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  • 1. The Doctorate of Nursing Practice: Responding to a Changing Health Care Environment Geraldine Polly Bednash, PhD, RN, FAAN Executive Director American Association of Colleges of Nursing
  • 2. Dramatic Changes in Health Care
    • Aging population
    • Growing diversity
    • Bio-medical advances
    • New areas of knowledge, i.e. genetics, environmental health
    • Internationalization of Health Care Issues
  • 3.  
  • 4. Acuity Levels
    • Acuity level in general, non-intensive care units of a hospital is higher than acuity levels in ICUs ten years ago.
  • 5. Lusting for the Purple Pill
    • Creating demand – Direct to Consumer marketing
    • Billions in advertising
    • TV – Newspapers – Magazines
  • 6.  
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  • 10.  
  • 11.  
  • 12.  
  • 13. How Safe is It?
    • Institute of Medicine –
      • To Err is Human
      • Crossing the Quality Chasm
      • Joint Commission on Accreditation of Healthcare Organizations –
      • Sentinel Events – 25% nurse related
      • Competence/Orientation/Training
  • 14. What error?
  • 15. Converging Realities – Nursing and the Quality Dilemma
    • Keeping Patients Safe – Transforming the Work Environment of Nurses: “Research is now beginning to document what physicians, patients, other health care providers, and nurses themselves have long known: how well we are cared for by nurses … can be a matter of life and death.”
  • 16. Health Professions Education: A Bridge to Quality
    • Education for the health professions is in need of a major overhaul. …education simply has not kept pace with or been responsive enough to shifting patient demographics and desires, changing health system expectations, evolving practice requirements…a focus on improving quality or new technologies.
    • IOM, 2003
  • 17. A Paradigm Shift is Underway in Graduate Education in Nursing
    • Expansion of Knowledge Underlying Practice;
    • Increased Complexity of Patient Care;
    • New expectations for competent and safe practice- systems savvy, business acumen, policy, interprofessional, use of data sets;
    • Shortages of Prepared Nursing Faculty, Leaders in Practice, and Nurse Researchers, and
    • Increasing Educational Expectations for the Preparation of other Health Professionals
  • 18. Changing Perspectives on Doctoral Education in Nursing
    • Strong history of growth in research focused doctoral programs
    • AACN set standards for the research programs – Indicators of Quality in Research Focused Doctoral Programs
    • Both PhD and DNSc programs have a focus on development of researchers to create the evidence base for nursing
  • 19. History of Practice Doctorates
    • DNS and DNSc originally conceived as practice doctorates
    • Over time these programs also focused upon development of researchers
    • Nursing Doctorate programs (ND) originally focused on development of an entry level generalist but over time changed dramatically with little congruence across the four ND programs
  • 20. Evolution of the Practice Doctorate
    • 1999 -Task Force on Research Intensive Doctoral Programs Established
    • 2001 –Indicators of Quality in Research-Focused Doctoral Programs Published and Recommended that Task Force on Clinical Doctorates be Established
    • 2002 –Task Force on Clinical Doctorate Established – Obtained Data, Input, and Consultation from a Broad Range of Constituencies and Developed 13 Recommendations
  • 21. Focus on the DNP
    • Task Force that created standards for research focused programs recommended that AACN create a standard set of assumptions and guidelines for the terminal practice degree programs
    • Emergence of DNP with first program at U of Kentucky and many others in development
  • 22. Task Force on Practice Doctorate
    • Created in March 2002 to make recommendations on the future of the practice doctorate
    • Quickly became apparent that the issue was more complex than a focus on the single degree program and included issues that were universal in health professions education
  • 23. Charge to the Task Force
    • clarify the purpose of the professional clinical doctorate, specifically core content and core competencies;
    • describe trends over time in clinical doctoral education;
    • assess the need for clinically focused doctoral programs;
    • identify preferred goals, titles, outcomes, and resources;
  • 24. Charge to the Task Force
    • discuss the elements of a unified approach versus a diverse approach;
    • determine the potential implications for advanced practice nursing (APN) programs;
    • make recommendations regarding related issues and resources; and
    • describe potential for various tracks or role options.
