Experiences of dual PHD-DNP nursing students during doctoral education

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Experiences of dual PHD-DNP nursing students during doctoral education ⁎

Jennifer T. May , Chloe O.R. Littzen, Helena W. Morrison, Lois J. Loescher The University of Arizona College of Nursing Biobehavioral Health Sciences Division, United States of America

A R T I C LE I N FO

A B S T R A C T

Keywords: Doctoral dual degree nursing Nursing education Distance education Hybrid dual degree programs

Background: Nursing doctoral education now includes an option with a growing national interest: the PhD-DNP dual degree. Although programs have existed for 10 years, little is known about experiences of dual PhD-DNP degree nursing students (DDNS) during doctoral education, including their perceptions of mentorship during coursework, comprehensive exams, and dissertation readiness. Objective: To explore and describe the experiences of DDNS during hybrid dual doctoral education at one Southwestern university. Method: Using a qualitative descriptive design, DDNS (n = 4) at a Southwestern university were interviewed about their experiences during coursework and comprehensive examinations. Results: Three categories fundamental to DDNS were identified through an inductive and deductive iterative process: coursework experiences, including the key findings of in-betweenness and isolation; mentorship; and comprehensive examination experience. Categories of dissertation readiness and DDNS recommendations were inductively derived. Conclusion: Current interest in the PhD-DNP dual degree underscores the importance of knowing more about the experiences of DDNS. The key findings of in-betweenness and isolation have previously not been described in the nursing literature and need to be considered for the DDNS. Facilitators and inhibitors, mentorship experiences, and mentor attributes affect progression of DDNS through coursework. Strategies for success for DDNS, faculty and program success are provided.

Nursing doctoral education has changed over the past 10 years and now includes opportunities to obtain a Doctor of Nursing Practice (DNP) degree (clinical doctorate) or a Doctor of Philosophy (PhD) degree (research doctorate). An increasingly popular option is the dual PhD-DNP doctoral degree. PhD-DNP dual degree nursing students (DDNS) receive education to become expert practitioners who are prepared to generate knowledge to improve health or health outcomes, accomplished through innovation of practice change, the translation of evidence, and the implementation of quality improvement processes in specific practice settings, systems, or specific populations. This new knowledge is transferrable but not generalizable (American Association of Colleges of Nursing [AACN], 2015). Concurrently, DDNS gain preparation to become nurse scientists—to generate knowledge through rigorous research and statistical methodologies that may be broadly applicable or generalizable. Having both degrees prepares DDNS to uniquely bridge the borders between research and practice, where clinical observations lead to clinical questions, which then can be transformed in an accelerated manner into clinically relevant studies (Kwan et al., 2017; Mackay, 2009).

Currently, four major nursing programs in the U.S. offer the dual doctoral degree, with one university pending Board of Regent approval. These programs have comprehensive and rigorous curricula that can be completed within approximately 5 to 6 years, depending on whether students are in a baccalaureate (BSN)-dual option or masters (MS)-dual option. A range of funding options are available for DDNS. Some dual degree nursing programs offer full funding or a tuition stipend, whereas others do not. Thus, DDNS must be highly motivated, goal-oriented, organized, and persistent to achieve two doctoral degrees simultaneously. Little is known about the experience of DDNS during coursework. Our study creates a foundation for filling this knowledge gap. Knowledge of DDNS is important as it enables understanding of the complexities of the degree and the student experience during coursework. This knowledge is necessary for improving PhD-DNP dual programs and program outcomes. Therefore, the purpose of this qualitative descriptive study was to explore DDNS' perceptions of their experience prior to doctoral candidacy (e.g., coursework, comprehensive examinations), including mentorship. Aims were to describe 1) facilitators

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Corresponding author at: 22 Longstreet Road, Weldon, NC 27890, United States of America. E-mail addresses: [email protected] (J.T. May), [email protected] (C.O.R. Littzen), [email protected] (H.W. Morrison), [email protected] (L.J. Loescher). https://doi.org/10.1016/j.profnurs.2020.02.004 Received 25 September 2019; Received in revised form 10 February 2020; Accepted 12 February 2020 8755-7223/ © 2020 Elsevier Inc. All rights reserved.

