Doctor of Nursing Practice


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Doctor of Nursing Practice

  1. 1. The DNP and PhD: Bridging the Gap to Advance Nursing Practice and Science California Association of Nurse Practitioners 33rd Annual Education Conference March 25-28, 2010 Donna M. Emanuele, DNP, FNP-BC
  2. 2. Remembering Nightingale This year is the centennial of Nightingale's death and a chance for nurses around the world to celebrate her achievements, not just as the pioneer of nursing, but as an advocate for hospital reform, statistical analysis and nursing education. Florence Nightingale May 12, 1820-August 13, 1910
  3. 3. Presentation Objectives 1. List and compare two differences between research-focused and practice-focused doctoral education 2. Identify two benefits of practice-focused and research-focused doctoral programs 3. Examine the relationships of Master’s, Practice Doctorate, and Research Doctorate Programs 4. Discuss doctoral education in nursing and the application of scholarly nursing practice that both DNP and PhD graduates and academic roles create in practice and scientific inquiry
  4. 4. Doctoral Nursing Education
  5. 5. Changes in Health Care • Aging population • Growing diversity • Global health care system • Bio-medical advances • New areas of knowledge: genetics, neuro- science, environmental health Require nurses to have more knowledge
  6. 6. Building Momentum for Change in Graduate Nursing Education • Influencing Factors and Healthcare Challenges Rapid expansion of knowledge underlying practice Increased complexity of care (disease burden/cost) National concerns about the quality of care and patient safety (fragmented care/poor coordination/access issues) Nursing personnel shortages (doctorally prepared faculty) Demands for higher level of prepared leaders to design and assess care Increasing educational expectations for other health professionals
  8. 8. History of Doctoral Education • Research-Focused Programs Academic Doctorate – PhD Professional Doctorate – DNS, DNSc, or DSN • Practice-Focused Doctor of Nursing (ND): • Case Western Reserve University (1979), Rush University, University of South Carolina, Univ. of Colorado Doctor of Nursing Practice (DrNP): • Columbia University, NY Doctorate of Nursing Practice (DNP): • University of Kentucky (2004) • > 120 other programs in existence today
  9. 9. Statistics and FAQs • Doctorate in Nursing Represents <0.4% of the nursing population (11,548 of the nearly 3 million RNs in the U.S.) 15, 552 of RNs earn a doctorate in a related field representing approximately (0.535% ) • Of these doctorally prepared nurses (21.3%) studied in Education (17.7%) in Research (11.3%) in Law (9.5%) in Administration among other fields but; only (5.8%) studied clinical practice HRSA. (2004). The registered nurse population: Findings from the 2004 National Sample Survey of Registered Nurses.
  10. 10. Statistics and FAQs • In the 2004 HRSA data, doctorally prepared nurses performed as: Faculty (11.8%) Administrators (4.1%) Researchers (3.6%) Consultants (2.5%) HRSA. (2004). The registered nurse population: Findings from the 2004 National Sample Survey of Registered Nurses. Faculty + Researchers=(4,173) or 15.4%
  11. 11. Statistics and FAQs • Average age of students enrolled in doctoral programs: Full-time (42.7 yrs.) Part-time (44 yrs.) • Doctorally prepared faculty by rank: Professors (59.5 yrs.) Associate Professors (56.6 yrs.) Assistant Professors (51.8 yrs.) • Faculty teaching in 2007 Junior faculty (47.4 yrs.) Instructors (46.7 yrs.) Source: AACN Annual Report (2009). 50.1% of newly appointed Professors began teaching with a doctoral degree Only 3.8% of new nurse educators practicing at the instructor level are doctorally prepared 22.8 % of these students teach in SONs
  12. 12. PhD’s Prepared in Nursing Education • Provides an environment for the preparation of new scientists: to generate the evidence-base for nursing emphasis is on the development of new knowledge commitment to a research career • Establishes competence to conduct original research within his/her academic discipline: to test and model ways new science affects outcomes research practice models /comparative effectiveness modeling • Research-intensive curriculum & theory building as the foundation to advance nursing science
  13. 13. Research-Focused Doctorates • Program Faculty Leadership experience in area of sustained research funding • Resources Mentors and precepts in research settings Access to research settings, dissertation support dollars, & research technology congruent with program of research Source: AACN.
