Societal drivers, as well as trends in education and health care, are advancing the practice doctorate in nursing. For nurse practitioner preparation, the current resurgence of interest in the practice doctorate could precipitate change that mimics the evolution from post-basic certificate to Master’s level education. The National Organization of Nurse Practitioner Faculties (NONPF) is a resource for the study of the practice doctorate relative to quality nurse practitioner education. This article will offer some insights into the movement toward the practice doctorate by describing, from the NP perspective, the societal impetus for change, the historical perspective of NP and doctoral education, the 4 Ws (why, what, where, and when) of the movement, and some of the myths and realities about the practice doctorate.
Key words: practice doctorate, nurse practitioner, nursing education, NONPF
The question facing the nursing community is no longer whether the practice doctorate is "future or fringe" (Marion et al., 2003) but rather how do we move forward together to ensure quality, educational programs? The National Organization of Nurse Practitioner Faculties (NONPF) has been examining key elements of the practice doctorate movement since 2001 to consider the impact of this new level of education on nurse practitioner (NP) education. The movement toward the practice doctorate seems to have reached the "tipping point" (Gladwell, 2000), in that a critical mass of organizations and institutions are committed to the future development of this degree. Although the pioneering doctor of nursing (ND) programs began the practice doctorate movement over 25 years ago, the current resurgence of interest in the practice doctorate may transform NP and other areas of advanced practice registered nursing (APRN) education in a manner similar to the evolution from post-basic certificate to Master’s degree in NP education.
The early phase of development and the uncertainties about the practice doctorate in nursing have generated anxiety among clinicians, educators, and researchers. The recommendation in a recent position statement by the American Association of Colleges of Nursing (AACN) (2004) for the transition of all APRN education to the practice doctoral degree by 2015 has created alarm among some. Nursing leaders are pressed to provide answers as to how this level of education will affect each of the APRN roles. Since 1980, NONPF has assumed responsibility for developing the competencies and educational standards to guide NP programs and plans to continue to be a resource to faculty in shaping NP educational programs to accommodate the continued evolution of the NP role (NONPF, 1995). This article offers some insights into the movement by describing from the NP perspective the societal impetus for change, the historical perspective of NP and doctoral education, the 4 Ws (why, what, where, and when), and some of the myths and realities about the practice doctorate.
Impetus for Change
Today's health care is inextricably related to health policy, informatics, and business practices.
Societal trends drive a new level of practice in nursing and resurgence of interest in the practice doctorate. Today’s health care is inextricably related to health policy, informatics, and business practices. Educational programs in nursing have responded through expansion of master’s degree curriculum; clinicians are attaining multiple master’s degrees and certifications in an attempt to keep pace with the growing need for knowledge and skills. Continued expansion in breadth and depth of the master’s programs is no longer socially responsible. Yet gaps remain between what can be covered in master’s programs and what is required for advanced nursing practice. This section will describe the societal shift to an information society, an aging and more diverse health care consumer, a complex health care delivery system emphasizing quality care, and health care workforce shortages.
Peter Drucker (2001) describes a true knowledge revolution and a shift in institutions as we know them. There will be much less manufacturing and far more knowledge work worldwide.
Clinicians are "knowledge workers" who increasingly need to navigate complex and evolving systems, synthesize and integrate bodies of knowledge, and advocate for quality care in an interdisciplinary and evidence-based environment.
The current information age has created a vast potential for dramatic health care improvements in procedures, medications, and behavioral change interventions. To realize this potential, we need carefully designed, competency-based, formal education programs for the expert clinician positions of today and tomorrow. Most other health care professions have expanded their master degree programs and created practice doctorates (e.g., public health, pharmacy, psychology, physical therapy) in response to the need for increasing knowledge and skills. Increasing courses and time spent in an already lengthy course of study for NP master’s degree programs will not advance the profession. Nor is the PhD in nursing—a research degree—the answer. The practice doctorate in nursing provides the opportunity to continue excellent clinical education while increasing the knowledge-worker abilities needed by the future health care system.
