- Email: [email protected]
Why Have a Doctorate of Nursing Practice?
just as MSN or PhD.The degree does not indicate in what area of practice one is prepared.Therefore, a graduate would use the DNP credential along with the specific NP credential earned, such as Jane Doe, DNP, ANP, or DNP,WHNP. As professionals, NPs are life-long learners engaged in professional development, self-improvement, on-the-job learning, and continuing education courses. Recognizing the need for additional formal education is only an extension of this learning continuum. NPs are assertive and vocal, which is one of the primary reasons they have been so successful in attaining their current position within the health care system. As advocates within the profession, we cannot sit back and rest on our accomplishments.We must continue to fight for our place at the policy table and to be recognized for the significant contributions in addressing this country’s health care needs. NPs have never shied away from a challenge and cannot do so now. As leaders in nursing, NPs must address the mandates and challenges put forward by the IOM,7 the American Hospital Association,14 and the Robert Wood Johnson Foundation.15 A thoughtful approach by the NP community to the DNP as the degree for future NP educational preparation is one step in meeting this challenge. References 1. American Academy of Nurse Practitioners. US Nurse Practitioner Workforce 2004. Available at: www.aanp.org/NR/rdonlyres/exenwjnl3eybaktqli266uvk4 kw364gapgzjhyyvey2d7fziiv2uhd55atxojxgdjrp3q5vu4e6akp/NPStateWorkfor ceData120004.pdf. Accessed 2005 September 1. 2. American Association of Colleges of Nursing. Final Report: Advocacy/ Mentorship Program for the Recruitment of Certified Nurse Practitioners. Washington, DC: American Association of Colleges of Nursing; 1993. Unpublished report. Contract Work Item I.C. 3 for HRSA Contract No. 240-910020. 3. Berlin LE, Wilsey SJ, Bednash GD. 2004-2005 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing. Washington, DC: American Association of Colleges of Nursing; 2005. 4. American Association of Colleges of Nursing. Position statement on certification and regulation of advanced practice nurse. Originally issued in October 1994. Available at www.aacn.nche.edu/Publications/positions/ cerreg.htm. Accessed 2005 September 1. 5. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. 6. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 7. Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: National Academy Press; 2003.
8. American Association of Colleges of Nursing. Position statement on the practice doctorate in nursing. 2004. Available at: www.aacn.nche.edu/ DNP/DNPPositionStatement.htm. Accessed 2005 September 1. 9. National Research Council. Advancing the Nation’s Health Needs: NIH research Training Programs. Washington, DC: National Academies Press; 2005. 10. American Association of Colleges of Nursing. Position statement: indicators of quality in research-focused doctoral programs in nursing. 2001. Available at: www.aacn.nche.edu/Publications/positions/qualityindicators.htm. Accessed 2005 September 1. 11. Pearson L. Opinions, ideas and convictions from NP’s founding mother Dr. Loretta Ford. Nurse Pract World News. 2005;10(1):7,20. 12. Bellack J, Graber D, O’Neil E, Musham C, Lancaster C. Curriculum trends in nurse practitioner programs: current and ideal. J Prof Nurs. 1999;15:15-27. 13. Lenz ER, Mundinger MO, Hopkins S, Clark J, Lin S. Patterns of nurse practitioner practice: results from a national survey [unpublished data]. Presented at the State of the Science Conference, Washington, DC, September 2002. 14. American Hospital Association Commission on Workforce for Hospitals and Health Systems. In Our Hands, How Hospital Leaders Can Build a Thriving Workforce. Chicago, IL: American Hospital Association; 2002. 15. Kimball B, O’Neill E. Health Care’s Human Crisis: the American Nursing Shortage. Princeton, NJ: The Robert Wood Johnson Foundation; 2002.
