The History and Future of the DNP in Nursing

GAIL E. ARMSTRONG; DEBORAH LINDELL

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1: The History and Future of the DNP in Nursing

DOI:

10.1891/9780826188632.0001

Authors

ARMSTRONG, GAIL E.
LINDELL, DEBORAH

Abstract

The clinical doctorate model of education, also called the practice doctorate, is a model shared by most practice professions. The clinical doctorate is designed to be the terminal degree to prepare one for the highest level of clinical practice within one’s profession. This chapter provides tables outlining the clinical doctorate degree in a variety of clinical professions. Nursing has had a turbulent history regarding a lack of agreement on one model for the clinical doctorate. This chapter outlines that history, clarifying the influences that led to this tumultuous history. Current leadership trends in healthcare indicate that the needs for the clinical leadership offered by doctor of nursing practice (DNP) graduates will only increase in the future. The continual rapid growth of DNP programs indicates that the DNP degree and DNP graduates are addressing current needs in the healthcare system.

INTRODUCTION

Nursing has had a turbulent history regarding a lack of agreement on one model for the clinical doctorate. This chapter outlines that history, clarifying the influences that led to this tumultuous history. The standardized model for the DNP degree was formally introduced in 2004 in a position statement by the American Association of Colleges of Nursing (AACN; 2004). Since the appearance of this cornerstone document, the rapid growth of DNP programs and graduates speak to an alignment of timing, ideas, and needs in the healthcare system. Current leadership trends in healthcare indicate that the needs for the clinical leadership offered by DNP graduates will only increase in the future.

Confusion About Nursing’s Non-PhD Doctorate

Leadership within the nursing profession is shared by several professional organizations (e.g., the American Nurses Association [ANA], the AACN, the National League for Nursing [NLN], the National Organization of Nurse Practitioner Faculty [NONPF], the National Association of Clinical Nurse Specialists [NACNS]). Without one unifying professional voice, nursing has lacked a single clinical doctorate model to address the needed clinical leadership within the profession, outside of the PhD in nursing, a doctorate clearly focused on generating and advancing nursing research. Several models emerged over many years, offering differing elements of what educational leaders believed was needed. As early as 1979, a variety of non-PhD doctoral degrees emerged in nursing, including the doctor of nursing science (DNS, DNSc), doctor of science in nursing (DSN), and the nursing doctorate (ND). Sandra Edwardson offered a concise classification of doctoral degrees in nursing (Figure 1.1). Edwardson’s proposed model (2004) is similar to models suggested by the AACN at the same time.

TABLE 1.1

CLINICAL PROFESSIONS AND CORRESPONDING CLINICAL DOCTORATE DEGREES

Profession	Clinical Doctorate Degree	Degree Abbreviation
Medicine	Doctor of Medicine	MD
Dentistry	Doctor of Dental Medicine	DDM
Veterinary medicine	Doctor of Veterinary Medicine	DVM
Optometry	Doctor of Optometry	OD
Osteopathy	Doctor of Osteopathy	DO
Public health	Doctor of Public Health	DrPH
Pharmacy	Doctor of Pharmacy	PharmD
Psychology	Doctor of Psychology	PsyD
Physical therapy	Doctor of Physical Therapy	DPT

The ND Degree

The ND degree is the clearest predecessor to the DNP, aiming to provide clinical nurse leaders. Although there were never more than a handful of ND degrees at U.S. nursing schools, there was notable variation among the existing programs. In the 2004 AACN position statement outlining the DNP, the lack of uniformity among existing ND programs was cited as a guiding factor in the development of the DNP model (AACN, 2004). To highlight the variations in the ND degree, two early ND models will be examined in depth: (a) Case Western Reserve University and (b) University of Colorado.

FIGURE 1.1

Classification of NDs.

Source: From Edwardson, S. R. (2004). Matching standards and needs in doctoral education in nursing. Journal of Professional Nursing, 20(1), 40–46. doi:10.1016/j.profnurs.2003.12.006

The Evolution of the Professional Doctorate (ND) at Case Western Reserve University

Laying the Foundation (1935–1960)

During the 1960s and 1970s, visionary nurse scholars began to articulate their views of nursing as both a profession and a discipline. Their views of nursing differed according to their experiences in practice, education, and perspectives of health, persons, and the environment. Dr. Rozella Schlotfeldt, RN, PhD, FAAN, was noted to be “an original thinker, outstanding scholar, and an educator having innovative, progressive, and sometimes startling concepts for nursing” (Safier, 1977, p. 334). Schlotfeldt’s vision for advancing the discipline of nursing focused on nursing education and had several elements, of which the “cornerstone” was the ND, a postbaccalaureate professional doctorate, as preparation for entry into nursing practice (Center for the Study of Nursing, n.d.).

Schlotfeldt was born in Iowa in 1914 and earned a BS degree in nursing, after which she worked as a direct-care RN, head nurse, combined instructor–supervisor, and Army nurse in Germany. Following World War II, Schlotfeldt served in faculty roles at two universities prior to pursuing her PhD at the University of Chicago. In 1960, following completion of her PhD and 3 years as associate dean for research and development at Wayne State University, Schlotfeldt was appointed dean and professor of nursing at the Frances Payne Bolton (FPB) School of Nursing, Case Western Reserve University (CWRU) in Cleveland, OH.

