive of areas such as clinical epidemiology and the dissemination and implementation of evidencebased intervention into service settings.59 The new conceptualization of intervention research includes quality of care and dissemination studies that examine how to modify and adapt efficaciously proven interventions to fit with the realities of daily practice. Differential responses to interventions are examined with respect to the heterogeneity in clinical epidemiological profiles of patients, providers, service systems and settings—including factors that influence disparity in the quality, delivery and accessibility of health care.

Practice inquiry curiculum Processes and Domains In winter of 2004, the term “practice inquiry’” was chosen by the Practice Doctorate Task Force (PDTF) to capture the essence of the clinical investigative focus of the DNP. Practice inquiry is an ongoing, systematic investigation of questions about nursing therapeutics and clinical phenomena with the intent to appraise and translate all forms of “best evidence” to practice, and to evaluate the translational impact on the quality of health care and health outcomes. Through the process of translating science to practice, APNs observe, describe, understand and appraise clinical phenomena and their interface with empirically and theoretically based knowledge. The investigative focus integrates scientific curiosity and inquiry with the realities of everyday practice. Typically, the investigative process reflects a collaborative effort carried out with colleagues and, depending on resources, with scientists. The investigation contributes to the collective advancement of nursing science, theory, and practice. The term “practice inquiry” portrays clinical research competencies that are integral with advanced practice and, thus, relevant to learn during a practiceintensive doctoral program. Although APNs have contributed to efficacy, effectiveness and service systems research investigative teams, the APNs are more likely to engage in the realm of practice research on a daily basis that closely integrates inquiry with their everyday practice. If investigative endeavors are relevant and informative to APNs’ practice, then APNs are more likely to sustain their interest and pursue practice inquiry opportunities throughout their careers. Practice inquiry becomes an integral part of their practice. As Benner and Leonard60 stated, “the goal is for practice to be a self-improving practice through science, experiential clinical learning and correction . . . self-improving practice depends on experiential learning and clinical

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inquiry of every practitioner in the every day course of their practice.” Student DNP learning objectives and their interface with the practice inquiry curricular threads are listed in Table 1. The term “practice inquiry” encompasses a broad set of inter-related conceptual domains and processes that are explained below and visually illustrated in Figure 1. Scientific Curiosity and Scientific Thinking: Although the DNP program primarily focuses on the mastery of advanced clinical competencies, the process of clinical mastery itself requires an inquisitive stance towards one’s practice. Graduate study is a process whereby clinicians are socialized to be intellectually curious about their practice and know how to frame compelling questions about clinical phenomena as experienced and observed in practice. The challenge is to sustain a scientific attitude of mindfulness and reflection despite the daily demands and rigors of everyday practice. Advanced Practice Nurses are educated to critically appraise assumptions and evidence underlying practice habits as well as innovations. The APN with a curious and inquisitive mindset toward his/her practice is positioned to be an ideal collaborative partner on clinical investigative endeavors to advance nursing science, practice, and health care in general. Scientific Collaborative Process: The delivery of health care is increasingly carried out by interprofessional provider teams who share perspectives, knowledge and competencies.30 Concomitantly, clinical investigative projects often entail a collective effort carried out by an inter-professional team of clinicians, information analysts, administrators and, perhaps, scientists— depending on the complexity of the study. And yet, very few graduate programs prepare professionals to engage successfully in collaborative partnership-building.30 The process of engaging in collaboration requires an appreciation and understanding of the process itself as well as a set of competencies that include knowing how to cultivate and sustain partnerships that embrace diverse perspectives, share knowledge and expertise, negotiate responsibilities, and arrive collectively at decisions. In addition, collaborative teams need to be resourceful in negotiating institutional sanctions and garnering resources. Nursing Perspective, Theory, Science and Clinical Phenomenon: Advanced Practice Nurses bring nursing perspective, knowledge, and expertise to interdisciplinary investigative endeavors. Clinical and translational questions are grounded from a conceptual framework that reflects nursing theory, substantive knowledge, and empirically-based evidence. With their comprehensive perspective on health and illness, APNs are ideal for not only nominating topics for clinical guideline development, but also participating on expert panels that generate clinical guidelines. In addition, APNs are M

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Table 1. Student Learning Objectives Interface with Practice Inquiry Curricular Threads Learning Objective

Practice Inquiry Thread

1. Provide advanced nursing care to individuals, families, communities and/or clinical populations

2. Create, manage and evaluate innovative programs and practices of care for diverse populations.

3. Appraise and utilize current technologies to advance quality and accessibility of care. 4. Critique and selectively translate science to guide clinical decision-making and program development. 5. Demonstrate advanced clinical investigative competencies.

