INTRODUCTION

TERMINAL DEGREE FOR NURSING

As the healthcare system has become more complex, the need for clinicians to have a broader scope of understanding on how to deliver the highest quality care was identified as a major concern by the nursing profession. It has been noted that clinicians today must be astutely aware of the financial aspects of providing care, including ordering diagnostic tests, prescribing medications, and admitting patients to the hospital. These concerns and challenges in the delivery of care have led to the need for and development of a terminal practice doctoral degree. Therefore, nursing adopted the terminal practice doctorate, which has become the standard for several other healthcare disciplines. The AACN reviewed and researched other clinical specialties, such as physical therapy (DPT), occupational therapy (OTD), pharmacy (PharmD), and audiology (AuD), that have incorporated a practice doctorate as their terminal clinical degree. The nursing practice degree was first introduced as a professional path for NPs to obtain a doctoral practice degree in order to combat the issues of autonomous practice, changing healthcare environment, including the Affordable Healthcare Act, and the shortage of qualified nurse educators. Nursing’s ability to utilize the practice doctorate has created a significant increase in the number of nurses pursuing higher education.

In 2006, the terminal degree in nursing dramatically changed with the addition of the DNP. The development and acceptance of the DNP has altered the climate of nursing programs and curricula both nationally and internationally. Canada has been involved in exploring the DNP degree for NPs (Brar, Boschma, & McCuaig, 2010). International nursing schools and universities have been following the progress of the U.S. practice doctorate programs.

In the beginning stages of the development of the DNP program, there existed a significant amount of controversy among the nursing community and nursing scholars. Many nurses questioned the usefulness of the DNP and challenged its creditability. Countless publications in peer-reviewed journal articles highlighted the potential disruption of the practice doctorate. Originally, the DNP degree was specifically aimed to be the highest degree for NPs.

Most DNP programs require the candidate to have an MSN degree, specialty certification and be currently practicing. However, there are some universities that offer a bachelor of science in nursing (BSN) to DNP program embracing the concept that the DNP is a terminal-level degree.

THE USE OF THE “Dr.” TITLE

DNP programs have been embraced by the nursing community and recognized as a leader in scholarly nursing practice. Historically, the “Dr.” title has evolved from the academic arena since the Middle Ages. The recognition of the DNP as a terminal practice degree has offered the opportunity to use the official “Dr.” title. There are numerous definitions related to the term doctor. Doctor can be used to refer to a professor holding a terminal degree in the academic setting. Doctor can also be used to address healthcare professionals, such as physicians, dentists and/or veterinarians.

In most settings, nurses with a DNP degree are using the “Dr.” title with little difficulty. For example, in the academic setting, the use of “Dr.” is widely accepted among colleagues, students, and universities. Historically, the title “Dr.” was initially formed in the academic arena and has been used since the 1800s. In addition to those in academia, DNP-prepared nurses in administration, education, research, and leadership roles can utilize the title “Dr.” without controversy. However, this is not true in the practice setting. Unfortunately, the use of the title by DNPs in clinical practice remains a controversial issue among other healthcare providers. Interestingly, some states do not allow the use of title “Dr.” for clinical-practicing DNP nurses.

Certain healthcare organizations may also have specific requirements and/or restrictions for nurses and NPs utilizing the earned “Dr.” title. Therefore, it is important for a DNP to investigate and understand an organization’s viewpoint and potential restrictions of the earned “Dr.” title before making a decision of employment.

The controversy of using the “Dr.” title exists among other healthcare providers, and the major concern expressed is the patient may experience role confusion. The rationale used by the medical community for the disagreement toward nurses using the earned “Dr.” title is related to the concern that patients will be confused as to who is the medical physician. However, practice confusion can be avoided by NPs and DNPs using clear and distinct nurse–patient communication. For example, a proper DNP introduction in the practice setting includes “Hello, my name is Dr. Susan Smith. I am your nurse practitioner.” It is important to address the title issue before entering the workplace, and DNPs need to be confident and professional in presenting themselves to their colleagues and patients.