A “Plan for Progress” of Nursing Education (1960–1978)

From the time Schlotfeldt first worked as a nurse educator in 1939, she began “thinking about better ways to combine teaching and practice while experimenting with creative approaches that held promise for improving nursing care” (Center for the Study of Nursing, n.d.). She pursued these interests during her doctoral study and, as dean at CWRU, articulated her “Plan for Progress” of nursing education: (a) collaboration between academic and healthcare organizations, (b) faculty roles, (c) her view of nursing, and (d) educational preparation for nursing practice. Schlotfeldt believed that academic and healthcare organizations should collaborate to implement faculty roles that integrated education, research, and practice. In regard to the focus of nursing, Schlotfeldt frequently described her views as aligned with those of Nightingale that nursing is “the helping profession whose primary practice concern is to promote the gamut of health-seeking behaviors of human beings in the several environments” (Schlotfeldt, 1976, p. 105). The fourth part of Schlotfeldt’s vision was that “if nursing is to become a full-fledged professional discipline,” then its practitioners need a full-fledged, professional program of study, with entry at the postbaccalaureate level (Schlotfeldt, 1978, p. 302). In the American Journal of Nursing, she noted: “My view is that all programs of professional study in nursing should be intellectually demanding and that they should warrant the award of the professional doctorate in nursing—the ND degree” (Schlotfeldt, 1976, p. 107).

During 1960 through 1972, and following her deanship at CWRU, Schlotfeldt was a prolific writer and speaker on her vision of nursing education and educational preparation for nursing practice. Moreover, she was a strong advocate for the changes needed within nursing to achieve her vision. At CWRU, under Schlotfeldt and her successor, Dean Janetta MacPhail (1972–1982), the leadership and faculty of the Frances Payne Bolton School of Nursing, initiated changes that reflected elements of the plan for progress. In 1972, the PhD program was established (third in the country) and, in collaboration with University Hospitals of Cleveland, faculty received dual appointments integrating the three roles described earlier.

Launching of the First Professional Doctorate (ND) Program (1978–1989)

In 1978, the CWRU nursing faculty prepared and distributed a “formal document describing the new Doctor of Nursing (ND) program” (Fitzpatrick, 1986, p. 4). In 1979, the BSN program was closed and the first nursing professional doctorate program was launched.

The initial ND program lasted six semesters over three academic years and, by 1981, was accredited by the NLN. The concept of the professional doctorate was disseminated widely in popular and professional literature. In the CWRU General Bulletin of 1983 to 1985 (CWRU, 1983, p. 287), the ND program was described as “the basic program for entry into professional nursing practice. This program leads to the ND degree and prepares individuals as generalists with the knowledge, skills, and values necessary to enter first-level positions in a variety of healthcare settings and to be licensed as registered nurses. … The sequencing of educational offerings is comparable to the educational preparation offered in other practice professions such as medicine, dentistry, law and pharmacy. The professional doctorate (ND, MD, DDS, JD, PharmD) is the degree necessary for entry into professional practice. ND graduates could transition into the MSN or PhD programs.”

In 1986, Dean Joyce Fitzpatrick reported that the program had reached the halfway point projected as necessary for acceptance of the new program and there were 134 ND graduates. She acknowledged the ND program had encountered “unpredicted resistances and changes in patterns of healthcare delivery and education that directly or indirectly influenced program development” (Fitzpatrick, 1986, p. 8). Based on formative feedback from faculty and students and findings of a formal external evaluation, the curriculum was modified frequently “to develop more fully the program focus as a professional doctorate” (Fitzpatrick, 1986, p. 8).

TABLE 1.2

ND CURRICULUM, 1986

Year	Overview of ND Curriculum, 1986
1	Foundations of the Discipline I & II, Foundations of Nursing Practice, Health Promotion and Maintenance I & II, Health Restoration & Support I
2	Health Restoration & Support I: a multidisciplinary course in ethics, nursing theory, and research with MSN students during which students will develop a proposal; includes clinical practice with concentrated opportunities to integrate knowledge and skills (20–24 hr per week)
3	Systematic study and/or practice in nursing in one of the four focal areas of choice: Organizational Theories, Information Systems. Two clinical research seminars in which students (a) implement and write an individual report of a pilot study or (b) develop an individual in-depth paper on an aspect within the proposal such as concept, method, or tool 91–97 total credits

Source: Case Western Reserve University. (n.d.). General Bulletin, 1991–93: Undergraduate Programs, Graduate Programs, Professional Schools. Cleveland, OH: Author.

Schlotfeldt’s views of nursing practice, refined in the “Health Seeking Nursing Model,” were integral to the ND curriculum. Nursing was defined as the “art and science of assisting people to enhance their health-seeking behaviors as they strive to attain, maintain, or regain optimal health” and as “a fully autonomous practice profession, a scholarly discipline, and an integral part of the healthcare system” (Glazer & Pressler, 1989, p. 242). Table 1.2 provides an overview of the ND curriculum in 1986.

The Case Western ND Program Is Restructured (1990)

In 1990, in response to the evaluation findings, the faculty completely restructured the ND program and reinstituted the BSN program with an emphasis on acute and critical care. The revised ND was “a clinical doctorate designed for baccalaureate prepared college graduates from a variety of disciplines … and for BSN and MSN prepared nurses who desired advanced clinical knowledge” (CWRU, n.d., p. 388). The program was “characterized by educational depth and emphasis on advanced practice nursing, inquiry and management” (CWRU, n.d., p. 388). As noted in Table 1.3, the revised ND program differed from the 3-year ND in several key respects.

The ND Program Evolves (1990–2005)

From 1990 to 2005, the ND program continued in two phases: prelicensure and postlicensure. Administratively, a director of the ND program was responsible for the prelicensure and post-MSN components. A separate director was responsible for the MSN program, including students enrolled in postlicensure advanced practice nursing (APN) courses.

TABLE 1.3

COMPARISON OF 3-YEAR AND 4-YEAR DNP PROGRAMS

	“Original” ND (1979–1990)	Restructured ND (1990–2009)
Length of curriculum	3 years	4 years (first 2 years prelicensure)
Outcome of prelicensure phase	“Knowledge, skills, and values for clinical practice, clinical scholarship, and for a professional career” (Fitzpatrick, 1986, p. 9)	Levels I and II: An entry-level RN ready to move directly into levels III and IV (CWRU, 1993–1995)
Outcome of full program	3-year ND degree; same as prelicensure phase	4-year ND degree: Students can apply for the MSN; in levels III and IV, students prepare as an APN in a primary care specialty; the APN courses are integrated with 24 credits of professional doctorate courses and a clinical research thesis (CWRU, 1993–1995)
Pathway options	Single pathway to ND isfull-time participation	Multiple pathways: (A) nonnursing baccalaureate graduates can enter at level I (prelicensure) and complete levels I–IV, (B) RNs with the BSN can enter at level III (APN and doctorate), and (C) RNs with the MSN can enter at level IV (doctoral); in addition, levels III and IV can be completed part time or full time (CWRU, 1993–1995); the post-MSN ND curriculum had a clinical focus or “practice doctorate”

APN, advanced practice nurse.