Joan M. Stanley, PhD, CRNP, FAAN, is the director of education policy for the American Association of Colleges of Nursing in Washington, DC, and an adult nurse practitioner in the Faculty Practice Office at University of Maryland Hospital in Baltimore. She can be reached at [email protected]. Editor’s Comments: Dr. Stanley, in her position with AACN, has been involved with the DNP from its inception and speaks with some authority about the status of this new policy.This article discusses questions that are most frequently raised on the subject; however, clearly she nor anyone can answer every question in one brief article. Notably, reviewers of her article observe that she does address the need for the development of the Essentials which will provide standardization for DNP education programs. However, at least two schools offering the DNP currently require a full dissertation. Hence, although she states, “…programs must be distinct and not become blurred…,” the distinction between DNP and PhD is already beginning to be blurred. Additionally, the article does not clarify whether MS programs will still be in existence after 2015 or whether every program by that time will be required to be at the doctoral level.This is a recurrent question that requires further exploration. 1555-4155/05/$—see front matter. © 2005 Inc. All rights reserved. doi:10.1016/j.nurpra.2005.10.021
Why Have a Doctorate of Nursing Practice? Margaret (Peggy) Rowberg
A
fter becoming a nurse practitioner (NP), I thought I was finally finished going to school. After all, I was a diploma nurse from the 60s who had finally gone 212
back to college in the 90s to obtain bachelor and master’s degrees.What possible reason could there be to obtain a doctorate, particularly because most degrees are November/December 2005
focused on conducting original research? It did not sound appealing or necessary for my clinical practice. Shortly after graduation, though, an administrator for my employer misinterpreted the Medicare guidelines for that year and sent out a mandate that NPs could not order lab work. All blood draws were to be ordered by the physician. On questioning my employer, I was informed that the physician would write the orders and I should not argue with the ruling. My collaborative physician was not only too busy with his own patients to write orders for me, but this mandate was a professional affront to my right to practice. Having studied the state nurse practice act in school and becoming a member of the state NP association as a student, I was fully aware of my rights as a professional and was determined to have this mandate overturned. Out of this situation came my desire to become more involved in the state NP association. Never before had I cared about politics, nor had I been a member of any organized group. When the opportunity arose a few months later to become a regional representative to the California Association for Nurse Practitioners (CANP) board of directors, I jumped at the chance and quickly realized how little I really knew about politics, organizations, and the effect of legislation on my clinical practice. I discovered that, despite holding a master’s degree, there were huge gaps in my knowledge. NP education gave me the tools to be an excellent clinician but provided little background in policy, organizational behavior, business, leadership, and practice management. I spent the next 5 years focusing on improving my clinical expertise. During that time an occasion arose to teach in an NP program, which was followed in a few months with an offer to be the academic coordinator of the program. At the same time, my commitment to CANP remained strong and provided opportunities to assume leadership roles. As an officer for CANP, many questions came into focus. How could someone obtain the information needed to understand and change health care policy? Who discusses leadership and the many roles it takes? Is there any program that discusses practice management? www.npjournal.org
Where does someone learn about evaluating outcomes without also having to do the related research? What is organizational behavior and how does it affect the people involved? These and many other questions were going unanswered. At first it seemed logical that day-long seminars would help fill the gap, but after several frustrating attempts, it became clear that even attending a large number of seminars would not provide the level of comprehension needed. I spent many hours reviewing nursing schools around the country and the variety of degrees available, but the areas of study needed to address the many issues facing the health care system and nursing are not included in most NP programs. In reviewing business school curriculum, it became evident that the required robust concentration on health care was not present. My goal was not to become a business professional, so a master’s degree in business administration did not fulfill my need. Although there are now some master’s of business administration (MBA) degrees that focus on health care, most do not. An MBA program usually has students from diverse backgrounds who have little understanding of or experience in the problems in health care. Nothing seemed to fit my requirements until the discovery of the nursing doctorate program at Rush University.The doctor of nursing practice (DNP) is a unique degree taught by nursing professionals who focus on the issues related to the health care system.The program allows an intense concentration of study on the concerns facing the health care system and nursing. Graduates finish with the ability to influence policy and practice.This degree also provides the tools and knowledge to effect change that will improve the health care system and its related outcomes. The nursing doctorate has received both criticism and praise. Some people fear that the position statement released by the American Association of Colleges of Nursing (AACN)1 that states that advanced practice nurses (APNs) must be educated at the doctoral level by 2015 is creating another barrier to acceptance of APNs as legitimate health care providers. As Dr. Jacqueline Rhoads2 stated in the first 213
