Considerations for the Doctor of Nursing Practice Degree

Today’s progressively complex healthcare landscape increasingly demands leaders who are adept at managing change in uncertain environments. Representing this country’s largest group of healthcare workers, RNs influence how research translates to practice and ensure quality patient outcomes. Doctoral programs provide prospective nursing students with opportunities to pursue degrees focused on research or practice. The doctor of nursing practice (DNP) degree emphasizes leadership in clinical settings.

The DNP degree supports the growing need for well-prepared nurse leaders who can navigate complicated health systems and successfully implement innovations that change practice. Advanced practice nurses (APNs) working at the bedside or in administrative positions require leadership skills to rapidly synthesize information and apply new, setting-specific knowledge to improve patient outcomes. The American Association of Colleges of Nursing ([AACN], 2004) defined nursing practice as “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” (p. 3). The AACN’s broad definition of nursing practice makes the DNP degree the preferred career development path for nurses working in a variety of direct and indirect care roles and practice settings (Chism, 2009).

The number of DNP programs has increased annually since 2004 when the AACN first endorsed the DNP as the entry degree for APNs, outpacing the growth of doctor of philosophy (PhD) programs (AACN, 2015b) (see Figure 1). As of June 2015, 264 DNP programs existed, with another 60 programs in the planning stages (AACN, 2015b). Many programs that offered the doctor of nursing science (DNS) degree converted to programs awarding a PhD degree (Reid Ponte & Nicholas, 2015). DNP programs across the country enrolled 18,352 students in 2014, with 3,065 graduating that year (AACN, 2015b). These figures demonstrate the strong interest of nurses in pursuing the DNP degree. The purpose of this article is to provide brief background information concerning the evolution of the DNP degree and its present status, to define the DNP degree, and to guide oncology nurses’ decision-making process regarding the DNP degree.

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Background

The first doctoral degrees for nurses focused on education and research, not practice. In 1979, Case Western Reserve University in Cleveland, Ohio, offered the first “clinical” doctoral program in nursing: the nursing doctorate (ND) (Bednash, Breslin, Kirschling, & Rosseter, 2014; Chism, 2009; Loomis, Willard, & Cohen, 2006; Patzek, 2010). During the next two decades, few schools offered the ND; however, the number of nurses obtaining research doctorates (e.g., PhD, DNS) increased (Reid Ponte & Nicholas, 2015). Although the DNS was designed to be a professional doctorate focused on the preparation of clinicians (Chism, 2009), the degree prepares nurses as researchers with little attention paid to clinical practice. Responding to the variability in curricula among practice doctorate programs, the AACN formed a task force in 2002 to examine the status of practice doctorates (Chism, 2009). Subsequently, the findings from this task force led to the creation of an AACN position statement that endorses the DNP as the terminal degree for nursing practice (AACN, 2004).

Other factors influencing the movement toward the DNP degree include the shortage of doctorally prepared nursing faculty, the increased national attention on healthcare quality and safety, and the desire for parity with other healthcare professionals (AACN, 2015a; Bednash et al., 2014; Patzek, 2010). DNP-prepared nurses contribute to the availability of faculty in schools of nursing, particularly regarding the provision of clinical and leadership content. An Institute of Medicine ([IOM], 2001) report titled Crossing the Quality Chasm: A New Health System for the 21st Century proposed changes to healthcare professional education, as well as emphasized the redesign of education programs with the objective of better preparing healthcare professionals to translate new knowledge into practice and integrate new technologies. These competencies are reflected in the AACN’s list of essentials of doctoral education for advanced nursing practice (Chism, 2009) (see Figure 2). Many other healthcare disciplines (e.g., pharmacy, medicine, physical therapy) offer clinical doctorates. Nurses graduating with master’s degrees often have completed a similar number of credit hours as those required for doctoral degrees in other professions. Therefore, the DNP creates parity between nurses and other professionals.

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Status of the Doctor of Nursing Practice Degree

The AACN’s (2004) position statement on the practice doctorate in nursing called for a transition in graduate programs preparing APNs with the practice doctorate and indicated that the DNP should be the standard for entry into advanced practice by 2015. This change is academically driven—no state boards of nursing require greater than a master’s degree for licensure at the advanced practice level (National Association of Neonatal Nurses [NANN], n.d.). In 2015, a task force of the AACN charged with evaluating the impact of the DNP degree updated recommendations for curriculum requirements, including clarification of the final project and practice hours.