Prelicensure component. Upon completion of the prelicensure curriculum, students received a certificate of professional nursing (CPN), participated in the School of Nursing’s pinning ceremony, could apply for RN licensure in most states, and were expected to continue on to the MSN/ND. The curriculum was updated as indicated by evaluation findings (e.g., adding courses in genetics and health and aging). The most significant change (2003) revised the curriculum to four semesters, for 16 continuous months of study. Enrollment remained steady with a dramatic increase for the classes starting in 2003 to 2005. Approximately 65% of CPN recipients proceeded into the MSN program within 2 years of receiving the CPN; however, few proceeded onto the ND (C. Quinn, personal communication, May 15, 2007).

Postlicensure component. Over time, some MSN and all post-MSN courses were revised from meeting regularly over a semester to an executive or “intensive” format that allowed flexibility for nurses in full-time positions. Enrollment in the post-MSN ND was limited until 2005, when it significantly increased following several key changes: (a) the post-MSN ND graduate was seen as prepared to teach in pre-RN, MSN, and ND programs and the ND curriculum was revised to have two “tracks”—clinical leadership and educational leadership; (b) the program built on the “intensive” format by implementing a highly successful model of off-site cohorts; (c) funding to support post-MSN students; and (d) in line with national trends, the ND was officially revised to the post-MSN DNP. Previous ND graduates who held the MSN could apply to convert their ND degree to the DNP. Administratively, the pre- and post-MSN components of the ND program were divided to have separate directors and were designated as graduate entry ND and post-MSN ND programs.

The DNP Program: 2005–2018

Graduate Entry DNP Program. As nursing evolved, recipients of the CPN experienced limitations of opportunities in education and practice. In 2009, the curriculum was heavily revised, returned to 4 semesters, 2 academic years; clinical hours were increased by 25% to over 1000, and the CPN was replaced with the Master of Nursing (MN) degree. Several years later, in response to ongoing evaluation, admission to the graduate entry nursing program was changed to the MN and MSN only with students strongly encouraged to consider the DNP, PhD, or DNP/PhD and a concentration in “Leadership for Quality Improvement” was added. CCNE accreditation was achieved in 2015 and enrollment remains steady.

Post-MSN DNP Program. The DNP program was accredited by the Commission on Collegiate Nursing Education (CCNE) in 2011, the intensive and cohort formats continue, funding support is available for nurse educators, the “research study or thesis” has transitioned to a “scholarly project,” and enrollment remains robust.

Today, CWRU’s Frances Payne Bolton School of Nursing continues to be a leader in nursing education with both the DNP and MSN programs highly ranked (#5 and #6, respectively) by US News and World Report Education (2018). Faculty use a continuous-improvement approach to consider internal and external evaluation findings and to revise all of its programs, including the Graduate-Entry Nursing and Post-MSN DNP, accordingly.

The Evolution of the ND at the University of Colorado

Dr. Jean Watson served as dean of the University of Colorado School of Nursing (CU SON) from 1983 to 1990 and was the visionary leader driving CU’s ND program. Much of Jean Watson’s thinking about the ND at Colorado was built on the foundation of the ND at Case Western by Rozella Schlotfeldt (Watson & Bevis, 1990). Jean Watson’s theoretical work, which centers on nursing as the art and science of human caring, had a strong impact on the philosophical foundations of Colorado’s ND program. Colorado accepted its first ND students in 1990 and continued until 2005, whereupon it transitioned into a DNP program. Colorado’s ND program was designed to prepare a broadly educated and technically competent, caring, professional nurse to practice with extended responsibilities, among diverse populations and clinical settings in order to address increasingly complex healthcare needs.

Dr. Watson’s guiding ideas for Colorado’s ND were based on future trends in healthcare: increased acuity in hospitalized patients, increase in scope of care provided in the home by home-care nurses, an increased emphasis on wellness care, an increased focus on models that provide patient-centered care, and emerging roles for nurses to coordinate care for patients across time and across settings (Watson, 1989). Watson (1988) proposed that the elements found in Table 1.4 provide the educational base for Colorado’s ND.

TABLE 1.4

WATSON’S CORE COMPONENTS OF THE UNIVERSITY OF COLORADO’S ND PROGRAM

Element	Educational Component
Foundation	A more extensive liberal arts foundation focused on understanding of and appreciation for cultural diversity and on the human subjective dimensions of health–illness, caring, healing experiences, and needs Core knowledge underpinning biomedical science, social behavioral sciences, and organizations/systems management theory and practice
Clinical preparation	Preparation in critical thinking and advanced problem solving, contributing to clinical judgments and independent decision-making
Decision-making model	Extensive preparation in philosophical and ethical decision-making skills based on the ethics of human caring, which addresses both health policy and contextual, compassionate, relational, ethical dilemmas as well as knowledge of the traditional rationalistic approach to principled biomedical ethics and traditional health policy positions
Caring core	Exploration of the contextual value-laden relationship theory that is associated with human caring and healing transactions, emphasizing self-care and more autonomous decision-making processes
Curriculum	A curriculum based on human science and nursing theory that incorporates the latest research and practice knowledge of human caring, healing, and health and emphasizes the relationship between human and system caring approaches and health/healing outcomes

Source: From Watson, J. (1988). Human caring as moral context for nursing education. Nursing and Health Care, 9(8), 423–425.