ADVANTAGES OF THE DNP DEGREE

The DNP degree is a huge accomplishment for the nursing profession. The literature supports that nurses with doctoral degrees account for approximately 1% to 2% of the nursing population. Doctoral degrees included in the literature encompass DNPs, PhDs, and EdDs as well. Statistically, this is a small number of nurses pursuing an advanced degree. However, DNP program enrollment and completion is surpassing that of the PhD programs and continues to increase steadily. Being the DNP is clinically and practice focused, it has afforded nurses across all nursing fields to follow the path of doctoral education. The DNP allows nurses the opportunity, time, resources, and interest to pursue a higher level of education. According to the AACN, currently there are close to 350 DNP programs in the 50 states plus the District of Columbia. There are approximately 121 new DNP programs in the planning stages within the United States. The number of DNP student enrollment from 2017 to 2018 significantly increased from 29,093 to 32,678 (AACN, 2019). This growth indicates the wide acceptance of the DNP degree among the nursing population as a viable option for practice. These numbers speak volumes in the nursing arena. DNP programs provide multiple options for nurses to pursue a terminal degree in nursing. Most importantly, the DNP degree is not isolated to NPs as originally suggested but for all nurses planning to pursue the highest educational experience.

The healthcare environment is multifaceted and requires nurses to have a keen understanding of evidence-based practice/research, health policy, change theories, science of nursing, nursing theories, and business concepts. In order to execute the above mentioned concepts, advanced educational preparation must be the target for nurses and NPs. To deliver high-quality patient outcomes, meet national safety benchmarks, become actively involved with healthcare policy, and maintain a financial balance, a doctorate degree is essential.

EVOLUTION OF THE DNP DEGREE

Nursing is a unique profession regarding educational preparation, credentials, and titles. The global changes in healthcare have been a primary reason for the lack of uniformity within educational levels in nursing. For example, a nurse can be eligible for applying to the nursing licensing exam by attending either a diploma, an associate’s, or a bachelor’s program. There is no standardization of an educational program to become a registered nurse, unlike other healthcare professionals. The reason for the diversity within the educational preparation is directly related to nursing’s flexibility. The strategic implementation of numerous options for entering nursing schools was in direct response to the ever-changing global healthcare and patient needs. Nursing created the educational variations and changes to the professional preparation and titles to ensure an opportunity to increase the number of nurses entering the profession and ultimately meeting the demands to care for increased aging patient populations. Examples of how the nursing profession adapted to the changing healthcare environment were the development of licensed practical nurse (LPN) and associate degree (2-year community-based) nursing programs during the times of severe nursing shortages.

In some instances, it has led to a lack of respect for nursing among other healthcare professionals, as nursing does not follow a uniform approach to the educational preparation. The AACN needs to be recognized as a leader and motivator for the nursing profession. The DNP degree should be viewed as a vehicle and innovator for nurses to obtain a terminal degree. The DNP degree has highlighted a clinical practice doctorate and has empowered nurses and NPs. DNP nurses have the ability to directly impact the perception of the nursing profession as well as have an opportunity to provide the highest quality care within a complex healthcare system. NPs and DNPs are leaders within the profession and can be viewed as change agents.

The AACN was at the forefront of the development of the DNP degree. The concept originated from the AACN in 2002. A task force was formed to determine and answer the question regarding a practice doctorate. Although a practice doctoral degree was not a new idea, the ability to successfully implement a standardized practice program was not yet established. In addition, complete endorsement of the practice degree was not widely accepted.

In order for the practice degree to come to life, the AACN task force worked diligently on reviewing the preexisting practice programs, determining the purpose of the degree, initiating appropriate terminology/verbiage goals, and proposing a path for curriculum development. In 2004, the AACN published a position statement, which clearly outlined the benefits of the practice doctorate, and hence, the adoption of the DNP as the terminal practice degree became illuminated. The position paper emphasized that the DNP program must develop advanced competencies for complicated health practice and faculty members; pursue leadership roles; impact nursing practice and patient outcomes; strengthen care delivery; provide advanced practice knowledge without a strong research component; improve program requirements, credits, time, and credentials; provide a venue to attract nonnursing individuals to the profession; and ultimately increase faculty to provide clinical instruction.