There are a number of changes predicted ahead for the population of the United States (US) and the rest of the world. One of these changes is an expected increase in the life expectancy both from birth and after age 65 (Mouton & Espino, 1999). The incidence of chronic illness increases with age, and often the elderly person has more than one illness that alters cognitive, psychological, and physical functioning. This means that the demand for quality, cost-effective, and acceptable management of co-morbid chronic illnesses will increase. The current system of illness management predicated on the ability to cure a condition will not work for this new population. Instead, the successful new practitioner will be able to blend broad knowledge from science, ethics, and non-traditional approaches to meet the needs of these new patients.
A second change ahead for the population is increasing ethnic and cultural diversity for all age groups. Many of this new population have language, health beliefs, and life ways that are not easily understood by today’s clinician. Clinicians of the future must be able to communicate with these new patients, must understand what constitutes illness within the context of the patient’s culture, and must be able to assist in the construction of acceptable approaches to care that are both evidence based and culturally competent. This is no small order and cannot be achieved in the master’s programs of today. The practice doctorate can offer a solution to the dilemmas faced by today’s clinician.
Emphasis on Quality in Health Care Systems
...management and executive training for clinicians can create a larger and better prepared workforce for improving our health care delivery systems.
The Institute of Medicine (IOM) (2000; 2001) has documented the dire status of the U.S. health care delivery system and proposed changes in the preparation of health care professionals (IOM, 2003). The IOM has challenged the health professions to raise the bar in leadership training and to instill a minimal set of competencies across disciplines to emphasize quality and minimize medical errors: (1) provide patient-centered care; (2) work in interdisciplinary teams; (3) employ evidence-based practice; (4) apply quality improvement; and (5) utilize informatics. These trends inform the competencies that will be needed by nurses seeking the practice doctorate. To ensure a culture of quality, health professions training must prepare clinicians for safe, effective, patient-centered, timely, efficient, and equitable health care.
Additionally, management and executive training for clinicians can create a larger and better prepared workforce for improving our health care delivery systems. As change agents with clinical skills and a system orientation, these leaders, many of whom will have NP preparation and experience, will use evidence-based methods to plan and implement direct care via one to one encounters, groups, and community venues. They will have a background in health care finance and policy, process and outcomes measurement and analysis, and change agentry. They will evaluate and translate the literature from clinical and community-based controlled trials to standard practice.
Health Care Workforce Shortages
APRNs are taking on a variety of roles to offset the shortage of other health care providers because these master’s-prepared nurses are versatile and competent in different settings. The number of physicians interested in primary care careers continues to decline as specialized medicine lures new graduates (Croasdale, 2005). Cooper, Getzen, McKee, & Laud (2002) identified a shortage of primary care providers and forecast an increased need for other types of fully accountable primary care providers to meet the needs, particularly for rural and other underserved communities. The demand for NPs (and other APRNs), coupled with high consumer satisfaction with this type of provider (Hooker, Cipher, & Sekscenski, 2005), will only intensify in the future. The nursing practice doctorate is a way to increase the workforce of accountable, quality, health care providers and clinical leaders, particularly through attracting new types of students seeking these roles. These new students are drawn from individuals who demand an independent professional role at the doctoral level.
Increasing Educational Demands
Given the nature of clinical education, nursing faculties are engaged in almost constant curriculum revision and expansion of essential content to maintain the currency of NP programs. Business practices, information management, health literacy, end-of-life care, genetics, mental health concepts, caring for older adults, and managed care are just some of the topics identified needing increased emphasis in existing curricula (National Organization of Nurse Practitioner Faculties, in press; Bellack, Graber, O’Neil, Musham, & Lancaster, 1999). Between 1995 and 2000, NP classroom and practicum hours increased significantly but the total number of formal credit hours did not increase (Berlin, Harper, Werner, & Stennett, 2002). To add breadth and scope to their practices, NPs and NP/APN students also continue to seek additional education through dual, blended, and joint degrees and various post-master’s certificates. Multiple master’s and post master’s programs do not achieve the same terminal objectives that can be built into a strong doctoral program. As the educational demands increase, the option of a longer program with commensurate credentials becomes more appealing and authentic.