A vital aspect of Watson’s image of the career professional nurse was that the ND graduate would help address the fragmentation of care and isolation of the patient and family. With augmenting complexity in the healthcare system, Watson knew that this fragmentation and unintended segregation of the patient and family from the care team would increase. Watson imagined a new level of professional nurse whot would follow patients and families across time and across settings. “The ND regulates and monitors the highest level of professional care between and among multiple health personnel; coordinates, educates, counsels and advises the patient and family regarding different treatment protocols” (Watson, 1989, p. 370). The increasing complexity of the future U.S. healthcare system was becoming evident, and Watson wanted to educate highly functioning nurse clinicians whose education included explicit focus on the complexity of emerging healthcare systems, had the broad view of healthcare policy, but was patient/family centered in their core values and practice center. “The ND personalizes complex, acute and chronic healthcare needs, including symptom management, demystifying the medical world, and instructing patients on how to optimize self-care and inner healing resources, including better use of the traditional (medical) system (Watson, 1989, p. 374). Watson hoped to graduate clinicians whose education promoted both human care and the management of human caring systems.

Colorado developed its ND program, planning to be a model for other schools considering the practice doctorate model. The ND program at Colorado was selected by the Helene Fuld Health Trust in New York as a national demonstration program for postbaccalaureate caring and healing health curriculum, awarding CU over $500,000 for the implementation of the ND program. From its earliest planning, Watson included regional clinical agencies in the exploration and planning of the curriculum. The goal was not only to transform the model for clinical doctorate education, but also to design and test new care-delivery models with innovative roles for doctorally prepared nurses. Watson was also active in coordinating the ND model with other statewide projects, funded by The Colorado Trust, to develop a new articulation model to link all nursing education programs in the state, for more seamless progression from associate nursing degree programs to the ND (Watson & Phillips, 1992).

A unique characteristic of Colorado’s model was its strong clinical preparation. Baccalaureate preparation provides students with approximately 750 hours of clinical practicum; Colorado’s ND program included more than 3,800 hours of clinical practicum. Longer clinical rotations as well as two intensive clinical experiences contributed to the strong clinical proficiency of ND graduates. Colorado developed an ND professional residency, which was 1 calendar year of full-time practice, incorporating 1,960 hours of clinical practice into the ND degree. After graduation, many ND graduates begin their practice at the site that sponsored their residency.

The University of Colorado’s ND curriculum was based on an academic, professional educational model that parallels the preparation of other clinical doctorates in health professions with respect to the nature and degree of educational preparation. Similar to the clinical doctorate in medicine, pharmacy, or dentistry, the University of Colorado’s ND provided core clinical preparation during the program’s first 2 years, developed the student’s professional practice in the third year, and culminated in a clinically based residency in the fourth year.

The original ND curriculum was focused on four basic core areas: clinical sciences, clinical arts and humanities caring, health professional and ethical foundations, and discipline-specific human caring nursing. In the first 10 years of Colorado’s ND program, courses were rearranged, renamed, and reconfigured to keep up with changing nursing education standards. These curricular changes are outlined in Table 1.5.

TABLE 1.5

COMPARISON OF THE UNIVERSITY OF COLORADO ND CURRICULUM 1990–1999

	Original ND Curriculum (1990)	ND Curriculum (1999)
Year 1	Philosophy, ethics, and science of human caring in nursing	Reflective practice
		Discipline and practice of nursing
	Clinical inquiry	Clinical inquiry
	Anatomy and physiology	Anatomy and physiology
	Health assessment and promotion	Health assessment and promotion
	Health assessment clinical practicum	Health assessment clinical practicum
	Microbiology	Microbiology and infectious diseases
	Primary care	Pathophysiology
	Primary care clinical practicum	Pharmacology
	Caring in art	Nursing interventions—arts and skills
	Caring in music	Nursing care of adults and older adults (Med/Surg I)
		Med/Surg I clinical practicum
		Caring in literature
		Nursing theory
Year 2	Nursing care of childbearing families	Nursing care of childbearing families
	Nursing care of children	Nursing care of children
	OB and pediatric clinical practicum	OB and pediatric clinical practicum
	Mental health nursing	Mental health nursing
	Mental health clinical practicum	Mental health clinical practicum
	Clinical externship	Clinical externship
	Practice and disciplinary role socialization	ND clinical seminar
	Pathophysiology	Health systems and policy issue
	Pharmacology	Caring in art and music
	Caring in literature	Primary healthcare nursing
		Nursing care of adults (Med/Surg II)
		Med/Surg II clinical practicum
		Interdisciplinary ethics
	Eligible for NCLEX	Eligible for NCLEX
Year 3	Evaluation methodologies
	Case management	Case management
		Care management
	Clinical practicum for case management	Clinical practicum for case/care management
	Public health nursing	Public health nursing
		Clinical practicum for public health nursing
	Health systems and policy issues	Inferential statistics
	Elective	Advanced assessment
		Human technology interface
	Professional residency	Introduction to ND residency
Year 4	Professional residency	Professional residency
		Capstone project

OB, obstetric.

Colorado also placed clear emphasis on the rigor of the ND’s Capstone Project, requiring that ND students spend their 4-year residency completing a Capstone project that is focused on system improvement, care management across settings, care management across time, or strategies contributing to emerging patient-centered care models. These Capstone projects are showcased each May, as ND students are about to graduate. Table 1.6 provides examples of ND Capstone projects between 1998 and 2005.

AACN’s Position Statement on the Practice Doctorate

Within the nursing literature of the 1990s and early 2000s, there was ongoing disagreement about the most beneficial model to use for a nursing practice doctorate degree. As early as 1993, there was a call for a clear model of a nursing clinical doctorate for the 21st century (Starck, Duffy, & Vogler, 1993). The focus and intensity of this disagreement heated up as awareness grew that the existing ND programs lacked a consistent model. In 2003, the NONPF published an opinion, stemming from the work of a task force, aptly titled, “The Practice Doctorate in Nursing: Future or Fringe?” (Marion et al., 2003). The growing need for expert clinical teachers and clinicians was not being adequately met by existing graduate nursing education models, and NONPF, along with professional organization and educational institutional partners, began calling for a new, standardized model that would prepare graduates for future needs in healthcare (Marion et al., 2003).