After the decision to proceed with the practice degree, the AACN initiated another task force. This time, the task force was assigned the mission of developing the requirements and expectations of the degree. The major component of the task force was the establishment of the DNP essentials (AACN, 2006). These essentials serve as the foundation of the degree and act as a guide to mold the curricula and programs that are currently in existence.

NURSING ROLES FOR THE DNP DEGREE

As previously mentioned, the DNP was specifically designed as the entry-level degree for the NP and has evolved to include nurses practicing in direct patient care or indirect patient care roles. The ability for nurses to apply to DNP programs regardless of their specialty or nursing role contributes to the successful growth of these programs. Nurses are expanding their educational process because of the desire for advanced knowledge, practice, competencies, theories, evidence-based practice, and research.

Direct patient care is associated with the hands-on approach encompassing inpatient or outpatient settings, ED, critical care, oncology, cardiology, and medical/surgical nursing, to name a few examples. The advanced nursing roles such as NP and clinical nurse specialists also qualify as direct patient care. The role of DNP direct care provider is focused around the patient and family. It is imperative for the DNP provider to review and understand the patient’s disease process and pay special attention to critical labs, diagnostic tests, and current treatment options in order to implement and ensure positive clinical outcomes. The DNP emphasis is to provide high-quality outcomes for patients and their family members.

The roles of indirect nursing incorporate management/leadership and education. Indirect nursing roles influence the patient from a global aspect. Patients are affected by the changes in healthcare from the governmental policies or state-level organizational policy and procedures and identification of educational deficiencies. For example, indirect nursing roles that have correlation to patient care have been the changes in fall policy and procedures, alterations in visitation times for critical care and oncology units, and the development of bloodless medicine centers. The staff development/education DNP role can also impact patient care. For example, the development of new and updated hospital-based educational programs, such as advanced emergency/critical care, oncology/bone marrow transplant, and maternal/child health, will ultimately influence patient care. Some hospitals are on the cutting edge of new nurse orientations and include advanced simulation classes. Regardless of how or where a DNP chooses to practice, the DNP degree will afford the chance to explore the following in depth: difficult patient issues and procedures; controversial, ethically charged patient situations; and the ability to implement change in any practice setting.

DIFFERENCES IN DOCTORAL PROGRAMS

Diversity is a common theme in nursing. Educational programs are varied and have different requirements based upon the curriculum and goal of the degree. As stated previously, there are numerous educational paths to receive a registered nurse title; now the same holds true for a doctoral degree. There is no one-size-fits-all in nursing; however, it is imperative for students to pursue the degree that will match/fit best in their career goals and lifelong plans. There are three options from which to choose regarding doctoral degrees: DNP, PhD, and EdD. These are all considered terminal degrees and can yield multiple options in relation to the nursing profession. It is important to remember that each degree has its own distinct feature, which will add to the current nursing arena.

One degree is not better than the other. What is most significant is that the appropriate degree is chosen based upon an individual’s professional and personal long-term career goals. Making a decision to engage in doctoral education should not be taken lightly, and one should research and investigate several universities and options before making the final decision.

In some instances, a student may decide to obtain a dual doctoral degree. After reviewing the differences, some may determine that in order to create a diverse career path, two degrees may be a perfect match. In some rare instances, a nurse may aspire to be a perpetual student and enjoy the vigorous thought-provoking stimulation of learning. In any event, whatever the reason and choice, a doctoral education is one of the most rewarding experiences. Table 1.1 reviews the differences between the doctoral degrees.