edition of this journal, most other disciplines, including the medical profession, already have clinical doctorates. It is my belief that adding a practice doctorate to the nursing profession will aid in obtaining the respect of others in the health care field. I have received nothing but esteem and admiration on the attainment of the DNP degree. Colleagues with a DNP agree that this degree has had a positive effect on their careers. Graduates indicated they were better prepared in the business and organizational aspects of practice in opening their own private clinical offices; others have been able to effect positive change for all NPs. One NP was paramount in changing pharmaceutical industry policy in Florida through the removal of delegation of authority forms that required NPs to obtain MD authorization to receive medication samples. In certain career positions, the DNP provides the background education needed by a leader who will effect change in clinical practice. Recently, a DNP-prepared APN, a certified nurse anesthetist (CRNA), became the director for the nurse anesthesia program at Wake Forest University with a visiting assistant professorship at the University of North Carolina. He believes his education was the key to his employer hiring him for the position. In the DNP Essentials draft3 released by AACN, eight components focus on the valuable information required for the APN to become a leader in the health care system.The Essentials for the DNP Task Force should be commended for its progressive thinking. Because current APN programs already address the education needed for clinical practice, the additional content of a practice doctorate should focus in other areas. The Essentials suggest the other critical curricular content, such as leadership, organizational behavior, policy, and practice management, which was most helpful for me when I obtained my doctorate and started this new phase to my career. Gaining that understanding has aided me in effecting change in quality and ensuring that best practices are being instituted, as well as provided a greater understanding of policy development and change. There is room in nursing for both clinical and research doctorates. In fact, both degrees are necessary because the profession must conduct research so best practices are identified.This valuable research can be applied throughout all levels of the health care system by nursing and other professionals who possess the expertise in policy, 214
organizational behavior, and practice management and the clinical skills obtained in a practice doctorate. Having the DNP has allowed me the opportunity to continue work begun during my doctoral studies.The initial project involved teaching a standardized clinical breast examination to NP students and incorporating that standardized examination into NP curriculum through a cost-effective and time-sensitive method.This work evolved into collaborating with three PhD-prepared individuals who are experts in standardized clinical breast examinations. Having done research in this area since the 1970s, they were pleased with the opportunity to develop an interactive, web-based, standardized, clini-
Colleagues with a DNP agree that this degree has had a positive effect on their careers.
cal breast examination course that will use some of the most advanced computer technology.The course is still in development with the goal of completion within the next 2 to 3 years.The practice doctorate provided the background and skills to ensure that best practices are being used in the clinical setting. Although entry into practice as a registered nurse is confusing with 2- and 4-year programs, APN has progressed to the graduate degree level with few issues. Moving from a master’s degree to a doctoral degree during the next 10 years will allow NP programs to add courses that can delve into policy, practice issues, and health care problems. Because of the obvious need for competency in disease management, there is little time left in the current NP curriculum to appropriately discuss these other topics. As a practitioner and an educator of NPs, I believe there is no way to include those courses now. Adding additional content to APN programs and awarding a doctorate to the graduates will provide time for this needed focus. This change will not take away from NPs who are in practice and possess a master’s degree. On the contrary, I would expect that many NP programs will allow their November/December 2005
alumni to enroll in the new courses as a way to enhance their careers. Many practicing NPs are expressing concern as they become aware of their knowledge gap. CANP, for instance, has held three business and technology conferences in recent years because of the demand by its members for information related to implementing change and improvements in the health care system. The AACN position statement recommending that APN programs move to the doctoral level by 2015 allows a sufficient amount of time for the needed curricular changes. Nursing should embrace this exciting change as the method by which it can achieve equal status with our fellow health care professionals. In the final analysis, the DNP will fill the knowledge gap for the APN and permit graduates to become the leaders of and change agents for an improved health care system. If APNs are to achieve the provider status to which many of us aspire, a practice doctorate must become part of the solution and a critical option. References 1. Association of American Colleges of Nursing. Position statement on the practice doctorate in nursing. 2004. Available at: www.aacn.nche.edu/ DNP/pdf/DNP.pdf. Accessed 2005 September 1. 2. Rhoads J. Support for the practice doctorate. J Nurs Pract. 2005;1(1):29. 3. Association of American Colleges of Nursing. Draft DNP Essentials (2005 August 18). Available at: www.aacn.nche.edu/DNP/pdf/DNPEssentials Draft_8-18-05.pdf. Accessed 2005 September 1.