Please cite this article as: Jennifer T. May, et al., Journal of Professional Nursing, https://doi.org/10.1016/j.profnurs.2020.02.004

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of the four investigators were female second-year PhD nursing students, both of whom had completed a qualitative methods course and signed confidentiality agreements. The other two investigators were female nursing faculty experienced in qualitative descriptive methods. The qualitative descriptive approach used in this study illuminated the dynamic experiences of DDNS, while allowing the investigators to maintain authenticity of the data (Neergaard, Olesen, Andersen, & Sondergaard, 2009).

and inhibitors of progression through coursework, 2) types of mentoring experienced by DDNS, and 3) mentor attributes. A secondary purpose was to generate strategies for success for future DDNS. Review of the literature Articles on the DDNS were not found during our literature review. Limited nursing literature is available on the topic of mentoring or mentorship during coursework in DNP, or PhD nursing programs (Harris, Birk, & Sherman, 2016; Lewinski et al., 2017; Welch, 2017). Outside of nursing, considerably more research exists to support mentoring, mentorship, PhD student support, and the PhD student experience during candidacy (Goodwin-Lee, 2010; Jairam & Kahl, 2012; Joerg, 2004; Kumar & Coe, 2017; Kumar, Johnson, & Hardemon, 2013; Pifer & Baker, 2014; Schmidt & Hansson, 2018). Thus, there is a critical need to expand research to support DDNS, as well as current and future dual PhD-DNP programs. Additionally, no articles on the historical development of dual doctoral degree programs in nursing were found. Dual doctoral degree programs have an historical presence in other disciplines. In medicine, for example, physician scientist (MD-PhD) training began in the 1950's and has since proliferated by over 10,000 graduates based upon data from the Medical Scientist Training Program (MSTP) (Harding, Akabas, & Anderson, 2017). In lieu of a Pharmacy faculty shortage, PharmDPhD dual degree programs were developed in the 1980's (Gourley et al., 2006). The PharmD-PhD dual degree program used the MD-PhD program as a framework for development. There has been a growth of PharmD-PhD programs since that time, with > 15 programs in the United States (Gourley et al., 2006). In nursing, the first dual doctoral degree program is < 15 years old. Schools of nursing that offer dual doctoral degree nursing programs provide limited information or rationale for their development. The slow and meager proliferation of dual doctoral degree nursing programs, and the support of the nurse clinical expert-researcher role, has been thought to stem from the debate on what constitutes nursing science, the lack of positions that support concurrent work in academia and healthcare facilities, and organizational issues that support the PhD-DNP dual role (Knafl, Bevis, & Kirchhoff, 1987; Mackay, 2009). It is only speculated that the lack of proliferation of PhD-DNP programs is related to the aforementioned reasons, but also due to lack of financial support for DDNS, difficulty in prospective students in understanding the dual degree role in the workforce (Morton, n.d.), the length of the program, and lack of best practices in PhD-DNP program development (AACN, 2019). Embedded in this debate on what constitutes nursing science, is the concern of the theory-practice gap, or as some may refer to, the academic practice gap (Huston et al., 2017). Littzen, Langley, and Grant (2020) in discussing the cause of the theory-practice gap argued for two considerations: 1) the gap may be translational in nature, where those in the practice environment are simply unaware of the knowledge being produced, and b) relevance to practice, knowledge produced in the academic environment is not relevant to the practice environment. These considerations pertain to the nurses with a dual doctoral degree because these nurses are uniquely positioned to witness a problem in the practice environment while conducting research to change clinical practice. Thus, they have the potential to provide a bridge to translation and relevance, while assisting in the complex conversation of nursing science. However, as nursing doctoral programs continue to develop dual doctoral degree options, it is important to examine the experience of current DDNS in order to inform doctoral educators and program directors, as well as future potential DDNS about the potential complexities of the dual doctoral degree.