Historical Perspective of NP and Doctoral Education
Nurse practitioner educational programs emerged at first in the mid-1960s as non-degree certificate programs of varying length. The increase in these post-basic certificate programs in the 1970s led to the development and release of NP educational guidelines by 1980. The continued evolution of the role and the availability of curricular guidelines led to the increase of Master’s degree granting programs and the sharp decline of certificate programs over the next decade. Within the 1990 Advanced Nursing Practice: Nurse Practitioner Curriculum Guidelines, NONPF identified that "advanced nursing practice as a nurse practitioner is grounded in graduate level preparation (master’s, post-master’s, or doctoral study)" (NONPF, 1990, p.3). The big boom of educational programs during the 1990s reflected the shift to Master’s level preparation or higher with less than 1% of all NP clinical tracks remaining at the post-basic certificate level in 2004 (Berlin, Wilsey, & Bednash, 2005).
Nursing doctoral programs began in the latter part of the 20th century after the development of most other fields. What delayed growth of the PhD programs may have been the profession’s adoption of the Master’s degree early as the appropriate degree for a nursing leader. The Doctor of Education (EdD) or other functional degrees were first available between 1900 and 1940. A basic or social science degree with no nursing content was available until 1960, when the minor in nursing was offered. By 1970, the proliferation of DNSc and nursing PhD programs began (Edwardson, 2001).
Originally conceived as a professional degree, the Doctor of Nursing (ND) emerged in 1979 at Case Western Reserve University to prepare college graduates as nurses at a level similar to other health professional doctoral programs such as medicine, veterinary medicine, dentistry, optometry, and others. For the first time, nursing had a doctoral degree that was open to non-nurses and prepared the beginning clinician at the doctoral level. Rush University, the University of Colorado, and the University of South Carolina then developed additional programs that prepare the clinician at the doctoral level to exert leadership in evidence-based practice, health policy, and management or education. Unlike the DNSc curriculum that required mastery within a field of knowledge and demonstrated ability to perform scholarly research - the very characteristics of the PhD (Standing & Kramer, 2003), the ND focused exclusively on preparing the clinical leader.
The current and emerging practice doctoral programs share many of the same curricular components of the early ND programs with emphasis on direct health care and/or health systems and clinical leadership. Nevertheless, the AACN (2004) recommended phasing out of the ND title and the broad adoption of the Doctor of Nursing Practice (DNP) as the common degree title. All four of the previous ND programs followed this recommendation and have changed their designation to the DNP. Over 40 existing and developing DNP programs are underway in major universities throughout the nation (see www.aacn.nche.edu/DNP/dnpprogramlist.htm).
The 4 Ws for the Practice Doctorate in Nursing
The ongoing changes in our society and the historical perspective for nursing education might help us to understand why nurse practitioners, as one of the APRN roles, may be primed for the evolution to doctoral level preparation. Yet for many of us, we need to address the most basic questions more specifically to determine the relevance and impact of this movement. NONPF has had a task force in place for four years studying the movement and repeatedly asking these questions: Why? What? Where? and When? Recommendations from this task force and statements from NONPF are fluid, continually shaped as we gain new information and new insights into how to guide development of quality NP educational programs. Nevertheless, some answers have emerged from this work to offer guidance.
Given the range of people’s comfort with change and the successes that NPs have achieved at the Master’s level, why consider doctoral level preparation? One reason is to ensure that NPs have a seat at the table with other professionals associated with health care. The "doctorate" table is filled with the PharmD, DDS, PsyD, JD, MD, EdD, DO, DPT, AudD – where is the NP? By continuing to offer only the master’s degree, the NP lacks parity with these other professionals (O’Sullivan, 2005a). NPs (as well as other APNs) have the clinical expertise and leadership potential to deserve parity with other disciplines. A second reason is to award a degree that corresponds with the level of educational preparation being offered. We should not continue to expand the NP educational program to accommodate more content and give only a Master’s degree (Marion et al, 2003). A third reason is that educational programs need to prepare clinicians with increased leadership and management skills in order to better understand and master the emerging complex health care systems (Marion et al., 2003). The doctoral program affords more time for additional content and honing of these skills. Finally, students want this degree (AACN, 2004). Existing practice doctoral programs are experiencing a rapid rise in applications for admission and developing programs are being pressured to open quickly.