FINANCIAL CONSIDERATIONS FOR THE DNP DEGREE

Finances may be a concern in pursuing a doctoral degree. However, there are several resources that need to be explored before making money a barrier to achieving one’s goal. DNP students working full time in healthcare organizations may have the advantage of tuition reimbursement. If tuition reimbursement is available, make sure to read the policy and deadline dates. Some organizations require final grades for courses to be registered in a computerized system or directly communicated to the human resources department by a specific date and time in order to be eligible for the reimbursement. Grades may also be another factor in the eligibility for tuition assistance, and most often the requirement is a C or better. However, maintaining adequate grades in the program is less likely to be a problem for DNP students compared with undergraduate and graduate students. Typically, doctoral students are highly motivated, extremely bright, and eager to learn.

Scholarships and grants are other viable options for tuition assistance. It is a crucial factor to remain diligent and pay special attention to requirements and deadlines when engaging in scholarships and grant applications. Some applications may require letters of recommendation; therefore, it is imperative to allot adequate time to make the request to fellow colleagues and provide them a specific deadline.

Specialty organizations usually offer scholarship opportunities at annual conferences and to the members of the organization. Therefore, being a member can yield numerous benefits. It is important to review the requirements and submit by the deadlines. Applying for scholarships and grants may take time and coordination; however, the results can be quite lucrative. Scholarships can range from $1,000 to $2,500. In some cases, scholarly grants, which usually require a significant amount of information, can be awarded from $10,000 to $60,000, depending on the topic and potential anticipated outcomes. Some faculty members may be able to assist in the process of grant writing if the topic is appropriate. Individual scholarships can be another option, such as from local businesses, community groups, and private corporations; these often provide a small sum of money, but it is worth completing the application process.

Lastly, scholarship and work study programs at the university/college level can be offered to students. These are usually limited, are highly competitive, and require a separate application process. Students are usually selected based upon the program chair and have to meet specific criteria. Additionally, some programs offer a stipend for graduate students who work with faculty on individual projects not related to the DNP project and may be required to work 10 to 20 hours per week. The amount of work time required is dependent on the program and the available resources. It is important to connect with the dean or program director regarding scholarships and work programs to gain information and access to the application process.

VARIETY OF DNP PROGRAMS

Just like there are no two nurses, patients, families, and physicians who are exactly the same, the same holds true for DNP programs. The AACN developed key elements, including the competencies of the DNP essentials; however, each curriculum is significantly different. DNP curricula are built upon the foundation of traditional master’s programs that are highly focused on utilizing evidence-based practice, quality improvement, patient outcomes, leadership skills, and organizational systems concepts. It is important to understand that DNP programs may include specific aspects of research methods and theories, which can be incorporated into the final project.

The majority of the DNP programs will offer different teaching styles/methods, which include either face-to-face or online interactions or a combination of the two strategies. Some universities have named their programs “hybrid classroom learning.” Regardless of the terminology used by the university or college to implement the DNP program, the most important decision is that a student makes the right choice for his or her learning needs, work requirements, and lifestyle.

DNP program educators are cognizant that DNP students are often working part time or full time. Many times, DNP programs encourage DNP students to continue to stay involved with patient care, as this is a practice doctorate and allows students to remain current in their area of expertise. DNP programs may utilize mixed teaching methodology, such as in-person class time, which may often be scheduled on weekends and/or designated times during the semester. Another variation of class time is to have students attend extended time on campus at the beginning or end of the semester and the rest of the time use distance-learning concepts. Lastly, there are many DNP programs that are purely online. Online courses are organized to include required assignments and specific deadlines and are presented at the beginning of the course. The opportunities are endless and offer multiple avenues to be successful in pursuing a DNP degree.

DNP students need to understand their learning styles to find the best match and to strike a healthy balance between work and school.