TABLE 1.6

EXAMPLES OF THE UNIVERSITY OF COLORADO ND CAPSTONE PROJECTS

Year	Title of Capstone Project
1998	Cost Analysis of a Medicaid Prenatal Care Coordinator Program
1998	Comparison of Community Care Management Programs
1998	Promoting Self-Efficacy Through Care Coordination and Community Links
1999	Needs Assessment for a Women’s Health Clinic in Rural Colorado
1999	Case Complexity in Short-Term Disability Care
1999	Evaluation of a Pediatric Asthma Management Program
2003	Utilization Trends of a Rural COPD Population
2003	Establishment and Evaluation of a Case Management Program to Assist Clients in Obtaining a PCP or Health Insurance
2004	Family Presence During Resuscitation and/or Invasive Procedures: A Survey of Health Care Providers, Patients, and Families
2004	Health Literacy in a Diabetic Population in a VA System in Eastern Colorado
2005	Evaluation of an Emergency Department Nurse Case Manager Program
2005	Sedation Assessment Practices Among Experienced CICU Nurses
2005	Developing a Program to Promote Education and Implementation of Advanced Directives in a Chronic Dialysis Setting

CICU, cardiac intensive care unit; COPD, chronic obstructive pulmonary disease; PCP, primary care physician; VA, Veterans Affairs.

In 2004, AACN shifted the conversation with y its position statement on the practice doctorate (AACN, 2004). This game-changing position statement emerged from a 2002 task force that was established to compare the various models of clinical or practice doctoral programs, to examine various models, and to make recommendations. The task force reviewed the literature, established a collaborative relationship with NONPF, interviewed key informants, and held open discussions at several nursing education conferences. Along with the task force’s formal recommendations (Table 1.7), this statement recommended that the DNP replace the master’s degree as preparation for advanced practice nurses (APNs). This recommendation later crystallized into a suggestion that schools of nursing move to eliminate their master’s programs by 2015. Table 1.7 summarizes the 13 formal recommendations proposed within the AACN (2004) position statement.

TABLE 1.7

SUMMARY OF AACN RECOMMENDATIONS FOR THE DNP DEGREE

	Recommendation
1	The task force recommends that the terminology used in practice doctorate, be used in instead of clinical doctorate
2	The practice-focused doctoral program follow a distinct model of doctoral education that provides an additional option for attaining a terminal degree in the discipline
3	Practice-focused doctoral programs prepare graduates for the highest level of nursing practice beyond the initial preparation in the discipline
4	Practice-focused doctoral nursing programs include seven essential areas of content (which were developed to become the DNP Essentials)
5	Practice doctoral nursing programs should include development and/or validation of expertise in at least one area of specialized advanced nursing practice
6	Practice-focused doctoral nursing programs prepare leaders for nursing practice; the practice doctorate prepares individuals at the highest level of practice and is the terminal practice degree
7	One degree title should be chosen to represent practice-focused doctoral programs that prepare graduates for the highest level of nursing practice
8	The DNP is the degree associated with practice-focused doctoral nursing education
9	The ND degree should be phased out
10	The practice doctorate should be the graduate degree for advanced nursing practice preparation, including but not limited to the four current APN roles: clinical nurse specialist, nurse anesthetist, nurse midwife, and nurse practitioner
11	A transition period should be allowed to provide master’s degrees to nurses who wish to obtain the practice doctorate degree using a mechanism to earn a practice doctorate in a relatively streamlined fashion, with credit given for previous graduate study and practice experience; the transition mechanism should provide multiple points of entry, standardized validation of competencies, and be time-limited
12	Research-focused doctoral programs are encouraged to offer additional coursework and practical experience that prepares graduates to fill the role of nurse educator
13	Practice-focused doctoral programs need to be accredited by a nursing accrediting agency recognized by the U.S. Secretary of Education

AACN, American Association of Colleges of Nursing.

Source: From American Association of Colleges of Nursing. (2004). AACN position statement on the practice doctorate in nursing. Retrieved from http://www.aacnnursing.org/DNP/Position-Statement

Support for AACN’s Statement on the Practice Doctorate

With the publication of AACN’s position statement, nursing literature experienced an eruption of responses, both in support of the DNP and challenging the emerging model. As it was a partner in the development of AACN’s recommendations, NONPF continued its support for the DNP model. The NACNS identified the paucity of national dialogue that led to AACN’s position statement as well as a lack of differentiation between master’s-prepared APNs and DNP- prepared APNs. NACNS ultimately committed to contributing to the emerging model by developing a doctoral-level clinical nurse specialist curriculum (NACNS, 2005).

Not all nursing leaders were supportive of AACN’s DNP model. Dracup, Cronenwett, Meleis, and Benner (2005) worried that the DNP would threaten the work of PhD graduates and the advancement of theory-based science in nursing. In addition, these prestigious nursing leaders worried about a decline in already negligible PhD program admissions, and whether the addition of a practice doctorate would increase the chasm between nursing practice and nursing research. Last, there was unease that the new degree would cause confusion among healthcare colleagues and the public (Dracup et al., 2005). These same authors offered additional concerns in 2011, focusing on the impact of the DNP on the nursing workforce. In 2011, reservations were expressed about the impact of the DNP elongating the preparation for APNs, thereby decreasing the APN workforce at a time in history when there was an increased need for APNs (Cronenwett et al., 2011).