Setting and sample Purposive sampling was used to recruit students enrolled in a hybrid dual degree option at a Southwestern University. Students may enroll in the BSN-dual or MS-dual track; coursework for both tracks is online. Students desiring a dual doctoral degree initially enroll in either the PhD or DNP program but take designated courses in the other program (PhD or DNP) during their first year of matriculation. Students apply to the other program in spring semester of their first year; upon acceptance, they begin the dual degree option in the fall of their second year of doctoral study. Students complete the remaining courses required in both programs but can share 17 credits between the programs. The time to degree approximates 5.5 years for full time study. Prior to recruitment, a list of current DDNS was retrieved from the student support office. A study disclosure, inclusion criteria, and contact information of the two PhD student investigators were sent to all matriculating DDNS (n = 14). Of those, three were on leave of absence, narrowing the recruitment pool to 11 DDNS. Eligible were, 1) a matriculating DDNS who had completed the last required academic course, and 2) access to a computer with internet, a video-camera and microphone. Seven matriculating DDNS met eligibility criteria, all of whom were invited to participate via email. Interested DDNS contacted the investigators via email to schedule an interview. Each participant received a $50 gift card after completing the interview. Procedures The investigators developed a semi-structured interview guide (see Table 1) to explore participants' perceptions of their experiences during coursework, including mentorship. In this study, mentorship was defined as any resource, experience, or person and their characteristics that enhanced participants' understanding of coursework or performance during coursework. The interview guide was based on literature that examined the mentoring experience of PhD and DNP nursing students in distance programs (Harris et al., 2016; Lewinski et al., 2017; Welch, 2017). Data were collected from December 2018 through February 2019. One-on-one interviews were conducted via Zoom Online Video Communications (Zoom Video Communications, 2019). DDNS reviewed the IRB-approved consent form and gave verbal consent prior to initiation of the interviews. The two PhD student investigators who conducted the interviews were not DDNS and had enrolled in their PhD nursing program three to four years after the participants matriculated. Therefore, the PhD nursing student interviewers did not have previous interactions with the participants and were not peers. All interviews were video- and audiorecorded. The interviews were 1) de-identified, 2) uploaded into a folder on a secure cloud server used by the university, 3) retrieved from the folder by the transcriptionist who transcribed each interview verbatim, and 4) uploaded by transcriptionist into the secure folder. Data were analyzed using qualitative content analysis (Sandelowski, 2000) which was completed independently by two investigators using an iterative process. Deductive codes derived from the literature on online doctoral programs reflected the responses to questions in the interview guide. Inductive coding involved the process of open coding and development of categories to guide the formation of a general description of the research topic (Elo & Kyngäs, 2008). Investigators created categories by systematically reviewing and grouping the open

Methods The University Institutional Review Board approved the study. Two 2

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Table 1 Interview questions for Dual PhD-DNP nursing students. Category

Interview questions

▪ Think back to your coursework. What experiences during that time were key in helping you move through your coursework as planned? ▪ What experiences may have inhibited your timely progress? ▪ How did your advisor help or assist you in managing successes or problems that arose during that time? ▪ In what way do you feel your advisor did not help or assist you in managing problems that arose during that time? ▪ Tell me what could have improved the experience? ▪ What things motivated you during the process of completing your coursework? ▪ Think back to your advisory committee. Explain your interaction and experience with your advisory committee. ▪ Did your advisory committee contribute to mentoring you through coursework? ▪ Explain if you felt your advisory committee did not contribute to assisting you through your coursework. o What could have improved the experience? ▪ What can be done to support future students during their coursework? Comprehensive Exams ▪ Have you completed your comprehensive exams? ▪ If yes, what did you need to feel adequately prepared to pass your comprehensive examinations? ▪ If No, what do you think you need to feel adequately prepared? Dissertation Readiness (Preparation) ▪ How confident are you that you can complete the dissertation process in a timely fashion? ▪ What skills/knowledge are you lacking to: develop, implement, evaluate, and present your dissertation? ▪ What best prepared you for your dissertation? ▪ Tell me what experiences you have had with your dissertation committee in preparation for your dissertation. Mentoring ▪ Discuss what attributes you value or do not value in a mentor. ▪ Researcher: Describe the draft of the mentoring plan to participant. ▪ Would you have benefited from this mentoring plan? ▪ Tell me what an ideal mentoring plan would be. ▪ Have you experienced peer-to-peer mentoring during your coursework? ▪ How was this effective or ineffective? ▪ Did the dynamics of the group affect the experience? ▪ Was the peer-to-peer mentoring more formal or informal? ▪ What platforms were used? ▪ Would you consider a mentor to be helpful during your coursework? Why or Why not? ▪ What suggestions do you have for a successful mentoring program at the PhD nursing program? ▪ Is there anything else you would like to add about your experience with mentoring during your coursework or mentoring in general? Coursework

2016). These criteria were met during the current study. Interviews lasted an average of xxx minutes. Participants were in the program for an average of 5.5 years. All participants were female and had a median age of 39.5 years. All participants entered into the program with their BSN between the years 2010–2014 and started with DNP coursework. Five categories were identified as being fundamental to the experience of DDNS prior to dissertation: 1) coursework experiences, 2) mentorship, 3) comprehensive examination experience, 4) dissertation readiness, and 5) suggestions for future students (Fig. 1). The following paragraphs provide a definition of each category, listing of subcategories, and summary of findings. Salient quotes, subcategories, and their categories are in Table 2.