  • 25. Evolution of the Concepts
    • Original charge was to focus on education to acquire a “clinical doctorate”
    • Outgrowth of the work and recommendations of the task force that established the AACN Indicators of Quality in Research-focused Doctoral Programs
    • That task force recommended the validation of the differences between the research and clinical doctorate
    • The Clinical Doctorate task force recommended that the term “practice doctorate” be used to reflect role
  • 26. Advanced Practice for the Future
    • Growing trend to extend MSN programs beyond the traditional master’s credits – need to give the right degree for the education required
    • Increased practice demands same for APNs as for entry level generalists – more complexity and more acuity
  • 27. Stakeholder Observations
    • Need to develop advanced competencies for increasingly complex clinical, faculty and leadership roles;
    • Need for enhanced knowledge to improve nursing practice and patient outcomes;
    • System change requires enhanced leadership skills to strengthen practice and health care delivery;
    • Credits and time invested in master’s programs not congruent with the credential earned;
  • 28. National Academy of Sciences 2005 Report on Nursing Research
    • The Report Focuses on Increasing the Number of Nurse Scientists and Increasing the Number of Productive Research Years for Nurses Prepared in PhD Programs
  • 29. National Academy of Sciences 2005 Report
    • “ The need for doctorally prepared practitioners and clinical faculty would be met if nursing could develop a new nonresearch clinical doctorate, similar to the M.D. and Pharm.D. in medicine and pharmacy, respectively.”
  • 30. “ Nurses prepared at the doctoral level with a blend of clinical, organizational, economic and leadership skills are most likely to be able to critique nursing and other clinical scientific findings and design programs of care delivery that are locally acceptable, economically feasible, and which significantly impact health care outcomes.” The Mission Becomes Apparent AACN Position Paper on the Practice Doctorate
  • 31. Position Statement on the Practice Doctorate in Nursing October 2004
  • 32. Practice doctorate
    • Recommendation 1 : The Task Force recommends that the terminology , practice doctorate be used instead of clinical doctorate .
  • 33. Practice Doctorate
    • The term practice , specifically nursing practice, as conceptualized in this document refers to any form of nursing intervention that influences health care outcomes for individuals or populations, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations, and the development and implementation of health policy. Preparation at the practice doctorate level includes advanced preparation in nursing, based on nursing science, and is at the highest level of nursing practice.
  • 34. Recommendations
    • Recommendation 2: The practice-focused doctoral program be a distinct model of doctoral education that provides an additional option for attaining a terminal degree in the discipline.
    • Recommendation 3: Practice-focused doctoral programs prepare graduates for the highest level of nursing practice beyond the initial preparation in the discipline.
    • .
  • 35. Recommendation 4
    • Practice-focused doctoral nursing programs include seven essential areas of content. The seven essential areas of content include:
    • scientific underpinnings for practice;
    • advanced nursing practice;
    • organization and system leadership/management; quality improvement and system thinking;
  • 36. Recommendation 4
    • analytic methodologies related to the evaluation of practice and the application of evidence for practice;
    • utilization of technology and information for the improvement and transformation of healthcare;
    • health policy development, implementation and evaluation; and
    • interdisciplinary collaboration for improving patient and population healthcare outcomes.
  • 37. Congruent Titling
    • Recommendation 7 : One degree title should be chosen to represent practice-focused doctoral programs that prepare graduates for the highest level of nursing practice.
    • Recommendation 8 : The Doctor of Nursing Practice (DNP) be the degree associated with practice-focused doctoral nursing education.
    • Recommendation 9 : The Doctor of Nursing (ND) degree title be phased out.
  • 38. Recommendations
    • Practice doctoral nursing programs should include development and/or validation of expertise in one area of advanced nursing practice.
    • Practice-focused doctoral nursing programs prepare leaders for clinical practice. The practice doctorate prepares individuals at the highest level of practice and is the terminal practice degree.
  • 39.
    • Recommendation 10: The practice doctorate 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.
  • 40.
    • Recommendation 11 : A transition period be planned to provide nurses with master’s degrees, who wish to obtain the practice doctoral degree, 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.
  • 41.
    • Recommendation 12: Practice doctorate programs, as in research-focused doctoral programs, are encouraged to offer additional coursework and practica that would prepare graduates to fill the role of nurse educator
  • 42.
    • Recommendation 13: Practice-focused doctoral programs need to be accredited by a nursing accrediting agency recognized by the U.S. Secretary of Education (i.e. Commission on Collegiate Nursing Education or the National League for Nursing Accrediting Council).