A common question centers on what is the practice doctorate for the NP. In more detail, what does the program look like, how does one approach this level of education, what will the graduate have that is different from today’s master’s programs? We may all have different visions on the potential or career options for the NP graduate of a practice doctorate program, but NONPF (2002; November 2002) has promoted development of a shared vision for the framework and competencies. NONPF has sought input from its members and the stakeholder community to build towards a shared vision, including co-hosting with AACN a stakeholders forum on the practice doctorate in 2002 (see www.nonpf.org/cdforum.htm) and collecting data from the NONPF members to identify key themes and concepts for the practice doctorate. A NONPF task force recently completed its work in developing a draft of NP competencies for the practice doctorate, and NONPF is now facilitating the work of a multi-organizational, national panel for identification of national, consensus-based competencies for the NP. A premise of this work is that the NP practice doctorate competencies will build on the existing core and specialty competencies for the NP at the Master’s level. The NP core competencies reflect a broad base of patient-centered, evidence-based, nursing competencies for helping individuals and families stay well and to return to optimal status following health problems. NONPF continues to update these competencies to reflect current practice and curriculum and is currently undertaking a new revision. AACN is also currently completing a draft of the essentials for the practice doctorate that would be common to all nursing practice doctorates, including those that prepare NPs (see www.aacn.nche.edu/DNP/index.htm). As in the past, the educational programs will most likely make use of both of these complimentary documents to craft quality programs. NONPF’s description of sample curriculum models will provide guidance to the planning of practice doctoral programs (Marion, O’Sullivan, Crabtree, Price, & Fontana, 2005).
Choosing when to pursue a practice doctorate in nursing is an individual choice, dependent on one’s career trajectory. The innovators will want this degree as soon as possible. These might be new candidates for nursing, seeking the opportunity for the highest degree. Or these might be the Master’s-prepared NPs seeking new opportunities. The average person will likely wait awhile to assess the movement and study the program options. The skeptic won’t see an advantage initially or may not be in a position to pursue this degree. NPs and NP faculty need to be thoughtful about career goals and institutional issues in making the decision on when the practice doctorate make sense. Some individuals who are nearing the end of their careers will not likely continue their education at this level since the years left to practice may be few in light of the time required to complete the degree.
Prospective NP practice doctorate students will want to ensure that the program they do select reflects a genuine practice focus.
Once a decision is made that the practice doctorate is appropriate for a person, the remaining question is where to get one. Despite the AACN recommendation (2004) for full implementation by 2015, not all NP programs are located in institutions that have the legal authority, accreditation, ability, or inclination to change the program to a doctoral degree. A profile of NONPF reveals that the overwhelming majority of our members are in institutions that do not currently offer a doctorate degree and a move to a practice doctorate degree may necessitate new school-level approvals or affiliations with other doctorate-degree granting programs (O’Sullivan, 2005a). There is currently an explosive surge of interest in programs across the United States; however, the availability of the programs may remain limited for the foreseeable future. Prospective NP practice doctorate students will want to ensure that the program they do select reflects a genuine practice focus. The Master’s prepared NP who desires this level education will likely seek programs that provide credit or advanced placement in the program for previous knowledge.
Myths Versus Realities
Some of the tensions about the practice doctorate in the nursing community may be attributed to misunderstandings and perceptions. While many organizations have tried to facilitate discussion at the national level to keep nurses informed about the movement and related issues (National Forum on the Practice Doctorate in Nursing, 2003), we’ve not been as successful in addressing the individual concerns of clinicians and educators. Individuals less inclined to change may see the practice doctorate as unthinkable and then impossible before finally opening up to the possibility of the inevitable. We must work together to distinguish between the myths and realities.