The DNP final project is no longer referred to as a “capstone” and may not be a systematic review or a student portfolio (AACN, 2015a). The requirements now call for a focus on implementing change in a complex practice environment that affects healthcare outcomes, and the project should demonstrate planning, implementation, evaluation, and sustainability. Dissemination methods, determined by individual DNP programs, range from presentation to publication (AACN, 2015a).

Post-baccalaureate DNP degree students are required to complete 1,000 practice hours, whereas the number of hours for master’s degree students varies. The AACN (2015a) proposed standards for meeting this requirement and noted that years of experience are not a suitable substitute for practice hours. Ultimately, a DNP program must have ways to demonstrate to the faculty that a student has met the expected outcomes (AACN, 2015a). All DNP projects should have a systems focus, demonstrate implementation of a change, and include a plan for sustainability and a method for evaluation (AACN, 2015a).

The Doctor of Nursing Practice Degree Defined

The DNP degree is the proverbial handshake with the PhD. Nurses prepared with a clinical doctorate have the skills to integrate research into practice. In many organizations, DNP-prepared nurses move into leadership roles, which positions them well to implement new knowledge (Bednash et al., 2014). Nurses with a PhD typically advance the science by generating new knowledge, and those with a DNP degree lead the translation of evidence to practice (Reid Ponte & Nicholas, 2015). The DNP-prepared nurse and the PhD-prepared nurse work collaboratively to complete the research implementation cycle.

Graduates of DNP programs gain expertise in evaluating the best evidence and implementing innovations in complex practice environments. As expert clinicians, nurse practitioners (NPs) may influence the quality of patient care by continually reviewing the evidence and evaluating the need for changes in practice (Chism, 2009). Opportunities exist for NPs to lead the implementation of evidence-based practice in various settings, such as large, urban healthcare organizations, or to increase access to care for patients in rural settings. As direct care providers, NPs are most knowledgeable about the practical issues facing patients and can prioritize needs for improvement.

Although NPs and their professional organizations have led many efforts to champion the DNP (Bednash et al., 2014), the practice doctorate also prepares indirect care nurses who support direct patient care in organizational leadership, education, informatics, and health policy settings. DNP programs aim to grow visionary leaders who can apply situation-based strategies and work productively with interprofessional team members. These nurses lead efforts for cost reduction through implementation of evidence-based practice and integration of new technologies. The DNP-prepared nurse is skilled in organizational leadership and systems thinking, as well as adept at navigating complicated workflows to achieve quality improvement.

The shortage of faculty for schools of nursing significantly influences the future of the profession. As the DNP degree gains momentum, the increase in doctorally prepared nurses can help to meet this need (Bednash et al., 2014; Chism, 2009; Patzek, 2010). Graduates of DNP programs seeking faculty positions should consider additional education in the science of pedagogy (Bednash et al., 2014), if it is not included in their program curriculum. Having the skills to teach specialized knowledge related to nursing and the ability to create an environment that supports learning is important.

Choosing to Pursue the Doctor of Nursing Practice Degree

Practical considerations for pursuing the DNP degree may assist nurses in the decision-making process. DNP programs have grown substantially during the past decade (AACN, 2015b), demonstrating recognition of the value of the degree and suggesting long-term sustainability. Any effort to advance an individual’s education requires a serious commitment to learning, as well as a considerable investment of time and resources. Matching interests and career goals with the appropriate degree prior to taking this important step is imperative.

Nurses may pursue the DNP degree in one of two ways: (a) post-baccalaureate entry (these students require a more robust program of study with an increase in credit hours because they do not have a master’s degree) and (b) post-master’s entry (this is a common point of entry for many APNs with master’s degrees) (AACN, 2015a; NANN, n.d.). Although many graduate programs, particularly NP programs, have already transitioned to the DNP, master’s programs still exist as an option for post-baccalaureate nurses. Pursuing a master’s degree requires less time, but the student will graduate without a terminal degree. This may be a disadvantage to a novice nurse when pursuing career advancement, particularly as the DNP degree becomes the new standard for advanced practice nursing.