Numerous DNP programs use the concept of educational nursing cohorts. A “cohort” is a group of students who are educated at the same time with a specific curriculum. There are many advantages of cohorts, and they have been used primarily for higher education. A nursing cohort is beneficial to DNP students because it provides small group dynamics; fosters support, teamwork, and collaboration; and utilizes each student’s individual strengths, which create an environment to share resources. Additionally, nursing cohorts open perspectives on other nursing specialty areas. For example, members in a nursing cohort can be from different practice settings, such as oncology, administration, maternal–fetal medicine, and informatics, to name a few. Each nurse will bring a wealth of knowledge related to his or her expertise. The ability to share patient experiences, current practice methods, concerns, and barriers creates a chance to eliminate silos among nurses’ specialties. In some instances, nurses may recognize that each specialty may encounter similar challenges and/or outcomes within different patient populations. Sharing of knowledge enhances the respect for how other disciplines practice and provides a network of resources that can be used after completing the DNP degree. Nursing cohorts also create positive bonds between the members and can be the foundation for lifelong friendships and collaboration.

REQUIREMENTS FOR DNP PROGRAMS

A universal requirement of DNP programs is the completion of clinical hours. Some programs can require as much as 1,000 clinical hours. Depending upon the university and curriculum design, there are a variety of mechanisms to reach the 1,000 hours. Some courses may have embedded clinical hours, whereas others are correlated with the DNP project. The amount of clinical hours is also dependent on the degree while entering the DNP program. For example, those who have a BSN degree may require more clinical hours than a nurse entering with an MSN degree. The dean or program director will be able to assist with questions and concerns regarding meeting the clinical requirements.

Perseverance, dedication, positivity, hard work, and time management are all skills required to fulfill the DNP program requirements. Time management is truly the key to success and will allow the ability to envision the end result, the final project. Words cannot describe the thrill and elation walking on stage or across the stadium at the respective university and being announced as doctor of nursing practice.

THE DNP PROJECT

The DNP project is the pinnacle for completion of the degree. Much like the nursing profession, there is not a standardized terminology for the project. Each program will identify the project by a different name or title. This is an excellent example of semantics; however, it really does not matter what the final project is named. What matters is that it meets the requirements of the curriculum and that it is scholarly based and completed within the allotted time. Common terms for the DNP project include capstone, DNP project, final project, evidence-based project, quality improvement, and scholarly project. The project is designed to identify challenges in healthcare, current issues in the practice setting, and health policy concerns. The results of the project are to ultimately provide a potential solution, strategy, and/or increased awareness and understanding of the potential issue. Additionally, the project is to add to the body of knowledge and nursing literature.

Another factor regarding the DNP project is the potential influences of the teaching faculty. For example, if the faculty member is teaching with a PhD background, the project may be based on a more traditional research approach. Conversely, if a DNP faculty is teaching, the focus may be on a single evidence-based project, a quality improvement issue on a nursing unit, community health issue, or a current health policy concern. For example, DNP projects range from students developing a preop and postop checklist, to performing a meta-analysis of the role of the DNP, to determining the usage of personal protective equipment among oncology nurses. There is a great deal of diversity among the DNP projects. Each project adds to the nursing knowledge and expertise within the specialty. More importantly, it provides value to the DNP degree, and in certain instances, it can be the beginning of further study. Therefore, one project is not better than another, and what matters the most is that the project is special to the individual practice. Regardless of what the project is named or termed, it is imperative to have careful consideration of the topic before final decision.

The curriculum will dictate the specific requirements for the DNP project but most will include a well-thought-out question, a comprehensive review of the literature, use of tool (if applicable), connection to essentials, plan of implementation, review of data collection, analysis of the outcomes, relationship to nursing practice, and conclusion. In order to avoid struggling with project selection, choose a topic that sparks passion and one that will have the ability to develop a deep connection with and impact individual practice. The DNP essentials will be another factor in topic selection. The essentials will assist in narrowing the focus of the project and, once incorporated, will guide the method and outcomes to final results.

The DNP project will be infused into daily life for a brief period of time. Remember there is a beginning and an end to the DNP project. Just before the completion of the project, it may take on a life of its own. However, faculty guidance, time management, and endurance will lead to the final product. There may be some days when the project is more important than eating and sleeping! Just know that once final papers are signed, the project will be laid to rest and forever in print. Don’t ever give up!