  • 43. Moving Forward
    • AACN has created two task forces:
      • Essentials of the Doctorate of Nursing Practice
      • Task Force on the Roadmap to the DNP
    • Goal is to complete transition to the DNP by 2015
  • 44. The Essentials of the Doctorate of Nursing Practice
    • Task Force charged to develop the curricular and content requirements for the DNP as well as identify the competencies to be acquired in a DNP program.
    • The document follows the model of the BSN and Masters Essentials
    • Provides direction for program development and accreditation.
  • 45. Charge to Task Force
    • Develop the curricular and content requirements for the DNP as well as identify the competencies to be acquired in a DNP program
    • Establish a clear strategy for educational changes and transition, and hallmarks that distinguish the DNP from existing programs that offer the Master of Science in Nursing
    • Identify the critical curricular content that should be present and competencies that should be acquired in the DNP programs in which master’s prepared nurses seek to acquire the DNP
    • Develop recommendations and strategies for AACN, and the full contingent of AACN’s academic programs to respond to this transition.
  • 46. Essentials Reflect Competencies for All Graduates DNP MS-APN MS-non-APN BS (nursing) BS (non-nursing) B A C C A L A U R E A T E C O M P
  • 47. Task Force Strategy
    • Re-confirm 7 essentials identified by original Practice Doctoral Task Force
    • Read a lot, and consult constituents and leaders
    • Discuss and deliberate—8 th essential added
    • “ Clinical Prevention and Population Health
    • for Improving the nation’s Health”
    • Draft document core—the essential competencies and related curricular content
    • Hold regional and stakeholder meeting for feedback
    • Post draft document on web site for feedback
  • 48. Preliminary Content for the Essentials
    • Introduction
      • Background/Trends leading to this paradigm shift
      • Summary of process and purpose of the document
    • Context of Graduate Education in Nursing
      • Relationship of MSN, DNP, and PhD
      • Integration of faculty/teaching role in graduate nursing education
    • Doctoral Education for nursing practice
      • Broad curricular model—includes links to specialty certifying bodies
      • Description of 8 Essentials (document circulated at regionals)
      • Curricular Elements (content circulated at regionals)
    • DNP Programs in the Academic Environment
      • Curricular parameters (eg, typical length/credit hours)
      • Residency
      • Capstone Project
      • Faculty characteristics
    • Glossary
  • 49. Format of Section of the DNP Essential Draft Currently Under Review Not the complete document or final format—only a section Introduction Review of 2004 TF recommendations Summary of Process Task Force creation Regional meetings Definition of advanced nursing practice Curriculum Model Essential Competencies
  • 50. Overview of the Curriculum Model DNP is a degree preparing individuals for multiple roles . Seven of the core competencies are for all graduates regardless of role. Core competencies form the basic foundation for advanced nursing practice (essential 8) where competencies bifurcate with the DNP program of study focusing on either: Roles involving the direct delivery of care to individuals, families, and/or populations Roles that influence the delivery of care indirectly through organizational and system leadership.
  • 51. *For those students who may choose a career in healthcare education or academia, additional pedagogical courses should be provided **Competencies, Content and Practica are delineated by specialty nursing organizations. Optional coursework in pedagogical methods* Advanced Nursing Practice Competencies for: A) Graduates focused on individuals & families B) Graduates focused on populations, systems & organizations Core Essential 8 Core Essentials 1-7 Specialty Focused Competencies**
  • 52. Recommended DNP Content
    • Some content overlaps or is noted multiple times due to the synergistic nature of competencies and the utility of some content for more than one essential.
    • Content ≠ Course
  • 53.
    • Essential Competencies for DNP Graduates
    • Scientific underpinnings for practice
      • Recognizes the philosophical and scientific underpinnings essential for the complexity of nursing practice at the doctoral level.
    • Organizational and systems leadership for quality improvement and system thinking
      • Recognizes the competencies essential for improving and sustaining clinical care and health outcomes, eliminating health disparities, and promoting patient safety and excellence in care.
  • 54.
    • Essential Competencies for DNP Graduates
    • Clinical scholarship and analytical methods for evidence-based practice
      • Recognizes competencies essential for translation of research into practice, evaluation of practice, practice improvement, and the development and utilization of evidence-based practice.
    • Technology and information for the improvement and transformation of patient-centered health care
      • Recognizes competencies essential to manage, evaluate, and utilize information and technology to support and improve patient care and systems.
  • 55.
    • Essential Competencies for DNP Graduates
    • Health care policy for advocacy in health care
      • Recognizes the responsibility nurses practicing at the highest level have to influence safety, quality, and efficacy of care, and the essential competencies required to fulfill this responsibility.