A common criticism of AACN’s 2004 position statement was the suggested deadline of 2015 for schools of nursing across the country to replace their master’s programs with the DNP as preparation for APNs. Many identified complex logistics, significant cost, and the lack of available nursing faculty to teach in practice-doctorate programs (Chase & Pruitt, 2006; Cronenwett et al., 2011; Ketefian & Redman, 2015). AACN contracted with Rand Health, a leading organization in health policy research, to investigate schools’ progress toward this 2015 goal. Rand’s report (Auerbach et al., 2015) identified several facilitators toward schools transitioning to the DNP (mostly focused on increased demand by healthcare systems and students) and several barriers to this transition (internal and institutional barriers such as approval, cost, faculty, resources, and securing clinical sites). History has indicated that these concerns about the feasibility of all nursing schools transitioning to the DNP were indeed valid, as schools of nursing continue to offer master’s degrees.

Rapid Growth of DNP Programs

Despite lack of agreement about many aspects of the DNP degree, DNP programs continue to flourish. Data from June 2017 indicate that there are 303 DNP programs in all the states in the United States, and 124 new programs in the planning stages. From 2015 to 2016, DNP graduates increased from 4,100 to 4,855 (AACN, 2017). Figure 1.2 compares the growth in DNP programs compared to PhD in nursing pPrograms from 2006 to 2016.

FIGURE 1.2

AACN growth in DNP programs 2006 to 2016.

Source: From American Association of Colleges of Nursing. (2017). Fact sheet: The doctor of nursing practice (DNP). Retrieved from http://www.aacnnursing.org/News-Information/Fact-Sheets/DNP-Fact-Sheet

FUTURE COLLABORATION BETWEEN DNP AND PhD NURSES

From its inception, concerns about the impact of the DNP degree on the PhD degree and the APN workforce have abounded. The loudest concerns identified a worry that the DNP degree would detract from the PhD preparation and slow the development of knowledge in the nursing discipline (Edwardson, 2010). Ongoing growth of DNP programs indicate that the DNP degree is in nursing education to stay; a commonly identified and exciting frontier explores models oft effective collaboration between DNP-prepared nurses and PhD-prepared nurses. What might effective collaborative models look like? One definition of collaboration is a model in which both sides value each other’s power with acknowledgment and acceptance of the other’s areas of responsibility, thereby forming a true partnership (Dougherty & Larson, 2005). Current thinking about effective collaboration between PhD-prepared and DNP-prepared nurses focuses on each understanding the other’s preparation and expertise and developing models in which differing areas of specialty are maximally used. Emerging models emphasize the complementary nature of the two-degree preparations, with an understanding that because the DNP is in its infancy, effective strategies are only beginning to surface. How do DNP- and PhD-prepared nurses effectively collaborate, and how might these models evolve in the future?

DNPs in Nursing Education

DNP-prepared nurses are rapidly entering nursing academia. Many nursing programs must limit their admissions due to the well-documented national nursing faculty shortage. According to AACN’s report on 2016 to 2017 enrollment and graduations in baccalaureate and graduate programs in nursing, U.S. nursing schools turned away 64,067 qualified applicants from baccalaureate and graduate nursing programs in 2016 due to a variety of contributing factors, including the faculty shortage (AACN, 2014). The national faculty shortage was identified as the prevailing reason responding schools did not accept all qualified applicants into baccalaureate programs (AACN, 2014).

A recent 2016 study indicates that most nursing programs are adding DNPs to their faculty, both on tenure and nontenure tracks, with DNP-prepared faculty experiencing challenges around scholarship (Oermann, Lynn, & Agger, 2016). Another 2016 study interviewed nursing faculty, examining determinants for effective DNP/PhD nurse faculty collaboration. This study revealed five predominant themes: (a) ongoing confusion about the training and role of the DNP prepared nurse, even among DNPs; (b) inconsistent use of the word research with DNP nurses; (c) opportunities for collaboration (e.g., committee work); (d) research teams in which the DNP-prepared nurse brings clinical expertise and the PhD brings research expertise; and (e) lack of structural support for effective collaboration and identification of the contribution of personal characteristics to effective collaboration (e.g., respect, clinical interest, time, and mutual goals; Staffileno, Murphy, & Carlson, 2016). Buchholz, Yingling, Jones, and Tenfelde (2015) explore whether collaborative opportunities during foundational coursework in DNP and PhD programs would facilitate better understanding of the distinct preparations. Coenrollment of the PhD and DNP students in courses, such as nursing inquiry and analytic methods, create opportunities for academic socialization and the development of collaborative working relationships (Buchholz et al., 2015). DNP-prepared nurses are actively joining nursing faculty across the United States, and more work needs to be done to explore and disseminate effective, productive, and mutual models of DNP/PhD nurse faculty collaboration.

DNP/PhD Nurse Collaboration in Practice

A commonly emphasized synergy facilitating DNP/PhD nurse collaboration focuses on the necessary paradigm shift that addresses the growth of DNP programs concurrent with the need to improve practice expertise and move the translation of evidence into practice more efficiently (Brown & Crabtree, 2013). Courtney and colleagues developed a valuable model that explains the ways in which DNP and PhD scholars are similar in their pursuit of active scholarship, but have different areas of expertise. Their model (Figure 1.3) emphasizes that the DNP and PhD have different, but equally important, foci in the scholarly activities they undertake, which lead to the development of practice science (Buchholz et al., 2013).

Dr. Peggy Jenkins, from the University of Colorado College of Nursing in Aurora, Colorado, has also explored elements of effective collaboration between the DNP and PhD nurses in the practice setting. Table 1.8 examines Jenkins’s model for effective doctoral nurse collaboration when focused on a similar clinical question.

CONCLUSIONS

Despite the ongoing dialogue about the benefit of the DNP model, and tremendous variation in DNP program structure, curricula, and outcomes, DNP programs remain on the rise. The continual rapid growth of DNP programs indicates that the DNP degree and DNP graduates are addressing current needs in the healthcare system. The DNP degree is a relatively new degree in nursing and is clearly an educational preparation in its infancy. The need for DNP graduates is impacted by healthcare system trends in quality, patient safety, patient-centered care, value-based payment models, process improvement, and sustainability of improvement within complex systems. The need to educae all DNP graduates in all spheres of systems leadership is becoming increasingly evident. The content of this text addresses these vital academic and clinical areas of opportunity.