codes to develop and reach consensus for the codes, categories, and subcategories. All investigators reviewed the categories in an iterative fashion and modified further until reaching consensus. The investigators established trustworthiness of the study by addressing the criteria of credibility, dependability, confirmability, and transferability (Lincoln & Guba, 1985). Credibility was supported by weekly meetings, peer debriefing, and checks of data analysis procedures by the research team. Additionally, the two investigators kept notes on the deductive and inductive coding schemes. Dependability and confirmability were upheld through the audit trail process. Transferability was maintained by providing a concise and rich description of the participants' accounts. The researchers are aware that because the interviewers were also students, this may have contributed to the potential of the participant to respond to interview questions that were socially accepted. The process of reflexivity was important for establishing credibility of the study, given that the two interviewers also were PhD students. Reflexivity allows the researcher to reflect on personal values and past experiences that may influence the findings (Jootun, McGhee, & Marland, 2009). Despite the knowledge and experience of the interviewers with mentoring, they adopted the “ear of unknowing” to promote reflexivity (Munhall, 2012). To further address reflexivity, the dialogue between multiple investigators included discussions of the divergent understandings of the study, and the contexts of researchers hidden beliefs, values, perspectives and assumptions (Jootun et al., 2009).

Coursework experiences Coursework experiences (any experiences that occurred during coursework and prior to comprehensive examinations) were further categorized as: 1) in-betweenness and isolation, and 2) facilitators and inhibitors. In-betweenness and isolation were defined as DDNS' perceptions of being “stuck” between many worlds with interrelated feelings of disconnection from other groups. Most participants expressed feelings of in-betweenness related to their lack of belonging to a specific cohort, whether PhD or DNP, or a specific dual degree cohort. Participants described their experience as a dual degree student as sometimes out of synch with other doctoral cohorts and more isolating. Additionally, they perceived less of a connection among the members of the PhD cohort and more connection with the DNP cohort throughout the program. Participants also described challenges in communication about the dual doctoral degree with others who have not experienced doctoral education. For example, one participant explained the challenges of communicating the complexities of the dual degree process with family members, noting difficulties explaining information that others perceived as simple, for example, her graduation date.

Results Data saturation was achieved with a sample of four participants. Saturation can be achieved with a smaller sample size when the aims of the study are very specific, the experiences and knowledge of the participants pertain to the aim, and there is a high level of quality and focus during the interview session (Malterud, Siersma, & Guassora, 3

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Fig. 1. Categories and subcategories describing the dual PhD-DNP nursing students' experiences during doctoral education.

and taking turns reviewing course papers. One participant spoke about hearing different experiences from peers that helped guide her decision making. In contrast, another participant described that she was not as close to her peers as other students because of her age; she thought she would have reached out to peers if she was younger and did not have other commitments. Additionally, some students described setting up formal meetings with peers, while others reached out via texting, email, telephone, or online videoconferencing.

All participants described facilitators and inhibitors that improved or impeded progression to the dual doctoral degree. Facilitators of progression were advisor and family support systems, financial motivators, and changes to professional work position. For example, family support was important to one DDNS who mentioned that type of support was vital for her mental well-being throughout the program. Participants described inhibitors to progression as loss of family members, lack of school-work-life balance, financial inhibitors, and conflict between faculty committee members. For example, one participant mentioned that conflict between advisory committee members can sometimes slow progression toward solidifying a research topic and contribute to changes in graduation date. Significant to both facilitators and inhibitors, were the financial experiences of the DDNS. One participant described her perseverance through coursework being driven by the financial motivation of becoming a nurse practitioner. Another participant described having to take a leave of absence because she did not have the funding to pay for her tuition.

Comprehensive examination experiences The comprehensive examination experience was defined as preparation for comprehensive examinations and included the subcategories of advisory experience and strategies. In preparation for their comprehensive examinations, all participants explained that their advisory committee or committee chair assisted them by reviewing material and being available for clarification, questions, or concerns. However, not all participants worked with their advisory committee to prepare for comprehensive examinations. One participant explained that she exclusively worked with her advisory committee chair and did not reach out to other committee members. Furthermore, participants perceived that individualized advisor guidance in preparing for comprehensive examinations was important for maintaining focus and adhering to due dates. Participants described the importance of developing strategies to prepare for their comprehensive examinations with a focus on the oral examination, which they identified as more challenging than the written examination. These strategies included learning how to speak using research language along with the more familiar practice of writing. Mock oral examinations with questions developed by the advisor were an important strategy to help participants feel less nervous and allowed them to become more comfortable with the material.