    • Interprofessional collaboration for improving patient and population health outcomes
      • Recognizes the critical role collaborative teams play in today’s complex health care systems and the competencies essential for doctorally prepared nurses to play a central role on these teams.
  • 56.
    • Essential Competencies for DNP Graduates
    • 7. Clinical prevention and population health for improving the nation’s health
    • Added to original competencies in response to:
      • IOM 2001 call for transformation “…of health professional education in response to the changing needs of the population and the demands of practice.”
      • Health People 2010 support of IOM and objective to include “core competencies in health promotion and disease prevention” in clinical education
      • In consideration of nursing’s the longstanding focus on health promotion and prevention
  • 57.
    • Essential Competencies for DNP Graduates
    • Advanced nursing practice for improving the delivery of patient care
    • Recognizes the essential competencies reflective of the distinct, in-depth knowledge and skills that form the basis for nursing practice at the highest level regardless of practice role.
  • 58. To Divide or Not to Divide: That is the Question (Apologies to Hamlet) 8a. APN or individual and population-focused competencies for the DNP graduate Recognizes the unique competencies associated with the specialized knowledge and clinical expertise essential for the direct care of individuals, families, or discrete population aggregates. 8b. Systems or organization-focused competencies for the DNP graduate Recognizes the unique competencies associated with the organizational expertise and specialized knowledge essential for leadership of health care delivery systems.
  • 59. Transforming Professional Nursing Practice
    • Issues are centrally focused on preparing professional nurses with the highest level of education to provide expert nursing care
    • Will not disenfranchise current APNs
    • DNPs will serve as the natural allies of researchers for the full implementation of evidence for practice
    • Discipline needs both researchers and high level clinicians to provide high quality care
  • 60. What Are the Issues? Perspectives from the Anesthetist
    • Should all APNs be expected to meet the requirements for the foundational framework of the DNP Essentials?
    • How long?
    • Who set the expectations for specialty practice education? The DNP is specialty focused education.
    • Do we really need that content? Reframing what is – not always adding more.
  • 61. What Are the Issues? Perspectives from the Anesthetist
    • What about the programs that are not housed in a nursing school? Depends upon who sets the standards for those programs.
    • How will we assure that all the programs are requiring similar outcome competencies? Is this an accreditation issue – and not an assault on the need to change the degreed?
    • What does it mean to be foundational?
  • 62. What Are the Issues? Perspectives from the Anesthetist
    • There is no compelling evidence to do this? -------Shouldn’t you get the degree you deserve for the time and energy you are required to undertake to complete the program?
    • Where will we get the faculty? They are there – we need to think differently about who will serve as faculty and remember how we began other innovations in nursing.
  • 63. How are other health professions changing their education?
    • The ACGME requires that all residency programs evaluate the competence of their residents in the following areas:
      • patient care,
      • Practice-based learning and improvement
      • medical knowledge,
      • interpersonal and communication skills,
      • professionalism, and
      • systems-based learning
  • 64. AANA Summit on the DNP
    • While the nurse anesthetist of today is safe and competent, the provider of the future will have to possess enhanced skills in analysis and synthesis of research and be able to apply them in the practice setting.
  • 65. AANA Summit on the DNP
    • Practitioners will need increased knowledge in business skills, management of less invasive procedures, multicultural healthcare, and biomedical ethics.
    • Subspecialties in practice will continue to emerge in areas such as pediatrics and pain management. (Populations??)
  • 66. What are the Transition Issues?
    • Creating standards to assure quality programs with consistency in goals and outcomes
    • Creating partnerships across multiple institutions to achieve goal
    • Seeking creative solutions to issues related to resources, faculty, regulatory structures
  • 67. What are the Transition Issues:
    • Collaboration with multiple constituents to create agreement on issues related to credentialing – including licensure, certification, and accreditation
  • 68. They say that time changes things. But you actually have to change them yourselves. Andy Warhol
  • 69.  
  • 70. Truth springs from arguments among friends. David Hume
  • 71. Wise Sayings
    • Remember - this ain’t a dress rehearsal
      • Famous nurse – Carole Anderson
  • 72.
    • “ Today as in the past, nursing remains pivotal in improving the health status of the public and ensuring safe, effective, quality care.”
    • ANA Scope and Standards of Practice
  • 73. Creating the Future
    • We have a responsibility to create the future for our patients, for our profession, and for the health of the public.