Letter to the Editor by Riedel, Sander and Miller-Wenning on Ethics: Is The Doctor of Nursing Practice Ethical?


December 8, 2009

response from Lisa M. Riedel, Theresa M. Sander, and Kimberlee Miller-Wenning  to Ethics: Is The Doctor of Nursing Practice Ethical? by Mary Cipriano Silva, PhD, RN, FAAN; Ruth Ludwick, PhD, RN.C, CNS (March 20, 2006)
with reply by Authors

Dear Editor:

We write in response to the Silva and Ludwick's (2006) Ethics Column, 'Is the Doctor of Nursing Practice Ethical?' which questioned the ethical basis of the doctor of nursing practice (DNP) degree. The American Association of Colleges of Nursing (AACN) endorsed moving the level of education for advanced nursing practice from a master's degree to a doctorate by 2015. Ethics (2009) are the principles of conduct governing an individual or a group; they are an integral part of the foundation of nursing. Silva and Ludwick argued that the DNP has been silent on the ethical principles of social responsibility, respect for persons, do no harm, and justice as fairness. The Essentials of Doctoral Education (AACN, 2006) specify eight essential curricular and competency (performance) expectations. We argue that these essentials facilitate meeting the four ethical principles outlined by Silva and Ludwick.

Social responsibility (2009) is the ethical theory that an organization, such as nursing, has an obligation to society. Changing the education of nurses affects society. Silva and Ludwick questioned how DNP education helps meet societal obligations, such as determining healthcare needs and delivering the necessary nursing care to meet those needs. The Institute of Medicine acknowledges that the healthcare delivery system has fallen short in its ability to translate knowledge into practice, taking an average of 17 years for new knowledge generated by randomized controlled trials to be incorporated into practice (2001, p. 5). Our response is that DNP education prepares experts in specialized advanced nursing practice to provide innovative and evidence-based practice, reflecting the application of credible research findings (AACN, 2006, p.3). DNP Essential I and II focus on the scientific underpinnings of practice and organizational leadership (AACN, 2006 pp. 8-10). These essentials guide DNP education in teaching the use and dissemination of scientifically based healthcare. Essential VII focuses on clinical prevention for improving the nation's health (AACN, 2006, p 15). These DNP essentials facilitate answering the call for social responsibility.

Respect means to take notice of; to regard with special attention; to regard as worthy of special consideration, to care for; to heed (Respect, 2009). Silva and Ludwick stated the discussion of the DNP has sometimes been debated disrespectfully amongst members of the nursing profession. We focus our discussion of respect for persons on the recipients of care and our role in the healthcare team. Essential VIII emphasizes conducting comprehensive and systematic assessments in diverse situations and providing culturally appropriate education and guidance to individuals through complex health transitions (AACN, 2006, p. 16). Essential VI focuses on interprofessional collaboration for improving patient and population health outcomes (AACN, 2006, p. 15). These essentials address respect for our patients and our colleagues.

With respect to the ethical principle of do no harm, Silva and Ludwick argued that there are no studies to support that the DNP will improve safety. However, the ANA (2008) has stated that more highly knowledgeable and skilled providers produce better outcomes. Essential I emphasizes using science-based theories to determine the nature and significance of health and healthcare delivery, actions, and strategies to enhance health and healthcare delivery, and evaluating outcomes (AACN, 2006, p. 9). How could this harm patients cared for by an advanced practice nurse with a DNP education? McGlynn, et al.'s study found Americans receive about half of recommended medical care processes and that automated entry and retrieval of key data is needed for clinical decision making (2003). Essential IV addresses the importance of using information systems/technology and patient care technology for the improvement and transformation of healthcare (AACN, 2006, p. 13). President Bush (2004) issued Executive Order 13335 'for the development and nationwide implementation of an interoperable health information technology infrastructure to improve the quality and efficiency of health care' by 2012 (U.S. Department of HHS, n.d.). The DNP is moving nursing into the new era of information technology and advancing evidence-based practice. We argue that increasing the number of DNP's will strengthen the healthcare system - helping, not harming, our patients.

Silva and Ludwick (2006) defined justice as giving persons what they are due or owed and asked how the DNP addresses fair access to and distribution of scarce resources. We argue that all persons are due quality care that includes the conscientious use of current best evidence. Essential III focuses on clinical scholarship and analytical methods for evidence-based practice, giving the DNP nurse the skills to use research to implement the best evidence for practice, develop practice guidelines, improve practice, improve the practice environment, and disseminate findings to improve outcomes (AACN, 2006, p. 12). Essential V focuses on advocacy in healthcare giving the DNP nurse skills to work at local, regional, and national levels for healthcare reform. The ANA has contended that bold action is needed to create a healthcare system that is accessible, high quality, and responsive to the needs of consumers (ANA, 2008, p. 2). The DNP prepares nurses to answer that call.

The move to the professional doctorate has enhanced the voice and power of the practitioners in medicine, dentistry, and pharmacy (Pierce & Peyton, 1999). Nurses are the most respected professionals as rated in Gallup's annual honesty and ethics poll (Saad, 2008). The Essentials of Doctoral Education serve to educate advanced practice nurses to ethically utilize this public trust for effective, efficient, and timely healthcare. We believe it would be unethical not to move advance practice nurses to the DNP level of education.

Lisa M. Riedel MS, DNPc, CRNA
Robert Morris University

Theresa M. Sander MSN, DNPc, CRNP-C
Robert Morris University

Kimberlee Miller-Wenning MSN, DNPc, CRNP-C
Robert Morris University


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