Advanced Practice - Is the DNP the best path for advanced practice nurses?

Appeared in: Advance for Nurses

By: Candy Goulette

Legislation introduced by Sen. Jack Scott (D-Pasadena) to allow the California State University system to grant doctorates in nursing practice (DNP) was explored in the From the Hill column in the last issue of ADVANCE for Nurses. In this issue, we'll look at the topic from the nursing side.


In 2004, the American Association of Colleges of Nursing (AACN) called for development of a terminal practice degree for nurses. That degree would be the DNP, an alternative to the research-focused PhD, and akin to practice doctoral degrees for medical doctors (MD and DO), dentists (DDS) and pharmacists (PharmD).

According to AACN's white paper, preparation at the practice doctorate level includes advanced preparation in nursing, based on nursing science, at the highest level of nursing practice. In place of an emphasis on theory, research methodology content and a final dissertation, the DNP focuses on evaluation and translation of research into scholarly practice; practice improvement; intervention and care delivery model innovation and testing; and leadership and expertise in policy and the development of clinical excellence. AACN visualized the DNP as the terminal practice degree of choice for nurses caring for individual patients, such as an NP or CNS; those caring for patient population, such as public health nursing; or those whose practice supports patient care, such as chief nursing officers, health policy advocates or nursing informatics.

Following AACN recommendations that all nursing specialty preparation should occur at the doctoral level by 2015, the DNP has gained favor as a terminal practice degree.

Moving Forward

The University of San Francisco was the first school of nursing in California to offer the degree. Judith Karshmer, PhD, RN, APRN, BC, professor and dean of the USF School of Nursing, already had experience with the DNP when she joined the USF staff, having established the degree at the University of South Florida. She called the degree the "train that's already left the station."

"When I earned my PhD, it was the only option," she shared. "You had to become a researcher, but what I really wanted was more evidence-based practice, to work with policy that impacted healthcare."

The USF DNP program allows students to follow a direct (FNP) or indirect (healthcare systems leadership) path. Most of the 28 students currently enrolled are in the indirect program, but all are required to do 1,000 hours of precepted clinical time. While the program currently admits master's-prepared students, another pathway for BSN-to-DNP students will begin in the fall.

Like USF, Samuel Merritt College in Oakland will be implementing a DNP program in the near future. Arlene A. Sargent, EdD, RN, professor and associate dean of SMC's School of Nursing said the DNP program will be a post-master degree tailored for working RNs.

"At this point the DNP curriculum that we are proposing will not have a direct impact on our master's programs," Sargent said. "A number of the alumni and current students have indicated their interest in pursuing the DNP so this curriculum will allow them to continue their studies upon completion of the master's and enable them to meet their goal of attaining the DNP."

SMC is in the early stages of the approval process for the DNP program.

"We are hoping to complete the approval process on campus by June with the goal of admitting the first students in fall 2009," she said. "We'll offer two courses at a time, so students will be able to complete the program going part-time in 2 years."

Karshmer foresees the master's-prepared nurse as a clinical nurse leader, noting current master's-prepared nurses with CRNA, CNS or FP licensure will pursue the DNP while the former master's programs in those fields phase out.

Noting the DNP is more "worker-friendly" than the PhD, Karshmer said students enrolled in the USF program are "at the top of their game."

"We have CNOs, nursing faculty and NPs who have been working for 25 years," she said. "They were champing at the bit for this opportunity."

Back to School

Among those students are KT Waxman, MBA, RN, and Cindy Day, MS, RN, CNAA.

Waxman is program director at the California Institute for Nursing & Health Care (CINHC) and leads both the Bay Area Nursing Resource Center and the Bay Area Simulation Collaborative, where she instructs their leadership excellence program. Waxman also is an author and president of her own consulting firm. She hasn't worked at the bedside for more than a dozen years, but her work impacts bedside care daily. For her, the ability to design her specialty around work with clinical simulation was a draw.

"I had wanted to go back to school, but I wasn't interested in research per se, and the length of time and dissertation were hurdles," she said. "The DNP will enable me to take research others have done and apply it to practice, to transform nursing practice here. The DNP ties in with evidence-based practice and will help me use the evidence to move clinical simulation to become the standard of practice in both schools of nursing and hospitals."