Margaret (Peggy) Rowberg, DNP, ANP, is a certified adult nurse practitioner at the University of California Irvine Weight Management Program in Irvine and president of the California Association for Nurse Practitioners. She can be reached at [email protected]. Editor’s Comments: Peggy Rowberg describes her personal experience as a graduate from one of the first programs to use the DNP credential.The Rush University ND program in which she was enrolled indicated to their graduates that they could use the DNP initials. Rush Uuniversity had rewritten the curriculum beginning with the class in which Dr. Rowberg was enrolled.Though listed as a ND program, this new curriculum reflected the content suggested in the DNP Essentials since the Dean from Rush was a member of the DNP Task Force. 1555-4155/05/$ see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1067/j.nurpra.2005.10.021
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8. American Association of Colleges of Nursing. Position statement on the practice doctorate in nursing. 2004. Available at: www.aacn.nche.edu/ DNP/DNPPositionStatement.htm. Accessed 2005 September 1. 9. National Research Council. Advancing the Nation’s Health Needs: NIH research Training Programs. Washington, DC: National Academies Press; 2005. 10. American Association of Colleges of Nursing. Position statement: indicators of quality in research-focused doctoral programs in nursing. 2001. Available at: www.aacn.nche.edu/Publications/positions/qualityindicators.htm. Accessed 2005 September 1. 11. Pearson L. Opinions, ideas and convictions from NP’s founding mother Dr. Loretta Ford. Nurse Pract World News. 2005;10(1):7,20. 12. Bellack J, Graber D, O’Neil E, Musham C, Lancaster C. Curriculum trends in nurse practitioner programs: current and ideal. J Prof Nurs. 1999;15:15-27. 13. Lenz ER, Mundinger MO, Hopkins S, Clark J, Lin S. Patterns of nurse practitioner practice: results from a national survey [unpublished data]. Presented at the State of the Science Conference, Washington, DC, September 2002. 14. American Hospital Association Commission on Workforce for Hospitals and Health Systems. In Our Hands, How Hospital Leaders Can Build a Thriving Workforce. Chicago, IL: American Hospital Association; 2002. 15. Kimball B, O’Neill E. Health Care’s Human Crisis: the American Nursing Shortage. Princeton, NJ: The Robert Wood Johnson Foundation; 2002.
Joan M. Stanley, PhD, CRNP, FAAN, is the director of education policy for the American Association of Colleges of Nursing in Washington, DC, and an adult nurse practitioner in the Faculty Practice Office at University of Maryland Hospital in Baltimore. She can be reached at [email protected]. Editor’s Comments: Dr. Stanley, in her position with AACN, has been involved with the DNP from its inception and speaks with some authority about the status of this new policy.This article discusses questions that are most frequently raised on the subject; however, clearly she nor anyone can answer every question in one brief article. Notably, reviewers of her article observe that she does address the need for the development of the Essentials which will provide standardization for DNP education programs. However, at least two schools offering the DNP currently require a full dissertation. Hence, although she states, “…programs must be distinct and not become blurred…,” the distinction between DNP and PhD is already beginning to be blurred. Additionally, the article does not clarify whether MS programs will still be in existence after 2015 or whether every program by that time will be required to be at the doctoral level.This is a recurrent question that requires further exploration. 1555-4155/05/$—see front matter. © 2005 Inc. All rights reserved. doi:10.1016/j.nurpra.2005.10.021
Why Have a Doctorate of Nursing Practice? Margaret (Peggy) Rowberg
A
fter becoming a nurse practitioner (NP), I thought I was finally finished going to school. After all, I was a diploma nurse from the 60s who had finally gone 212
back to college in the 90s to obtain bachelor and master’s degrees.What possible reason could there be to obtain a doctorate, particularly because most degrees are November/December 2005
focused on conducting original research? It did not sound appealing or necessary for my clinical practice. Shortly after graduation, though, an administrator for my employer misinterpreted the Medicare guidelines for that year and sent out a mandate that NPs could not order lab work. All blood draws were to be ordered by the physician. On questioning my employer, I was informed that the physician would write the orders and I should not argue with the ruling. My collaborative physician was not only too busy with his own patients to write orders for me, but this mandate was a professional affront to my right to practice. Having studied the state nurse practice act in school and becoming a member of the state NP association as a student, I was fully aware of my rights as a professional and was determined to have this mandate overturned. Out of this situation came my desire to become more involved in the state NP association. Never before had I cared about politics, nor had I been a member of any organized group. When the opportunity arose a few months later to become a regional representative to the California Association for Nurse Practitioners (CANP) board of directors, I jumped at the chance and quickly realized how little I really knew about politics, organizations, and the effect of legislation on my clinical practice. I discovered that, despite holding a master’s degree, there were huge gaps in my knowledge. NP education gave me the tools to be an excellent clinician but provided little background in policy, organizational behavior, business, leadership, and practice management. I spent the next 5 years focusing on improving my clinical expertise. During that time an occasion arose to teach in an NP program, which was followed in a few months with an offer to be the academic coordinator of the program. At the same time, my commitment to CANP remained strong and provided opportunities to assume leadership roles. As an officer for CANP, many questions came into focus. How could someone obtain the information needed to understand and change health care policy? Who discusses leadership and the many roles it takes? Is there any program that discusses practice management? www.npjournal.org