  14. 14. Research-Focused Doctorates • >120 programs available in 2009, with 8 new programs under development • Programs offer both distance education and traditional class preparation • Growing focus on BSN to PhD option Designed to move a younger population of students to the research degree • AACN Task force report on the future of the research-focused doctorate due July 2010 Source: AACN
  15. 15. PhD Program Curriculum • Philosophy of science • Theory construction and analysis • Research methods • Instrumentation and measurement • Research • Statistics • Cognates and other courses McEwen & Bechtel, 2000.
  16. 16. Emerging Trends • Knowledge revolution clinicians required to know more to navigate complex health systems advances in technology commanding specialized knowledge & skill • Competitive marketplace/institutional shifts emphasis on quality • Many health professions reforming their master degree programs to practice doctorate s moving toward doctoral education as entry level into practice OT, PT, audiology, pharmacy, psychology, public health
  17. 17. Doctor of Nursing Practice Evolution Revolution Transformation
  18. 18. Doctor of Nursing Practice Drivers • The Institute of Medicine (IOM) Reports • Joint Commission and Pew Commission • National Academy of Sciences on Nursing Research • Other authorities call for reconceptualizing health professions education to meet the needs of the health care delivery system preparing Advance Practice Nurses (APNs) for evolving practice
  19. 19. Institute of Medicine • The IOM defines quality as: “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Source: IOM (1990). Vol.1, p. 4
  20. 20. Institute of Medicine Reports • “To Err is Human: Building a Safer Health System”, (1999, November) focused on the high cost fragmented nature and inexcusable error rate of health care delivery • “Crossing the Quality Chasm”, (2001) stressed that the health care system does NOT make the best use of its’ resources and that consumers are demanding more timely & equitable health care
  21. 21. Institute of Medicine Reports • “Health Professions Education. A Bridge to Quality” (2003) report, which “makes the case that reform of health professions education is critical to enhancing the quality of health care in the United States”. • This report recommends: “a set of five core competencies that all clinicians should possess, regardless of their discipline, to meet the needs of the 21st-century health system”.
  22. 22. Institute of Medicine • Core Competencies Provide patient-centered care Work in interdisciplinary teams Employ evidence-based practice Apply quality improvement Utilize informatics
  23. 23. Pew Health Professions • “Recreating Health Professional Practice for a New Century. The Fourth Report of the Pew Health Professions Commission” , (1998) “offers recommendations that affect the scope and training of all health professional groups, as well as a new set of competencies for the 21st century”.
  24. 24. Pew Health Professions Five Recommendations Ensure that the health profession workforce reflects the diversity of the nation’s population Require interdisciplinary competence in all health professionals Continue to move education into ambulatory practice Encourage public service of all health professional students and graduates Change professional training to meet the demands of the new health care system
  25. 25. Joint Commission • “Health Care at the Crossroads” (2002) “focused on the principal factors that have contributed to the shortage, the growing threat of the nursing shortage to patient safety, and the priority solutions most likely to provide for a stable nursing workforce in the future.”
  26. 26. Joint Commission Recommendations • Create Organizational Cultures of Retention Transforming the workplace • Bolster the Nursing Educational Infrastructure Aligning nursing education and clinical experience • Establish Financial Incentives for Investing in Nursing Provide financial incentives for health care organizations to invest in high quality nursing care.
  27. 27. Changing Perspectives: Doctoral Education and Nursing Practice • National Academy of Sciences Report (2005) on Nursing Research focused on: Increasing the number of nurse scientists Increasing the number of productive years for nurses prepared in PhD programs Calls for a distinction between the “educational needs and goals of nursing as a practice profession that require practitioners with expertise, from nursing as an academic discipline and science that requires independent researchers and scientists to build the body of knowledge” (p. 74)
  28. 28. National Academy of Sciences Report, 2005 • Further….“the need for doctorally prepared practitioners and clinical faculty would be met if nursing could develop a new non-research clinical doctorate, similar to the M.D. and Pharm. D. in medicine and pharmacy, respectively.”