6. Evaluate and influence health care policy and systems.

7. Provide leadership and inter-professional collaboration in multiple health care arenas. 8. Evaluate and influence accessibility and quality of care across diverse, underserved, and vulnerable populations.

In collaboration/consultation w/others, use caseload-tracking registries and “clinical epidemiological” methods to generate and interpret clinical data patterns. In collaboration/consultation w/others, examine one’s clinical practice setting for variation in health care effectiveness by examining mediating and moderating factors. Critically apply and evaluate evidence-based clinical guidelines to enhance quality and accountability in clinical patterns of care at one’s clinical practice setting. In collaboration/consultation w/others, apply different designs, methods and analytic strategies to evaluate practices of care and program implementation and effectiveness across diverse populations within one’s practice setting. In collaboration/consultation w/others, evaluate usefulness of technology to advance the quality, accessibility and cost of care. In collaboration/consultation w/others, develop and evaluate models and methods of disseminating and sustaining appropriate evidence-based clinical guidelines in clinical practice and program development. In collaboration/consultation w/others, evaluate evidencebased clinical guidelines impact on the quality of care (safe, effective, patient/family/community-centered, timely, efficient and equitable). In collaboration/consultation w/others, critique and evaluate how organizational, structural, financial and policy decisions impact cost, quality, and accessibility of health care at one’s practice setting. In collaboration/consultation w/others, test and evaluate new practice models for the 21st century applicability to one’s practice setting. Evaluate effectiveness of personal leadership style across multiple health care arenas. In collaboration/consultation w/others, test strategies to understand and address variance within health care services and outcomes that account for health disparity.

ideally positioned to translate, evaluate and adapt new evidence into clinical practice, thereby advancing translational knowledge but also knowledge of the actual clinical phenomenon under study. Clinical Observations and Discourse: Knowledgegeneration itself often begins with clinical questions about carefully observed clinical phenomena not yet empirically documented or well-studied. How to frame researchable questions generated from clinical observations and discourse is an essential practice inquiry competency. Clinical observations discrepant with habitual ways of knowing and doing may reveal new insights into clinical phenomena that have received limited or no empirical inquiry. These types of revelations may generate questions that beg to be answered through rigorous scientific investigation. In addition, 144

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APNs have detailed conversations with patients and families who convey health beliefs, values and interpretations of health events and conditions. This access to such rich, narrative data enhances understanding about clinical phenomena and can provide a unique perspective relevant to why certain clinical interventions have therapeutic value. Certain interventions are known to be effective, but the underlying mechanisms that account for effectiveness are not always clearly understood.33,34 Scientific Focus: The central focus of practice inquiry is placed on evidence-informed nursing practice. The term “evidence-informed” practice was chosen rather than evidence-based practice because inform connotes a complex and dynamic process whereby empirically-based evidence is appraised and integrated O

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Figure 1. Practice Inquiry Curricular Processes and Domains

with theoretical and substantive nursing knowledge as well as clinical experiential knowledge and observations. Evidence-informed practice is evaluated for its impact on quality of care as referenced by the 6 health care improvement aims for the 21st century: safe, effective, patient-centered, timely, efficient, and equitable.1 In addition, the broader focus on quality of life and daily functioning in the context of patient, family— and even community— considerations, preferences and values is critical. Clinician involvement in quality health care studies is a critical component for successful performance improvement initiatives that ultimately enhance patient health outcomes.28,29,54 Scientific Methodology: As practice research gains prevalence and sophistication, conceptual and methodological challenges emerge for the future. Advancements in the field of practice research require building on traditional designs and methods, but also innovatively expanding the repertoire of quantitative and qualitative methodological approaches that are grounded in conceptual understanding of the clinical phenomena under study.37,55,61 Practice inquiry entails a wide spectrum of designs, methods and statistical approaches. Emerging conceptual and technological advances in clinical epidemiology and informatics provide APNs the instruments to identify and monitor clinical patterns over time. The scientific approach