Where does someone learn about evaluating outcomes without also having to do the related research? What is organizational behavior and how does it affect the people involved? These and many other questions were going unanswered. At first it seemed logical that day-long seminars would help fill the gap, but after several frustrating attempts, it became clear that even attending a large number of seminars would not provide the level of comprehension needed. I spent many hours reviewing nursing schools around the country and the variety of degrees available, but the areas of study needed to address the many issues facing the health care system and nursing are not included in most NP programs. In reviewing business school curriculum, it became evident that the required robust concentration on health care was not present. My goal was not to become a business professional, so a master’s degree in business administration did not fulfill my need. Although there are now some master’s of business administration (MBA) degrees that focus on health care, most do not. An MBA program usually has students from diverse backgrounds who have little understanding of or experience in the problems in health care. Nothing seemed to fit my requirements until the discovery of the nursing doctorate program at Rush University.The doctor of nursing practice (DNP) is a unique degree taught by nursing professionals who focus on the issues related to the health care system.The program allows an intense concentration of study on the concerns facing the health care system and nursing. Graduates finish with the ability to influence policy and practice.This degree also provides the tools and knowledge to effect change that will improve the health care system and its related outcomes. The nursing doctorate has received both criticism and praise. Some people fear that the position statement released by the American Association of Colleges of Nursing (AACN)1 that states that advanced practice nurses (APNs) must be educated at the doctoral level by 2015 is creating another barrier to acceptance of APNs as legitimate health care providers. As Dr. Jacqueline Rhoads2 stated in the first 213
edition of this journal, most other disciplines, including the medical profession, already have clinical doctorates. It is my belief that adding a practice doctorate to the nursing profession will aid in obtaining the respect of others in the health care field. I have received nothing but esteem and admiration on the attainment of the DNP degree. Colleagues with a DNP agree that this degree has had a positive effect on their careers. Graduates indicated they were better prepared in the business and organizational aspects of practice in opening their own private clinical offices; others have been able to effect positive change for all NPs. One NP was paramount in changing pharmaceutical industry policy in Florida through the removal of delegation of authority forms that required NPs to obtain MD authorization to receive medication samples. In certain career positions, the DNP provides the background education needed by a leader who will effect change in clinical practice. Recently, a DNP-prepared APN, a certified nurse anesthetist (CRNA), became the director for the nurse anesthesia program at Wake Forest University with a visiting assistant professorship at the University of North Carolina. He believes his education was the key to his employer hiring him for the position. In the DNP Essentials draft3 released by AACN, eight components focus on the valuable information required for the APN to become a leader in the health care system.The Essentials for the DNP Task Force should be commended for its progressive thinking. Because current APN programs already address the education needed for clinical practice, the additional content of a practice doctorate should focus in other areas. The Essentials suggest the other critical curricular content, such as leadership, organizational behavior, policy, and practice management, which was most helpful for me when I obtained my doctorate and started this new phase to my career. Gaining that understanding has aided me in effecting change in quality and ensuring that best practices are being instituted, as well as provided a greater understanding of policy development and change. There is room in nursing for both clinical and research doctorates. In fact, both degrees are necessary because the profession must conduct research so best practices are identified.This valuable research can be applied throughout all levels of the health care system by nursing and other professionals who possess the expertise in policy, 214
organizational behavior, and practice management and the clinical skills obtained in a practice doctorate. Having the DNP has allowed me the opportunity to continue work begun during my doctoral studies.The initial project involved teaching a standardized clinical breast examination to NP students and incorporating that standardized examination into NP curriculum through a cost-effective and time-sensitive method.This work evolved into collaborating with three PhD-prepared individuals who are experts in standardized clinical breast examinations. Having done research in this area since the 1970s, they were pleased with the opportunity to develop an interactive, web-based, standardized, clini-
Colleagues with a DNP agree that this degree has had a positive effect on their careers.