  29. 29. Education and Practice Congruence • Nursing clinicians need new and different knowledge/leadership skills for an increasingly complex healthcare system • Nursing needs to evolve as the world changes and be proactive in addressing system and patient needs • Nurse educators play a critical role in meeting this challenge and preparing nurses to thrive in a contemporary practice environment Source: Raines, F. C. (2009).
  30. 30. All these components are necessary to improve nursing practice and patient outcomes
  31. 31. What is a Practice Doctorate? • The term practice, specifically nursing practice refers to any form of nursing intervention that influences health care outcomes for individuals or populations • Preparation at the practice doctorate level includes: advanced preparation in nursing based on nursing science the highest level of nursing practice AACN. (2004). Position statement on the practice doctorate in nursing. Washington, DC: Author
  32. 32. The DNP Journey 1960: Boston University opens 1st clinical doctorate 1979: Case Western Reserve opens 1st ND program 1999: UTHSC opens DNSc practice doctorate 2001: University of Kentucky opens 1st DNP program 2003: Columbia University admits students 2004: AACN members approve DNP Position Statement & 2015 target implementation date
  33. 33. Historical Timeline Practice Doctorate Programs Year Number of Programs 1979 1st (Case Western) 2005 9 2006 20 2007 53 2008 92 2009 123 >100 programs in the planning stage Source: AACN (2009) 4 yrs 26 yrs.
  34. 34. DNP Statistics In 2009: 123 programs were enrolling DNP students (with >100 SON programs in current stages of planning) 1/3 of institutions provide distance-education options  34 SONs have focused on BSN to DNP option with 42 additional programs in planning phase Source: AACN Annual Report (2009).
  35. 35. Enrollments and Graduation Enrollments (Fall 2008) • Doctoral (research-focused) . . . . . . . . . . 3,976 • Doctoral (practice-focused) . . . . . . . . . . . 3,416 Graduations (August 2007-July 2008) • Doctoral (research-focused) . . . . . . . . . . . 555 • Doctoral (practice-focused) . . . . . . . . . . . 361 SOURCE: American Association of Colleges of Nursing. 2008-2009 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing.
  36. 36. Nursing Students in Doctoral Programs • Total numbers increased by 26.4% from 2007 to 2008 • Enrollment growth limited to DNP programs --doubling from 1,874 to 3,415 students (+82.2%) • Research-focused enrollments increased by only (0.1%) in same time frame Source: AACN Annual Report (2009)
  37. 37. Source: AACN (2009).
  38. 38. Overall Growth in Programs Number of Programs 2006 2007 2008 2009 Research-focused 103 113 116 121 Practice-focused 20 53 92 >120 Source: AACN Annual Report (2009).
  39. 39. Source: AACN (2009).
  40. 40. Characteristics of the DNP • Based on nursing science & the highest level of nursing practice to provide & influence the: delivery of direct care & management of care administration of nursing & health organizations development & implementation of health policy • Blending clinical, organizational, economic, & leadership skills to impact health outcomes Source: AACN Position Statement on the Practice Doctorate in Nursing (2004).
  41. 41. Characteristics of the DNP • Less emphasis on theory, meta-theory & research methodology content • Focus on evaluation and the use of evidence-based research • Creates a natural partner for the research- focused doctorate (to translate, apply & implement new knowledge) Source: AACN Position Statement on the Practice Doctorate in Nursing (2004).
  42. 42. Characteristics of the DNP • Different dissertation requirements range from practice-based/and or clinical dissertations to capstone projects: guided by clinical practice designed to solve practice problems to inform practice directly • Clinical practica/residency requirements 1000 hours of practice post-baccalaureate end of program practice immersion Source: AACN Position Statement on the Practice Doctorate in Nursing (2004).
  43. 43. Characteristics of the DNP • Two primary tracks: Clinical and Administrative (direct and in-direct clinical practice roles) direct care of individual patients care of patient populations practice that supports care  organizational & professional leadership  management  health policy  nursing/health informatics Source: AACN Position Statement on the Practice Doctorate in Nursing (2004).
  44. 44. DNP Program Curriculum & Competencies • Clinical practice • Philosophy and theory • Health care delivery systems • Health policy • Leadership • Quality • Technology • Practice Inquiry (Clinical Research) • Ethics Source: AACN (2006). The Essential of Doctoral Education for Advanced Nursing Practice
  45. 45. Curriculum & Competencies • Modeled after the Essentials for the BSN & Master’s Education for APN • Eight essentials are the fundamental outcome competencies for all DNP graduates provides direction for program development and accreditation • Specialty focused competencies and practica delineated by specialty organizations comprise a significant portion of the curriculum Source: AACN (2006). The Essential of Doctoral Education for Advanced Nursing Practice. Washington, DC: Author.