embedded in clinical diagnostic and decision-making at the individual patient level is shifted to an aggregate population level whereby clinical information systems are used to examine patterns and variations across individual patients. Subgroup analyses are completed and health disparities are identified and explained by examining variables and processes that account for differential therapeutic effects. Translational research focuses on the critical appraisal process of integrating all forms of best evidence in daily practice with consideration of provider, patient and system characteristics. Advances in health care service and quality research provide innovative ways to conceptualize and evaluate the quality of evidence-informed nursing practices and their impact on health outcomes and costs. Relationship-centered Care: Emerging evidence suggests that relationship-centered care is a critical health care dimension that is associated with patient satisfaction and improved health outcomes, even cost benefits.1,62 A provider’s interpersonal qualities and style of interacting with patients are influential in motivating patients to engage in healthy life styles.63 Subsequently, this growing knowledge base has generated evidence-informed best practices for establishing and sustaining therapeutic relationships and interactions with patients.64 – 67 Health care improvement studies often include measures to evaluate improvement in how M

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patients perceive and engage in their health care experiences— especially how preferences were considered when applying evidence-based clinical protocols.1,54 With the growing emphasis on community-based participatory research and informed consent, nursing’s traditional emphasis on relationship-centered care provides the knowledge base for APNs to partner with families and stakeholders in the investigative process. Scientific Ethics: The engagement in clinical investigations preserves the integrity of the therapeutic relationship with patients and families. Nurse clinicians respect and act in accordance with ethical principles and human subject guidelines, participating in the generation and evaluation of ethical guidelines. Scientific Context of Health Care System and Policy: The provision of care is influenced by organizational variables such as available resources, infrastructural support and system delivery designs, plus policy enactment—internal and external to the organization. Educating health care providers to view their practice within the broader context of health care systems and policy is a critical 21st century competency that shifts the role of providers from a reactive to a proactive stance in shaping their practice context.30 The investigative competency of using data to influence and persuade organizational decisions to improve the environmental and policy context of care is a critical leadership aspect of the practice doctorate curriculum. Scientific National Agendas and Initiatives: Clinical investigative projects are carried out with a sense of appreciation for how a specific project interfaces with national/ international agendas and initiatives. A wider lens to view the importance of an investigative project will enhance the ability of APNs to compete for and capture organizational resources in support of projects aligned with national or even global perspectives. This wider lens will also improve the potential securement of external funding support for inquiry in areas where practice improvements are essential, such as patient safety.

The 8 credits of core practice inquiry courses entail a required research overview course, Introduction to Scholarly Inquiry Methods (4 credits), and a required advanced research course, Evidence Informed Practice, Systems and Policy: Conceptual, Methodological and Clinical Issues (4 credits). Together, the required courses reflect the 2 central practice inquiry curriculum concepts: evidence informed practice and its interface with quality of care. Students will analyze conceptual translational models that depict the complexity and multiple phases entailed when translating evidencebased clinical guidelines to practice.68 –70 The Evidence Informed Practice course emphasizes not only how to access all forms of evidence from best possible sources, but also how to interpret, appraise, integrate and judiciously apply evidence to practice. Clinical guidelines often need to be modified to match certain types of clinical settings, the extent of clinical resources, providers’ expertise, and the heterogeneity of clinical populations and patient preferences. Students learn to develop evaluation plans that assess not only the actual process of translating evidence to practice, but also examine the translational impact on the quality of health care. Various health care improvement designs and methods are examined for addressing certain types of questions. Larson29 explains that evaluation efforts do not need to be restricted to costly and complicated clinical trials but, rather, less costly and more feasible designs can be used by clinicians and administrators who have access to qualitative and quantitative data collected for quality improvement and risk management purposes. The curriculum allows for flexibility in choosing a practice inquiry focus after mastering the basic competencies obtained in the core required courses. The remaining 10 credits of elective practice inquiry coursework are selected from a menu of nursing and interdisciplinary courses that highlight design, methods and statistical approaches appropriate for practice inquiry investigations. The categorical themes of elective practice inquiry courses entail clinical epidemiology, informatics and clinical information systems, translational/ dissemination research, quality of care improvement research, program evaluation research and health service system research. The students’ elective emphasis is reflected in the capstone investigative project. The 12-credit capstone clinical investigative project reflects the consolidation of practice inquiry knowledge and competencies. Ideally, the project interfaces with the student’s residency program, thus providing opportunities for students to learn how to interface daily practice with investigative endeavors. The capstone investigative project is mutually valued and agreed upon by the student, faculty and the community agency that sponsors the student’s residency program. Although the student assumes primary responsibility for their project, typically the project interfaces with a