cal breast examination course that will use some of the most advanced computer technology.The course is still in development with the goal of completion within the next 2 to 3 years.The practice doctorate provided the background and skills to ensure that best practices are being used in the clinical setting. Although entry into practice as a registered nurse is confusing with 2- and 4-year programs, APN has progressed to the graduate degree level with few issues. Moving from a master’s degree to a doctoral degree during the next 10 years will allow NP programs to add courses that can delve into policy, practice issues, and health care problems. Because of the obvious need for competency in disease management, there is little time left in the current NP curriculum to appropriately discuss these other topics. As a practitioner and an educator of NPs, I believe there is no way to include those courses now. Adding additional content to APN programs and awarding a doctorate to the graduates will provide time for this needed focus. This change will not take away from NPs who are in practice and possess a master’s degree. On the contrary, I would expect that many NP programs will allow their November/December 2005
alumni to enroll in the new courses as a way to enhance their careers. Many practicing NPs are expressing concern as they become aware of their knowledge gap. CANP, for instance, has held three business and technology conferences in recent years because of the demand by its members for information related to implementing change and improvements in the health care system. The AACN position statement recommending that APN programs move to the doctoral level by 2015 allows a sufficient amount of time for the needed curricular changes. Nursing should embrace this exciting change as the method by which it can achieve equal status with our fellow health care professionals. In the final analysis, the DNP will fill the knowledge gap for the APN and permit graduates to become the leaders of and change agents for an improved health care system. If APNs are to achieve the provider status to which many of us aspire, a practice doctorate must become part of the solution and a critical option. References 1. Association of American Colleges of Nursing. Position statement on the practice doctorate in nursing. 2004. Available at: www.aacn.nche.edu/ DNP/pdf/DNP.pdf. Accessed 2005 September 1. 2. Rhoads J. Support for the practice doctorate. J Nurs Pract. 2005;1(1):29. 3. Association of American Colleges of Nursing. Draft DNP Essentials (2005 August 18). Available at: www.aacn.nche.edu/DNP/pdf/DNPEssentials Draft_8-18-05.pdf. Accessed 2005 September 1.
Margaret (Peggy) Rowberg, DNP, ANP, is a certified adult nurse practitioner at the University of California Irvine Weight Management Program in Irvine and president of the California Association for Nurse Practitioners. She can be reached at [email protected]. Editor’s Comments: Peggy Rowberg describes her personal experience as a graduate from one of the first programs to use the DNP credential.The Rush University ND program in which she was enrolled indicated to their graduates that they could use the DNP initials. Rush Uuniversity had rewritten the curriculum beginning with the class in which Dr. Rowberg was enrolled.Though listed as a ND program, this new curriculum reflected the content suggested in the DNP Essentials since the Dean from Rush was a member of the DNP Task Force. 1555-4155/05/$ see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1067/j.nurpra.2005.10.021
Sign up to receive a FREE subscription, plus FREE access to the online version of the journal.*
Visit www.npjournal.org today! * npjournal.org is open to all visitors through December 31, 2005. Request your free subscription today to ensure continued access.