  46. 46. DNP Essentials 1. Scientific underpinnings for practice 2. Organizational & systems leadership for quality improvement & system thinking 3. Clinical scholarship & analytical methods for evidence- based practice 4. Technology & information for the improvement & transformation of patient-centered health care 5. Health care policy for advocacy in health care 6. Interprofessional collaboration for improving patient & population health outcomes 7. Clinical prevention & population health for improving the nation’s health 8. Advanced nursing practice for improving the delivery of patient care Source: AACN (2006). The Essentials of Doctoral Education for Advanced Nursing Practice. Washington, DC: Author
  47. 47. Perceived Benefits • Development of needed advanced competencies for increasingly complex clinical and leadership roles • Better match of program requirements and credits/time with credential earned (Master’s level preparation) • Terminal degree and advanced educational credential for those who do not need/want a research-focused degree Source: AACN
  48. 48. Perceived Benefits • Parity with other health professions • Improved image of nursing • Enhanced knowledge to improve practice • Enhanced leadership skills to strengthen practice and health care delivery • Increased # of faculty for clinical institutions • Improved patient care outcomes Source: AACN
  49. 49. Challenges and Concerns • Academic and Nursing Community Issues Impact on faculty and existing curricula Cost & funding Accreditation Licensure & Certification Political issues (Titling) Tenure Decisions & Eligibility (broadening the scope of scholastic excellence)
  50. 50. Choosing a Doctoral Focus • Both the practice-doctorate and research- doctorate enhance nursing skills & knowledge in a formal way • Both terminal degrees in nursing offer the advanced practice nurse many options and choices over decisions that support their career trajectory • BSN or Master’s level to DNP or PhD is an individual choice; APNs need to decide what is best for them and begin to chart a course to develop a plan
  51. 51. Creating Synergy within Nursing Education and Practice • Clear need for doctorally prepared nurse clinicians (room for both terminal degrees) Practice demands in health professions create need for this evolution Using varied nursing professionals to create a whole out of diversity • Understanding the complexity of care requires new knowledge and skill Nursing clinicians need this to respond to evolving changes and address system & patient needs • Addressing stakeholder and consumer demands (employers, policy makers and potential students) the mandate for change is all around us
  52. 52. Creating the Future It’s not the answer that enlightens, but the question Eugene Ionesco
  53. 53. References • American Association of Colleges of Nursing. (2004, October). AACN position statement on the practice doctorate in nursing. Washington, D.C.: Author. • American Association of Colleges of Nursing (2006). The essentials of doctoral education for advanced nursing practice. Washington, D.C.: Author. • American Association of Colleges of Nursing. (2009). Annual report: Advancing higher education in nursing. Retrieved from • American Association of Colleges of Nursing. (2009, April). Fact sheet: The doctor of nursing practice (DNP). Washington, D.C.: Author. • American Association of Colleges of Nursing. (2009, October). Doctor of nursing practice (DNP) talking points. Washington, D.C.: Author.
  54. 54. References • Health Resources and Services Administration (2006, June). The registered nurse population: Findings from the 2004 national survey of registered nurses. Retrieved from • Institute of Medicine (1990). Medicare: A strategy for quality assurance. Washington, DC: The National Academies Press. • Institute of Medicine. (1999). To Err is human: Building a safer health system. Washington, D.C.: National Academy Press. • Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C.: National Academy Press. • Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, D.C.: The National Academies Press.
  55. 55. References • McEwen, M. & Bechtel, G.A. (2000). Characteristics of nursing doctoral programs in the United States. Journal of Professional Nursing, 16 282-292. • Pew Health Professions Commission. (1991). Healthy America: Practitioners for 2005. Author. • Raines, F. C. (2010, February 5). Transformation of a profession: The call to doctoral preparation in nursing. Keynote presentation at the educational conference at Western University of Health Sciences on Doctoral Education: What it is and what it is not, Pomona, California.