In most programs, a project chairperson will be determined through a proposal committee. During this time, faculty members listen and review the DNP student presentations of the DNP project. The committee helps the student to determine if the project is acceptable, clinically significant, and implementable. Usually, the faculty chairperson and the student will develop a mutual agreement to work together. This is a time for the student to decide who will be the best person to assist and guide him or her through the DNP project. Having a relationship with the chair is paramount in the completion process. The chairperson has an integral role in assisting the student navigate through the project, providing positive and negative feedback, evoking critical thinking, critiquing scholarly writing, and ensuring the student is prepared for oral and written presentation (if applicable).

FUTURE DIRECTIONS: BRIDGE PROGRAMS

Oftentimes, the DNP project can take on a life of its own, requiring further refinement, and can be the foundation of another degree. Please note this path is not for everyone, but for some, the DNP may be the first doctoral degree. For others, the DNP is the pinnacle degree for practice and needs no further education. As this is a controversial issue, the goal of this book is to provide all options that may or may not be a choice of the reader. Bridge programs exist and may be a viable option for those who have been ignited from their work in their DNP program and want to delve deeper into the research focus. Many students may be sparked and motivated to add to the educational repertoire.

In contrast, this may sound overwhelming at this point in time because many are still deciding or planning on completing the DNP degree. However, it is important to think ahead toward the future in order to align yourself in the best possible position to navigate through your educational and professional journey. The objective is to increase awareness of the vast opportunities that can be built upon the DNP degree.

The DNP affords the best degree for practice nurses; however, if you decide to add upon the practice aspect and pursue research and or academia, a dual doctorate may be a viable consideration. A bridge program may offer a chance to obtain a dual doctorate with either a PhD or an EdD, depending on which nursing role you chose to practice. When deciding to further your doctoral education, make sure that you choose the best program that will match with your career goals.

Some universities will provide a “bridge program” that will accept approximately half of the credits based upon the DNP program. However, not all programs will accept DNP credits; so be careful in university selection. It would be advisable to take the time and call/email the program coordinator.

Some programs will request informal transcripts at first in order to determine how many credits of the DNP will be accepted or require informal transcripts to initiate the application process. Often times, the application process for doctoral degrees have rolling admission and do not have hard stop deadlines.

POSITIVE IMPACT OF THE DNP DEGREE

The DNP is a practice doctorate degree that focuses on the importance of patients’ outcomes and the existing difficult and unanswered healthcare dilemmas. The DNP incorporates the elements of nursing theories; understands patient care issues; and reviews current healthcare agendas, policies, and procedures, while utilizing the scholarly thinking and writing process. The DNP degree will allow the nurse to investigate and understand evidence-based practice, research, performance improvement, and quality concerns. The degree will cultivate academic/professional writing, which will be a welcomed addition to the nursing literature.

Obtaining the DNP degree will broaden views regarding all aspects of nursing as well as allow the opportunity to apply strategies and changes to each nursing setting and specialty. On a professional level, the DNP degree will enhance critical/global thinking, which will have the capacity to resonate to patients and organizations.

On the personal level, completing the DNP degree will provide enormous growth and satisfaction. A major accolade for the DNP degree is that it has the capability to be tailored to match individual strengths and professional and personal interests, and most importantly, it will be the fuel for long-term career goals. The achievement of the DNP degree will not only be professionally and personally rewarding but add to current nursing literature and knowledge and allow the prospect to become actively involved in creating nursing history. The DNP opportunities are boundless and will build upon the fundamentals of nursing practice.

SUMMARY

This chapter provided an overview of the evolution of the DNP degree, different programs, and learning environments available. In addition, it is hoped that this chapter will create a vision for potential personal and professional options offered with pursing the degree. Choosing the DNP degree will enhance multiple opportunities to open pathways in nursing that are not always available without a terminal degree.