Mentorship The mentorship category was defined as any resource, experience, or person and their characteristics that enhanced participants' understanding or performance during coursework. Two subcategories were: 1) mentor attributes, and 2) peer mentoring. Participants perceived positive and negative characteristics of a mentor. They described positive mentor characteristics as being approachable and communicative, with the ability to hold the DDNS responsible for completing extracurricular projects and tasks, such as completing software training. Participants described instances where the positive characteristics of a mentor assisted them in being accountable. For example, the mentor would “check in” with the DDNS regarding due dates and being present for meetings. Negative mentor characteristics were being unsupportive or uncaring, or not having research expertise related to participants' research interests. For example, a participant described an instance of a mentor not being supportive when the student had non-curricular-related obligations that delayed project timeline completion. Participants emphasized the importance of peer-to-peer guiding experiences during coursework. Participants' comments reflected the importance of having peer relationships in the dual degree option to provide support in program completion. Participants described specific instances of peer mentorship, including working through course content

Dissertation readiness All participants commented on their adequate preparation and readiness to complete their dissertation. Several participants expressed the importance of their advisors' role in strategizing through the dissertation process. Having the right fit of dissertation committee members as well as a timeline were important for dissertation readiness. Alternatively, a participant described that readiness stemmed from her ability to critically review published manuscripts and ability to 4

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Table 2 Categories, subcategories, and salient quotes of PhD-DNP dual degree nursing students. Category 1. Mentorship

Subcategories

Salient quotes

1a. Mentor Attributes

Positive Negative Participant 3. “…lack of support, apathy, bad listening Participant 1. “I value someone who's approachable, skills.” someone who is honest and who genuinely is invested in Participant 4. “Somebody who is not interested…” “… you and your self-development.” somebody who has no similar research background in your Participant 2. “…the timing of feedback is important to me interest.” and being articulate and knowledgeable.” Participant 1. “It would be helpful just to be able to get a student perspective and hear their insight and their experience with how they've experienced the program, just because it's kind of nice to be able to have that visualization to say, okay, he did it, this is how he did it. …you know you can do it but it's also nice to be able to see someone who has done it and to kind of learn from them, what their mistakes were, or what things worked for them so you can better able set yourself up for success.” Participant 3. “I don't have time to be social with the students. I work the night shift as a nurse practitioner, so I work 7 on and have 7 off, and then on the 7 off I have my family. Maybe if I were younger and didn't have a family I would reach out that way, but that didn't really apply. “ Participant 4. “…if I could bounce a paragraph off of them or a section off of them and likewise, they would do the same with me. So, we would just critique each other's writing.” Facilitators Inhibitors Participant 1. “…just trying to balance, like, your full-time Participant 1. “…just family support system because I'd job or your part-time job with your PhD…” be… I'd probably have had a mental breakdown by now if it Participant 3. “There were some periods of time that I had weren't for them…” to take off due to financial reasons. I couldn't afford to pay Participant 2. “…obviously financial, and I would say my the tuition.” advisor has been motivating telling me, you're almost Participant 4. “Well, unfortunately, I did lose both of my there… Financial, I would say, it's a huge reason and I'm parents during this process. That has slowed things down this far that, you know, you can't give up now.” significantly.” Participant 3. “…I have been working as a nurse practitioner since 2016 while going to school so I was the last class where you could get the MSN and actually start working. So that was a motivator, just being able to step out of the stress of the [bedside?] and working as an NP. That was the biggest motivator for me.” In-betweenness Isolation Participant 1: “So, I would say there was a difference and it Participant 1. “But to try to navigate and be stuck between is a little more isolating in that sense. It's more of a dual the two programs, it's definitely different than being just a student thing, not so much a PhD student thing. DNP student. I would say it was more isolating…” Participant 2: “There really was just not even a handful of Participant 3: “My experience was pretty unique. I was one us doing the dual degree so I would say we all stuck of the initial DNP/PhD dual degree students.” together and one who I was really close to, I don't think Participant 1: “…it's very hard to explain to an outside she's even trying to complete it right now.” person who hasn't been in a graduate program how it Participant 4. works, but there's people, like, they just don't get it. You tell “…it's so isolating, the online program, the online them a graduation date of one date but then you have to environment…” push it back because of your research. That doesn't make sense to people.” Participant 1. “She would basically just check in… she was an extrinsic motivator who kind of reminded me about deadlines and I spazzed out and stressed like we all do, and she brought me back down and we just kept chugging along.” Participant 2. “I mean, I don't think I had a whole lot of interaction with my advisory committee. I think I really just kind of have gone to my chair about everything. I mean, really I just followed the plan.” Participant 3. “They sent me what they were going to ask me on a sheet and then I went through it. I had the opportunity to ask questions for more clarification and I was able to do that.” Participant 1. “…the whole discussion piece and being able to speak research instead of write research actually that would have been really beneficial because I did have a harder time with my oral comps.” Participant 2. “I like to kind of prep with my chair so she can give me practice questions and I can get comfortable with material just because I do get nervous with things like that…” Participant 1. “Being aware and ready that you're not going to know everything but making sure you have the skills to be able to find your answers and the research tools to be able to figure out what you do need to do.” “…offering more resources for when we do graduate to be able to see what future learning opportunities are available or different workshops.” “…I would say my advisor definitely played a big role because she was basically the one who I would sit down and brainstorm with. She helped me come up with the idea and just offered her valuable expert opinion.” Participant 2. “I think the coursework really tailors you to focus on one subject and then allows you to expand it with your theories or your population at hand.” Participant 3. “Learning how to objectively tear apart a study and know that it's broad-based and generalizable. That knowledge has been helpful.” Participant 4. “Having the right committee. Also, the person who is chairing my committee, she gives me deadlines.” Participant 1. “I would say something that would start off with a little bit of structure prior to kind of help people kind of hold accountable because…” “…we're nurses. We're always triaging and prioritizing. If it's something that can wait, we're going to push it off to try to adjust the, you know, the big elephant in the room.” Participant 3. “…you need to have something a little more concrete as far as, okay, you want to study nurses, so here's a list of advisors that have also studied that…” “…I'm going to interview these three people to see who I mesh with.” Participant 4. “A peer support group for those folks who are doing either like-minded studies…”, “…a peer-to-peer mentor. You know, two heads are better than one when you're trying to figure out something and neither one of you know what the heck's going on.”