Coursework and Capstone Project Throughout coursework, experiential learning activities, clinical practicum, and residency programs, students are mentored to conceptualize and approach practice through a scientific mindset— challenging “habits” of practice, cultivating curiosity about the scientific and theoretical underpinnings of practice, and formulating practice inquiry questions. Despite the demands of day-to-day practice and productivity formulas, students are socialized to engage in practice inquiry endeavors. The PDTF proposal entails a total of 30 quarter credits (minimum) devoted to the practice inquiry, including 18 credits of coursework and 12 credits for the capstone investigative project. The specifics of the coursework are proposed as follows: 146

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broader, ongoing collaborative endeavor within the agency that coalesces different perspectives and expertise. The specific project is analyzed within the broader context of internal organizational issues, national initiatives and policy formulation. Moreover, the practice inquiry mindset and competencies are integrated throughout the other 2 DNP curricular dimensions of leadership (minimum 15 quarter credits) and advanced practice (minimum 45 quarter credits; number varies depending on post-master’s or post-baccalaureate program). Leadership and practice colloquiums will incorporate ethical, human subjects and legal considerations as related to clinical practice and practice inquiry. In addition, the leadership colloquiums will focus on how to use “evidence” and data to advocate for change in clinical practice patterns, system designs and policy.

Differentiation and alignment between DNP and PhD programs During deliberations on offering a DNP program, the task force took into consideration the University of Washington Graduate School memorandum71 that delineates the differences between 2 principal types of doctoral degree programs. The practice-oriented doctoral degree program emphasizes educating professionals to primarily engage in practice at the frontiers of existing knowledge. Completion of the program is signified by the award of doctor of a professional field. The research-oriented doctoral degree program emphasizes educating scientists to primarily engage in research to generate new knowledge or new modes of thought or expression. Completion of a research-focused program is signified by the award of Doctor of Philosophy degree (PhD). Thus the primary differentiating factor between the 2 programs lies in the purpose of preparing graduates for research-intensive careers as compared with clinically-intensive careers. The nursing research-intensive doctoral program encompasses multiple philosophical, theoretical and methodological perspectives on knowledge generation, extension and application through the broad spectrum of nursing research that encompasses basic, clinical and translational practice-oriented types of investigations as reflected in the NINR mission statement and funded grants.72 The breadth and depth of PhD researchintensive education would not be characteristic of the more selective focus of the DNP clinically intensive doctoral programs. Instead, education prepares clinicians to engage in the spectrum of nursing research that primarily focuses on practice-oriented clinical investigations that interface closely with the everyday application and evaluation of evidence-informed clinical knowledge and competencies. However, it is important to be cautious and not prematurely differentiate between the 2 programs.

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As the DNP programs develop, there is a tendency to become preoccupied with questions about the differentiation between practice-oriented doctoral programs and research-oriented doctoral programs. Although these kinds of questions are important, one needs to be cautious that the conversation does not exclusively focus on the divergence of these 2 programs and, inadvertently, polarize and exaggerate the practiceresearch duality as reflected in the translational gap between science and practice. Neither practice nor research benefit from this type of discourse. Alternatively, pedagogical conversations that broaden the discourse to include the commonalities between the 2 programs are more likely to dialectically resolve the practice-research tensions. Research informs practice, and in turn, practice informs research, and together this bi-directional synergistic process advances nursing science and nursing practice and, ultimately, the delivery of health care. When the educational process for PhD and DNP is approached from this perspective and with these values, then collaboration endeavors emerge during graduate education as well as after graduation. The increasing emphasis on the translation of research results to practice and policy is reflective in the NINR Strategic Planning for the 21st Century document73 and its interface with NIH Roadmap Re-engineering the Clinical Enterprise.17 The emphasis on developing partnerships between academic researchers with “practicing communities” could provide converging opportunities for collaborative efforts between PhD and DNP nurses. Higher education, in general, is increasingly characterized by programs that foster intellectual discourse from a boarder disciplinary and interdisciplinary perspective; forging interconnections across practice-oriented and research-oriented programs that are united to jointly shape and respond to societal and global challenges.74 –76 Thus, opportunities for intellectual interchange among PhD and DNP graduate nursing students begin to set the stage for appreciating the commonalities shared in collectively advancing nursing perspective, values, science and practice.