FIGURE 1.3

A model for practice and research scholarship.

EBP, evidence-based practice.

Source: From Buchholz, S. W., Budd, G. M., Courtney, M. R., Neiheisel, M. B., Hammersla, M., & Carlson, E. D. (2013). Preparing practice scholars: Teaching knowledge application in the Doctor of Nursing Practice curriculum. Journal of the American Association of Nurse Practitioners, 25(9), 473–480. doi:10.1002/2327-6924.12050

TABLE 1.8

JENKINS’S MODEL FOR EFFECTIVE DOCTORAL NURSE COLLABORATION

DNP Leader Role	PhD Leader Role	Collaboration
Formulate a PICO question asking whether richer skill mix has a positive effect on a certain patient population on her unit.	Formulate a research question asking what skill mix of RNs most positively correlates with desired patient outcomes.	Share questions so both aims contribute to a similar problem, one from the current system context and one from a larger, potentially generalizable context.
Search and evaluate the evidence for studies related to the question.	Conduct a literature search noting gaps in knowledge related to RN skill mix and patient outcomes.	Work together to identify gaps in knowledge. Collaborate in reviewing evidence using PhD expertise in analyzing research studies, finding high-quality evidence to implement in practice.
Use implementation framework to guide change of practice.	Use scientific research process to design a research study.	Communicate plans, timelines, and milestones. Adjust based on shifting practice context.
Organize a diverse team of key stakeholders.	Organize a research team to writea proposal and obtain funding.	Include common members on both teams for knowledge sharing and to link work.
Implement/evaluate change on unit.	Conduct a research study.	Transfer knowledge and expertise between teams.
Disseminate change process used and processes of implementation.	Disseminate results of a research study.	Present results internally/externally and publish together.

PICO, patient/problem, intervention, comparison, outcome.

Source: Developed by Peggy Jenkins, PhD, RN.

REFERENCES

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Google Scholar
Safier, G. (1977). Contemporary American leaders in nursing: An oral history. New York, NY: McGraw-Hill.
Google Scholar
Schlotfeldt, R. (1976). Rozella Schlotfeldt Says …. American Journal of Nursing, 76(1), 105–107.
Google Scholar
Schlotfeldt, R. (1978). The professional doctorate: Rationale and characteristics. Nursing Outlook, 26(5), 302–311.
Google Scholar
Staffileno, B. A., Murphy, M. P., & Carlson, E. (2016). Determinants for effective collaboration among DNP- and PhD-prepared faculty. Nursing Outlook, 65(1), 94–102. doi:10.1016/j.outlook.2016.08.003
Google Scholar
Starck, P. L., Duffy, M. E., & Vogler, R. (1993). Developing a nursing doctorate for the 21st century. Journal of Professional Nursing, 9(4), 212–219. doi:10.1016/8755-7223(93)90038-E
Google Scholar
Watson, J. (1988). Human caring as moral context for nursing education. Nursing and Health Care, 9(8), 423–425.
Google Scholar
Watson, J. (1989). The future-in-the making: Creating the new age. In E. O. Bevis (Ed.), Toward a caring curriculum: A new pedagogy for nursing (pp. 369–376). New York, NY: NLN Press.
Google Scholar
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Google Scholar
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Google Scholar

Focus

Previous Next

[bid_1_1] American Association of Colleges of Nursing. (2004). AACN position statement on the practice doctorate in nursing. Retrieved from http://www.aacnnursing.org/DNP/Position-Statement
Google Scholar

[bid_1_2] American Association of Colleges of Nursing. (2014). Nurse faculty shortage. Retrieved from https://www.aacnnursing.org/News-Information/Fact-Sheets/Nursing-Faculty-Shortage
Google Scholar

[bid_1_3] American Association of Colleges of Nursing. (2017). Fact sheet: The doctor of nursing practice (DNP). Retrieved from http://www.aacnnursing.org/News-Information/Fact-Sheets/DNP-Fact-Sheet
Google Scholar

[bid_1_4] Auerbach, D. I., Martsolf, G. R., Pearson, M. L., Taylor, E. A., Zaydman, M., Muchow, A. N., … Lee, Y. (2015). The DNP by 2015: A study of the institutional, political, and professional issues that facilitate or impede establishing a post-baccalaureate doctor of nursing practice program. Rand Health Quarterly, 5(1), 3.
Google Scholar

[bid_1_5] Brown, M., & Crabtree, K. (2013). The development of practice scholarship in DNP programs: A paradigm shift. Journal of Professional Nursing, 29, 330–337. doi:10.1016/j.profnurs.2013.08.003
Google Scholar

[bid_1_6] Buchholz, S. W., Budd, G. M., Courtney, M. R., Neiheisel, M. B., Hammersla, M., & Carlson, E. D. (2013). Preparing practice scholars: Teaching knowledge application in the doctor of nursing practice curriculum. Journal of the American Association of Nurse Practitioners, 25(2013), 473–480. doi:10.1002/2327-6924.12050
Google Scholar

[bid_1_7] Buchholz, S. W., Yingling, C., Jones, K., & Tenfelde, S. (2015). DNP and PhD collaboration: Bringing together practice and research expertise as predegree and postdegree scholars. Nurse Educator, 40(4), 203–206. doi:10.1097/NNE.0000000000000141
Google Scholar

[bid_1_8] Case Western Reserve University. (1983). Case Western Reserve University Bulletin: Undergraduate Programs, Professional Schools, Graduate Programs, 1983–85, 7(4). Cleveland, OH: Author.
Google Scholar