1b. Peer Mentoring

2. Coursework Experiences

2a. Facilitators and Inhibitors

2b. In-betweenness and Isolation

3. Comprehensive Exams Experiences

3a. Advisory Experience

3b. Strategies

4. Dissertation Readiness

5. Support for Future Students

5

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effective strategy to support PhD nursing students via new friendships and the ability to discuss school-related challenges (Lewinski et al., 2017). Connection and socialization are integral in informal peer relationships and help to reduce feelings of social isolation (Jairam & Kahl, 2012). Peer support and mentoring also are important for the success of distance learning doctoral students (Goodwin-Lee, 2010; Kumar et al., 2013; Kumar & Coe, 2017). In the current study, participants stated that informal peer mentoring from other DDNS was a form of social support, a source of comfort, and important to their progression. However, despite the use of peer mentoring groups and peer support, the feelings of isolation and in-betweenness among DDNS students remained. DDNS worked to form peer groups with other DDNS, but because of different timelines, these relationships were difficult to maintain; feelings of asynchrony with other cohorts added to their in-betweenness and prevented formation of relationships with other DNP or PhD students. Rationale for persistent feelings may stem from small peer groups of DDNS, infrequent meetings, asynchronous timelines, or navigating between two separate programs. While peer mentoring is an opportunity to reduce isolation, it may do little to address feelings of in-betweenness. Similar to all doctoral students, DDNS students described considerable facilitators and inhibitors that were present during coursework. Facilitators such as family support can mediate stressors and maintain or attain well-being (Jairam & Kahl, 2012). Finances, often considered an inhibitor, were described as both inhibitor and facilitator by these DDNS. Financial instability, growing debt, and financial strain is an inhibitor and a common source of stress that prevents doctoral students from participating in wellness activities that ultimately can affect well-being (El-Goroury, Galper, Saqaqdeh, & Bufka, 2012; Jairam & Kahl, 2012). Conversely, participants foresaw that the future financial stability and flexibility gained from completing their degree were positive and a motivation to carry on despite the stress. Financial strain and lack of financial resources have been discussed in other dual degree programs (Shaw, Harpin, Steinke, Stember, & Krajicek, 2017; Ziperstein et al., 2015). Funding for DDNS is inconsistent among the four current US dual-degree programs with most providing only tuition remission (Johns Hopkins School of Nursing, 2019; The University of Tennessee, 2019). In stark contrast, most MDPhD dual degree students receive both tuition and stipend by the National Institute of General Medical Science through their Medical Scientist Training Program at 50 different universities (National Institute of General Medical Sciences, 2019). Without sustainable funding, financial strain will be an ongoing problem for existing and potential students in nursing dual-degree programs. It is possible that DDNS require a particular type of mentor. Study participants described that desired mentor attributes included being approachable, honest, supportive, knowledgeable, and a good listener, offering timely feedback, sharing similar research interests, and being genuinely interested in DDNS' research and personal development. Although role modeling has been identified as an important mentor attribute for online DNP nursing students (Harris et al., 2016), role modeling was not an attribute mentioned by participants in our study. This reveals a potential variation in mentoring needs for DDNS and could be related to lack of dual doctoral degree prepared faculty available to mentor DDNS. For example, MD-PhD dual degree students prefer the support of a mentor who has lived the experience of being a dual degree student, compared to mentors who are MD-only or PhDonly (Chakraverty, Jeffe, & Tai, 2018). These dual degree mentors provided a “lived experience” for MD-PhD dual degree students and tools to cope with transitions during the program (Chakraverty et al., 2018). With the dearth of dual degree faculty in nursing, non-dual degree faculty need guidance for how to appropriately assist this unique group of doctoral students. Programmatic tools to strengthen faculty understanding of this unique doctoral student population will assist in the progression of DDNS through the program. Additionally, DDNS should reflect on the mentor attributes that would best suit them