The key consideration in choosing among degrees is related to the individual nurse’s interest in conducting research to answer clinical questions as a nurse researcher or in synthesizing and translating new knowledge and scientific findings to clinical care and healthcare systems. If the nurse’s interest centers on practice change and quality improvement in the clinical setting, DNP programs offer skills to succeed in these areas.

Implications for Nursing

The rapid cycle of change in health care raises the bar for nurses in leadership positions. New knowledge and innovations in the science of cancer care require nurses to stay ahead of change to ensure optimal patient outcomes. Oncology nurses are uniquely positioned to assume pivotal roles in the translation of research and implement evidence-based practice that will affect care delivery models. The DNP-prepared oncology nurse can fill a variety of roles, including those in organizational leadership of healthcare systems, health policy, government arenas, and professional organizations.

With new emphasis placed on controlling costs in cancer care, the DNP-prepared oncology nurse can leverage evidence-based practices to increase efficiency of care delivery. These nurses can identify new areas of opportunity to improve outcomes by enhancing patient empowerment and providing interventions based on research findings. With an advanced understanding of business concepts, organizational leadership, and regulatory affairs, combined with clinical knowledge, educated oncology nurses can exert greater impact on the design and implementation of cancer care programs globally.

Conclusion

The prevalence of DNP programs and nurses graduating with DNP degrees has increased rapidly since the AACN’s endorsement of the DNP as the terminal degree for nursing practice in 2004. Nurses with DNP degrees work collaboratively with nurse researchers and their interprofessional colleagues to translate evidence to practice, implement innovations, and evaluate outcomes. DNP programs prepare nurses as leaders and ready them to assume a variety of roles in the direct and indirect care of patients and populations. The oncology nurse can benefit from skills acquired in a DNP program by using expertise in evaluating evidence to change nursing practice in the rapidly evolving world of cancer care.

References

American Association of Colleges of Nursing. (2004). AACN position statement on the practice doctorate in nursing. Retrieved from http://www.aacn.nche.edu/publications/position/DNPpositionstatement.pdf

American Association of Colleges of Nursing. (2015a). The doctor of nursing practice: Current issues and clarifying recommendations. Report from the task force on the implementation of the DNP. Retrieved from http://www.aacn.nche.edu/aacn-publications/white-papers/DNP-Implementat…

American Association of Colleges of Nursing. (2015b). Fact sheet: The doctor of nursing practice (DNP). Retrieved from http://www.aacn.nche.edu/media-relations/fact-sheets/DNPFactSheet.pdf

Bednash, G., Breslin, E.T., Kirschling, J.M., & Rosseter, R.J. (2014). PhD or DNP: Planning for doctoral nursing education. Nursing Science Quarterly, 27, 296–301. doi:10.1177/0894318414546415

Chism, L.A. (2009). Toward clarification of the doctor of nursing practice degree. Advanced Emergency Nursing Journal, 31, 287–297. doi:10.1097/tme.0b013e3181be0fd6

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

Loomis, J.A., Willard, B., & Cohen, J. (2006). Difficult professional choices: Deciding between the PhD and the DNP in nursing. Online Journal of Issues in Nursing, 12, 6.

National Association of Neonatal Nurses. (n.d.). Understanding the doctor of nursing practice (DNP): Evolution, perceived benefits and challenges. Retrieved from http://www.nann.org/pdf/DNPEntry.pdf

Patzek, M.J. (2010). Understanding the DNP degree. American Nurse Today, 5, 49–50.

Reid Ponte, P., & Nicholas, P.K. (2015). Addressing the confusion related to DNS, DNSc, and DSN degrees, with lessons for the nursing profession. Journal of Nursing Scholarship, 47, 347–353. doi:10.1111/jnu.12148

About the Author(s)

Rodriguez is a nurse leader in the Department of Nursing at Memorial Sloan Kettering Cancer Center in New York, NY. No financial relationships to disclose. Rodriguez can be reached at rodrige2@mskcc.org, with copy to editor at ONFEditor@ons.org.