For Day, vice president of patient care services and chief nursing officer at Stanford University Hospital, the DNP is not a way back to the bedside, but a way to lead and empower those who are already there. She chose the DNP to stay fresh and engaged, with the application of research to practice drawing her to the USF program.

"My role here is about leading nursing practice from the theoretical and practical," she explained. "But I'm also responsible for pharmacy, speech, physical therapy and others. The DNP strengthens my role. The program has already broadened the way I look at things here. I've gained new knowledge and look at healthcare in a new light."

Schools of Thought

Sen. Scott's legislation allowing the CSU schools of nursing to grant the DNP was interesting news to system nursing deans. Under the proposed legislation, four of the 13 CSU campuses would initially be selected to offer the DNP.

Ann Stoltz, PhD, RN, chair of the division of nursing at CSU Sacramento, said while she's in favor of the degree, offering it would depend on funding and would be at least 5 years away. And, despite an AACN opinion that the DNP is not a faculty degree, she sees a place for it in schools of nursing.

"I have faculty who are currently enrolled in DNP programs," Stoltz shared. "I've noticed a real growth in our program as a result. We use our PhD- and DNSc-prepared faculty for graduate theory courses and our new DNPs for clinical courses. Not everyone needs to be prepared at the PhD level. There's a need for everyone — nurse researchers, nurse ethicists, nurse clinicians — and we have to make room at the table."

With 80 percent of full-time faculty doctorally prepared, CSU Dominguez Hills is closer to offering the DNP. Carole Shea, PhD, RN, FAAN, school of nursing dean said her school currently offers the FNP and CNS, but would transition those roles into the DNP and offer CNL generalist at the master's level. However, that plan couldn't happen overnight.

"It would take at least 3 years to develop," Shea explained. "We could do much of it online. We'd start with FNPs, and the DNP would essentially be a completer program."

The Hahn School of Nursing and Health Science at the University of San Diego School of Nursing is set to begin its DNP program in September. Susan Instone, DNSc, RN, CPNP, associate professor and director of the advanced practice/DNP program, said the school will phase out the master's degree for NP and CNS students by 2015.

"I'm an NP myself, and this is long overdue," she said. "It will give us more time to prepare ANPs with a greater scientific, economic, policy and systems foundation for clinical practice. The ultimate aim is for these graduates to develop innovative ways to improve access to quality care for those currently without it."

The USD DNP program will have a more clinical focus than that offered at USF. Instone noted the school would require a clinical residency for its students, and would have students on campus 1 day per week working with PhD students to encourage interaction. They also plan to create a DNP-PhD bridge program for those students who wish to pursue more research, but that doesn't mean they see the DNP as a marginal degree.

"This is absolutely a terminal degree for those who want a clinical practice," Instone said. "They will be able to apply what they're learning immediately to their practice."

Other Voices Heard

While many nurses embraced AACN's plan, others argued it would muddy the educational waters. In 2005, Afaf I. Meleis, PhD, FAAN, and Kathleen Dracup, DNSc, FNP, RN, FAAN, published The Case Against the DNP: History, Timing, Substance, and Marginalization, in the Online Journal of Issues in Nursing against the DNP. Long-time colleagues, Meleis, the Margaret Bond Simon dean at the University of Pennsylvania School of Nursing in Philadelphia, and Dracup, professor and dean, School of Nursing at the University of California, San Francisco, argued "separating the practice and research missions could undermine our ability to be equal partners in universities, as well as diminish our effectiveness in establishing the evidence for quality and safe healthcare."

Dracup sees the degree as superfluous. "No research indicates a deficiency in the current master's preparation for advanced practice," she offered. "All research conducted over the past 2 decades demonstrates that ANPs (prepared at the MS level) have clinical outcomes equal to or better than physicians."

That's not her only concern. The issue is complicated given the California master plan for nursing education. Of the new degree, she said she's not sure enough thought or collaboration with existing nursing programs and professionals has taken place. Sen. Scott said he did not speak with any nursing programs or organizations before offering the bill, but did work closely with the CSU system chancellors.

Dracup noted that, like the move from diploma programs to the ADN, the move from the MS to the DNP may have unintended consequences.

The dilemma is how to address the issues while advancing the profession. The DNP has breathed new life into some programs, but the number of applicants to master's programs has doubled.

"Unless state boards of nursing adopt the DNP as the requirement for advanced nursing practice, we are destined to duplicate the same confusion over the MS and DNP as we have for entry into practice," Dracup said.


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