effectively communicate with her advisor. Support for future students The participants provided many recommendations for supporting future DDNS interested in the dual doctoral degree. Participants recommended developing a peer mentorship program, having a voice in choosing a mentor or advisor, and having continuing education resources, such as future learning opportunities or workshops for graduates. All participants agreed that a structured individualized mentorship plan to provide guidance through the program would be helpful to aid progression, clarify processes, and decrease stress. Discussion While many of the findings are not unique to DDNS, the key finding of this study was DDNS' perceptions of in-betweenness and isolation. The concept of “in-betweenness” has not been presented in the nursing literature and may be unique to the experience of DDNS. In-betweenness has been reported in the context of sociocultural diversity and transgender experiences. Diversi and Moreira (2009), defined an “inbetweener” as an “(un)conscious body experiencing life in and between two cultures” (p. 19). Nordmarken (2013) described transgender inbetweenness as a complex phenomenon of movement; not necessarily moving between cultures but being read differently in the same cultural context. The concept of in-betweenness deserves more attention and analysis in the context of DDNS because it does shift the “subcultural order” evident in PhD and DNP cohorts. DDNS may perceive themselves as a fringe group with a need for more subcultural order (Giesen, 2018). The concept of isolation may parallel the concept of “otherness” described by Pifer and Baker (2014). These authors described “otherness” in doctoral students studying in the colleges of business and education, as feelings of isolation, the inability to fit in with group standards, and an awareness of difference between peers, faculty, family, and community members (Pifer & Baker, 2014). Participants in the current study had an awareness of being different from peers in the PhD and DNP programs, which became isolating. Compounding the feelings of isolation were the distance course format and feeling misunderstood by outside family, friends and peers. Feelings of isolation previously have been linked to attrition in doctoral programs (Schmidt & Hansson, 2018). To counter the experience of in-betweenness and isolation for the DDNS, relationships and socialization can be fostered using peer mentoring groups, which help DDNS to establish strategies to network with other doctoral students, alumni, and their faculty advisor (Kumar & Coe, 2017; Flores-Scott & Nerad, 2012). Dual doctoral degree cohort sessions, where DDNS and the program directors meet online via videoconferencing, and activities such as a university hosted dinner, can also be scheduled to foster a sense of community among DDNS. As described by the participants, DDNS require both mentoring and a substantial amount of support throughout their program. Although mentorship and support are often synonymous in the literature (Welch, 2017), a mentor is an experienced faculty who guides the novice student to gain the knowledge necessary to transition into the nurse clinical expert-researcher role (National League for Nursing, 2012; Rand & Pajarillo, 2015; Sanfey, Hollands, & Gantt, 2013; Welch, 2017) whereas support is the act of caring, encouraging, protecting and promoting mentees in their personal and professional development (Kumar et al., 2013; Sanfey et al., 2013). Our findings indicate that coupling mentorship with support from the advisor is fundamental for DDNS to progress forward in their coursework, toward dissertation, and eventually graduation. Providing mentorship with support fosters an environment where the student is assisted both academically and emotionally during the difficulties of this unique form of doctoral education. Peer mentoring groups are a form of informal mentoring and an 6

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plans can be further evaluated for efficacy. Information on strategies to support DDNS, faculty and dual degree programs is included in Table 3. The findings of this study may not be transferable to other settings because participants may vary in their individual context in comparison to other DDNS. As this study had an all-female sample, the male perspective is missing. Owing to the retrospective nature of the descriptions shared, recall bias could have impacted participants responses.