Expanding nursing capacity for collaborative investigation Although nurses have conducted exemplary clinical research and dissemination studies, nursing needs to continue to make strides to advance clinical knowledge and translate that knowledge to practice and quality of care. Nurses socialized and trained in clinical investigative methods during their practice-oriented doctoral program will be ideally positioned and prepared to collaborate on research endeavors that entail practice foci. Community-based nurse clinicians, in collaboration with academic-based nurse scientists, will form investigative partnerships to generate and investigate M

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salient clinical practice questions. Inherent in the concept of partnership is a reciprocal interactive process whereby the bi-directional exchange of perspectives, values, expertise and resources culminate in a commitment toward improving health care. These kinds of collaborative efforts are likely to sustain evidencebased innovative practices that address the daily realities of service systems and, thereby, bridge the gap between science and service—including policies that support service delivery systems that provide evidencebased care. With increased national focus on the quality, equality and safety of health care as made visible by the 3 IOM reports Crossing the Quality Chasm,1 Unequal Treatment,4 and To Err is Human,77 the role of nursing research has expanded importance in advancing the national health care research agenda. The Agency for Healthcare Research and Quality (AHRQ) is designated as the lead federal research agency charged with generating and translating research on quality of care, including its role to coordinate all federal quality improvement efforts and health service research.78 The Agency for Healthcare Research and Quality’s mandate and budget has grown considerably to advance its mission to improve the quality, safety, efficiency and effectiveness of health care for all Americans.78 The focus of AHRQ is reflected in its 4 study sections: (1) health care quality and effectiveness research, (2) health systems research, (3) health care technology and decision sciences, and (4) health research dissemination and implementation.78 The kind of research funded by AHRQ often requires alliances between community clinicians and academic researchers. An example of AHRQ-funded creative alliancebuilding is exemplified by “primary care practice-based research networks.” These practice-based networks are defined as a network of ambulatory practices devoted principally to the primary care of patients, and are affiliated with each other in order to investigate clinical questions related to community-based practices.79,80 Often, these kind of networks generate mutually enriching interactions between community-based providers, administrators and stakeholders, as well as academicbased scientists. The mission of the network alliance is to support the development, dissemination, adoption, adaptation, and evaluation of evidence-based primary care practices. The network provides an infrastructure that supports clinical investigation that transcends across clinical sites. As of 2002, 55 primary care practice-based research networks have been funded, and approximately 3 grants have nursing principal investigators.79,80 Although nursing presence within the agency has increased over the years, Hubbard et al81 noted that nursing-related applications and funded grants are “under-represented when compared to other disciplines”; stating that “Since 1994, nurse principal inves148

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tigators have accounted for 4%–7% of the total pool of AHRQ research grant applicants and 2%– 9% of all funded grants.” In view of these low percentages, AHRQ has enhanced its outreach efforts to the nursing community as well as collaborative efforts with NINR.81,82 The Agency for Healthcare Research and Quality acknowledges that nurses are the largest providers of health care, and they need to build the scientific capacity for a stronger presence in carrying out the AHRQ mission statement and research agenda.81 Nursing science and nursing profession have contributed to analyzing health outcomes from a comprehensive perspective that extends beyond the traditional measures of mortality, morbidity, complications, and cost to include measures of function, quality of life and patient satisfaction.81,82 It is imperative that nursing as a discipline and profession play an essential leadership and significant collaborative role in health care improvement research initiatives. Together, advanced practice nurses and academic nurses have complimentary scientific perspectives and expertise to examine a full range of practice questions. Examples of practice inquiry investigative areas are listed in Table 2. Through technological advancements, creative options such as teleconferencing could link geographically separated nurse clinicians with nurse scientists to collaborate on practice inquiry investigations. There are many potential clinical research areas ripe for practice inquiry investigation that will contribute toward bridging the gap between science and practice, service models and policy—and, ultimately, make true improvements in health.