[bid_1_9] Case Western Reserve University. (1985). Case Western Reserve University General Bulletin: Undergraduate Programs, Professional Schools, Graduate Programs, 1985–87, 9(5). Cleveland, OH: Author.
Google Scholar

[bid_1_10] Case Western Reserve University. (n.d.). General Bulletin, 1991–93: Undergraduate Programs, Graduate Programs, Professional Schools. Cleveland, OH: Author.
Google Scholar

[bid_1_11] Center for the Study of the History of Nursing. (n.d.). Biography/History, Rozella M. Schlotfeldt papers. Philadelphia, PA: School of Nursing, University of Pennsylvania. Retrieved from http://dla.library.upenn.edu/dla/pacscl/ead.html?q=rozella%20schlotfeldt&id=PACSCL_UPENN_BATES_MC113&
Google Scholar

[bid_1_12] Chase, S. K., & Pruitt, R. H. (2006). The practice doctorate: Innovation or disruption? Journal of Nursing Education, 45(5), 155–161.
Google Scholar

[bid_1_13] Cronenwett, L., Dracup, K., Grey, M., McCauley, L., Meleis, A., & Salmon, M. (2011). The Doctor of Nursing practice: A national workforce perspective. Nursing Outlook, 59, 9–17. doi:10.1016/j.outlook.2010.11.003
Google Scholar

[bid_1_14] Dougherty, M., & Larson, E. (2005). A review of instruments measuring nurse-physician collaboration. Journal of Nursing Administration, 35, 244–253. doi:10.1097/00005110-200505000-00008
Google Scholar

[bid_1_15] Dracup, K., Cronenwett, L., Meleis, A. I., & Benner, P. E. (2005). Reflections on the doctorate of nursing practice. Nursing Outlook, 53(4), 177–182. doi:10.1016/j.outlook.2005.06.003
Google Scholar

[bid_1_16] Edwardson, S. R. (2004). Matching standards and needs in doctoral education in nursing. Journal of Professional Nursing, 20(1), 40–46. doi:10.1016/j.profnurs.2003.12.006
Google Scholar

[bid_1_17] Edwardson, S. R. (2010). Doctor of philosophy and doctor of nursing practice as complementary degrees. Journal of Professional Nursing, 26(3), 137–140. doi:10.1016/j.profnurs.2009.08.004
Google Scholar

[bid_1_18] Fitzpatrick, J. (1986). The ND Program: Integration of past and future. Cleveland, OH: Case Western Resrve University.
Google Scholar

[bid_1_19] Glazer, G., & Pressler, J. (1989). Schlotfeldt’s health seeking model. In J. Fitzpatrick & A. Whall (Eds.), Conceptual models of nursing: Analysis & application (2nd ed., pp. 241–253). Norwalk, CT: Appleton & Lange.
Google Scholar

[bid_1_20] Ketefian, S., & Redman, R. W. (2015). A critical examination of developments in nursing doctoral education in the United States. Revista Latino-Americana de Enfermagem, 23(3), 363–371. doi:10.1590/0104-1169.0797.2566
Google Scholar

[bid_1_21] Marion, L., Viens, D., O’Sullivan, A. L., Crabtree, K., Fontana, S., & Price, M. M. (2003). The practice doctorate in nursing: Future or fringe? Topics in Advanced Practice Nursing, 3(2). Retrieved from https://www.medscape.com/viewarticle/453247
Google Scholar

[bid_1_22] National Association of Clinical Nurse Specialists. (2005). White paper on the nursing practice doctorate. Clinical Nurse Specialist, 19(4), 215–218. doi:10.1097/00002800-200507000-00014
Google Scholar

[bid_1_23] Oermann, M. H., Lynn, M. R., & Agger, C. A. (2016). Hiring intentions of directors of nursing programs related to DNP- and PhD-prepared faculty and roles of faculty. Journal of Professional Nursing, 32(3), 173–177. doi:10.1016/j.profnurs.2015.06.010
Google Scholar

[bid_1_24] Safier, G. (1977). Contemporary American leaders in nursing: An oral history. New York, NY: McGraw-Hill.
Google Scholar

[bid_1_25] Schlotfeldt, R. (1976). Rozella Schlotfeldt Says …. American Journal of Nursing, 76(1), 105–107.
Google Scholar

[bid_1_26] Schlotfeldt, R. (1978). The professional doctorate: Rationale and characteristics. Nursing Outlook, 26(5), 302–311.
Google Scholar

[bid_1_27] Staffileno, B. A., Murphy, M. P., & Carlson, E. (2016). Determinants for effective collaboration among DNP- and PhD-prepared faculty. Nursing Outlook, 65(1), 94–102. doi:10.1016/j.outlook.2016.08.003
Google Scholar

[bid_1_28] Starck, P. L., Duffy, M. E., & Vogler, R. (1993). Developing a nursing doctorate for the 21st century. Journal of Professional Nursing, 9(4), 212–219. doi:10.1016/8755-7223(93)90038-E
Google Scholar

[bid_1_29] Watson, J. (1988). Human caring as moral context for nursing education. Nursing and Health Care, 9(8), 423–425.
Google Scholar

[bid_1_30] Watson, J. (1989). The future-in-the making: Creating the new age. In E. O. Bevis (Ed.), Toward a caring curriculum: A new pedagogy for nursing (pp. 369–376). New York, NY: NLN Press.
Google Scholar

[bid_1_31] Watson, J., & Bevis, E. O. (1990). Nursing education: Coming of age in a new age. In N. L., Chaska (Ed.), The nursing profession: Turning points (pp. 100–105). St. Louis, MO: Mosby
Google Scholar

[bid_1_32] Watson, J., & Phillips, S. (1992). A call for educational reform: Colorado nursing doctorate model as exemplar. Nursing Outlook, 40(1), 20–26.
Google Scholar

Leadership and Systems Improvement for the DNP

Additional resources for this book

instructor material

Keywords for this chapter

1: The History and Future of the DNP in Nursing

INTRODUCTION