throughout the doctoral program and play an active role in determining their mentor. Outside of the discipline of nursing, distance learning doctoral students have described the importance of a supportive attitude, regular timely feedback, honesty, and shared research interests for their mentor, but these reports are specific to the dissertation phase (Goodwin-Lee, 2010; Joerg, 2004; Kumar et al., 2013; Kumar & Coe, 2017). Critical to participants' confidence to successfully transition through comprehensive examinations was their ability to speak about the components of the exam as well as write about them. Compounding this concern could be the hybrid learning environment, which may limit opportunities for oral discourse. Online courses need to include opportunities for DDNS to articulate their thoughts verbally as well as in writing. A suggestion to accomplish this would be by changing the discussion board formats to include periodic online videoconference to mimic seminars, and providing students the option to attend “brown bag” sessions to present their current research with cohort members and faculty and have the opportunity for discourse. Including a periodic online format would require faculty to follow the processes and protocols set forth by their institutions. Overall, there is an absence of literature on the topic of comprehensive exam experience in nursing doctoral education, and none regarding the DDNS. Further research is needed to evaluate the facilitators and barriers to successful comprehensive examination experience in DDNS. Participants described feeling adequately prepared to develop, implement, and complete their dissertation in a timely manner. Compared to the coursework experience, the advisor and dissertation committee had a more integral role for participants. Specifically, individualized advisor feedback became pivotal in promoting DDNS comprehensive exam preparedness and dissertation readiness, promoting students to learn on their own to develop critical thinking skills and writing (Odena & Burgess, 2017). These self-regulated learning skills have been shown to predict the timeline between comprehensive exams and the completion of dissertation, while controlling for financial support, social support, research self-efficacy, field of study, and gender (Kelley & Salisbury-Glennon, 2016). Participants' recommendations for future students were increased peer support and mentoring, active engagement in selection of a mentor, and use of an individualized development plan to enhance mentorship and a streamlined plan of study to navigate the program. Research is needed to evaluate strategies that assist DDNS in mentor selection, such as student-led interviews focused on mentorship styles. Additionally, mentorship aids, such as individualized development

Implications and conclusion The findings presented highlight the importance of understanding that DDNS have unique experiences that impact their progression through doctoral education. Adding further complexity to this experience is the factor of hybrid education environment. Nursing educators need to be aware that DDNS require support as well as mentorship in an individualized format to facilitate progression through doctoral education. Mentorship includes specific desired attributes of DDNS mentors: being approachable, honest, knowledgeable of the research topic and genuine. Peer mentoring, both one-on-one and group formats, have the potential to bolster DDNS in their progression, support their wellbeing, and limit feelings of isolation and in-betweenness. Faculty mentors need to look past the traditional model of pedagogy and embrace new ways to facilitate knowledge transmission as DDNS navigate this uncharted terrain. Suggestions include having open and frequent conversations with DDNS to address gaps in knowledge transmission, being open to challenging the “status quo” to finding novel ways to facilitate knowledge development in DDNS and asking for feedback from DDNS students. National organizations and institutions need to take an innovative approach in development of funding streams to support future DDNS. These will help to reduce financial burden, provide financial incentive to potential future DDNS, and sustain PhD-DNP dual degree programs for the future. Declaration of competing interest The authors have no conflicts of interest to disclose. This work was funded by the University of Arizona Graduate College. Acknowledgments The authors would like to acknowledge and express gratitude for the assistance of Santiago Tso, Tricia Fabijanic, Amanda Gluski, and the University of Arizona Graduate College.

Table 3 Strategies for success for PhD-DNP dual degree nursing students, faculty, and the dual doctoral degree program. Dual degree nursing student

Faculty

1. Reflect on the mentor attributes that you value or do not value in a mentor or advisor. 2. Have an active role in selecting your mentor or advisor. 3. Create an individualized development plan (plan of study, professional and academic goals, timelines, established advisor meeting times) with your advisor to guide you through your program. 4. Develop a core peer support group within the doctoral program and use chat apps and videoconferencing to regularly communicate with peers. 5. When transitioning from DNP to PhD (or vice versa) coursework, reach out to peers in that program and build relationships. 6. Communicate with advisor or mentor regarding accomplishments, uncertainty, and any inhibitors to progression. 7. Make it a priority to maintain a work-life balance for wellbeing and academic success.

1. Be familiar with the dual degree curriculum to facilitate advising dual degree students. 2. Understand that the dual degree nursing student has unique experiences that are different from other PhD or DNP students; these include feelings of in-betweenness and isolation. 3. Maintain contact with the dual degree student during the transition from DNP to PhD (or vice versa) coursework. 4. Assist the dual degree student to create an individualized development plan. 5. Provide timely and regular feedback, be approachable, honest, and genuinely interested in the dual degree student's work. 6. Facilitate and promote frequent online peer group meetings, including dual degree students with PhD or DNP students. 7. Require students to use oral and written skills. Change discussion boards to include a periodic synchronous online videoconferencing format or substitute monthly oral presentations that complement or replace papers.

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Dual degree program 1. Ensure that the curriculum is streamlined and plans of study are well articulated. 2. Hold educational sessions for faculty to increase awareness of the specific needs of dual degree nursing student. 3. Develop specific individualized mentorship plans focused on the dual degree nursing student. 4. Develop institutional funding mechanisms to support dual degree nursing students to facilitate their progression. 5. Collaborate with other dual degree programs to collect data on dual degree nursing student outcomes. 6. Work with national organizations to develop a database on outcomes for dual degree nursing students to leverage for future funding opportunities.

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