Evaluating the vision of practice inquiry A detailed DNP program and curricular evaluation process and plan have been designed that includes an assessment of the practice inquiry dimension. For example, during the program, curricular design and methods will be evaluated to assure that meaningful and effective practice inquiry learning experiences are provided to students, and that a practice inquiry foundation is successfully achieved in a timely way. The School of Nursing’s alliance-building with the community will be evaluated for generating student opportunities to complete their capstone clinical investigative projects within a collaborative partnership context. In addition, the extent and kind of intellectual discourse and exchange between students enrolled in the PhD and DNP program will be monitored, including collaborative efforts on various projects. After the program, graduate perspectives and activities are monitored to gain insight and refine curricular design and methods. Various evaluative questions will be asked about the DNP graduate’s practice inquiry activities. For example, does their employment position O

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Table 2. Examples of Practice Inquiry Areas ●

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Who does/does not have access to nursing services and health care programs, and why? How are nursing services and programs being delivered in a timely and cost effective way? What types of clinical, demographic, process, and outcome variable data need to be systematically collected and analyzed in order to monitor and evaluate clinical patterns over time and to monitor variance in health care services and outcomes that account for health disparity across subpopulations? How can clinical epidemiological benchmark comparison studies yield viable quality-improvement information? What system, structural, and technological changes are necessary to capture relevant and critical data? What types of evidence-based prevention and treatment nursing clinical guidelines are/are not implemented? What are the issues and barriers that prevent implementation of evidencebased nursing clinical guidelines? What are successful approaches for implementing and evaluating evidencebased nursing clinical guidelines to influence clinical processes and outcomes? Who is most/least likely to benefit from certain types of nursing services and programs (differential effects)? What types of moderating and mediating variables are linked to nursing intervention processes and outcomes? How are nursing interventions appropriately modified for subpopulations? How are evidence-based nursing clinical guidelines modified to be culturally relevant for diverse populations? What types of relational partnerships with patients, families, and communities are linked to health outcomes? How are individuals, families, and populations motivated to engage in intergenerational patterns of healthy life styles? What types of organizational structures, financial incentives, and health care policies positively or negatively impact how nursing practice and programs are delivered?

allow for the expression and advancement of their practice inquiry knowledge and expertise? What types of practice inquiry activities are conducted? What types

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of investigative partnerships are established? How are graduates contributing to evidence-based improvements in clinical practice patterns and health care systems? Are graduates in collaboration with others such as career-oriented nurse researchers obtaining AHRQ- and NINR-funded practice inquiry initiatives?

Summary The fact that the practice-oriented degree is now moving toward the doctoral educational level highlights and confirms the clinician’s role as a “Science Partner” who is positioned to assume newly defined leadership roles in bridging science and practice. Clinicians use their investigative expertise to visibly and effectively express their leadership influence within the health care system and public arena, including public policy. For example, clinicians as leaders are curious about how and why practice patterns are established, asking questions that challenge the rationale underlying common but nonscientific practice patterns. Clinicians as leaders cultivate newly structured alliances with other clinicians and scientists to jointly respond to research initiatives that strengthen the bridge between science and practice. Clinicians as leaders are influential and persuasive by using data to guide clinical decision-making and develop policies that support innovative and cost-effective service delivery systems. Through practice inquiry knowledge and methods, doctoral-prepared clinicians will be positioned to proactively shape the 21st century health care system and improve health for all populations. We expect this vision to become a reality for APNs who enter the next decade equipped with enhanced practice inquiry perspectives and competencies, plus enthusiasm and a sense of responsibility for practice inquiry. As nursing creatively reformulates APN education and practice to strengthen our ability to improve quality of care, the critical role of practice inquiry becomes even more apparent. The authors gratefully acknowledge the University of Washington School of Nursing Practice Doctorate Task Force (PDTF) and Faculty for their consistent guidance and feedback. The PDTF members, listed in alphabetical order, are: Michelle Acker, MarieAnnette Brown (Chair, December 2003–March 2005; Co-chair, March 2005–present), Mary Ann Draye, Diane Magyary (Co-chair, March 2005–present), Carole Schroeder, JoAnne Whitney, Sue Woods and Phyllis Zimmer.

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