Myth: The Practice Doctorate will have an adverse impact on the PhD degree
Reality: The Practice Doctorate helps to preserve the integrity of the PhD as a true research degree.
The PhD degree is devoted to research, and nurses with PhDs form an elite core with distinguished research achievements. They receive funding to build the discipline’s knowledge base. The doctorates of nursing science (DNS/DNSc/DSN) and education (EdD) may have been intended to meet the need for advanced clinical practice and education, but a review of these programs reveals little difference between them and the research-intensive PhD programs. (Edwardson, 2001; McEwen & Bechtel, 2000).
The PhD degree is devoted to research, and nurses with PhDs form an elite core with distinguished research achievements.
The institutions with existing practice doctoral programs all offer the PhD as well. The authors questioned if the opening of the practice doctoral programs affected enrollment in the PhD programs and informally queried directors from such institutions; none of these institutions reported a decrease in the number of people seeking the PhD after the practice doctorate was begun. In fact, several programs reported increased applications in the PhD. A decline in the number of people seeking a PhD might not be a negative issue if it means that those seeking research training will then devote their careers to research. As Joyce Fitzpatrick (2003) said, "it is unethical to accept students into PhD programs that do not develop research careers" (p.9). Those pursuing expert clinical practice or clinical teaching careers now have program choices that support their career trajectory. The practice doctorate is a terminal degree and as such does no t need to lead to other degrees.
Myth: All NPs will need to get a practice doctorate.
Reality: NPs will need to decide their own career trajectory.
Dr. Shaver (2005) discussed her role on the IOM planning group for the Summit on Interdisciplinary Education which advocated that, as a minimum, all health professionals be educated to deliver patient-centered care as members of interdisciplinary teams, emphasizing evidence-based practice, quality improvement approaches, and informatics. She encouraged all of us to participate in a transformational change in adopting as a cultural value, interdisciplinary education and collaborative practice. She recognized that there are power differentials inherent in the status of the health science disciplines but added she believed these can be modulated, and that the biomedical world which is dominant can be transformed over time to consider the importance of functional monitoring and life-style health behavior coaching.
This is an exciting time in the history of nursing education.
The practice doctorate is a plan for the future and will help to level somewhat the power differentials among other providers with practice doctorates. To fully bring about this plan will likely require at least 20 years. Many of today’s NPs will be exiting the work force prior to 20 years, despite encouragement to "retire retirement" (O’Sullivan, 2005b). Nevertheless, even those nearing retirement can feel just as excited by the emphasis on interdisciplinary teams and are in a stage of their lives still eager to experiment with new models of collaborative practice. Currently licensed NPs will have to decide what is best for themselves and to then chart a course to bring about that plan. As an example, when pharmacy moved to the Doctor of Pharmacy as the single degree, existing pharmacists had to make personal decisions about whether to return to school.
Myth: All NP educators will need the practice doctorate
Reality: Faculty of the future will all require the doctorate but some will have practice doctorates and some will have other doctorates.
NPs will at last be on parity with the other health professions and can continue to demand a place at the policy table.
Preparation of NPs is a complex web of different types of learning. Some of the education will be provided by nurses with PhDs, some by nurses with practice doctorates and some will be provided by other types of health care practitioners with doctorates in medicine, pharmacy, physical therapy, and other fields. Clearly, today’s master’s level nursing faculty will not be adequately educated for the emerging health care or educational systems. These individuals will need to determine if they should obtain additional education and what type of education that should be.
Looking at the trends across the country, it seems that progressive or forward-thinking regulators are supporting the idea that program directors should have a doctorate or be enrolled in a doctoral program that they would finish within the next five to six years (Pennsylvania State Board of Nursing, 2005). Since the movement to the practice doctorate is evolutionary – not revolutionary – NP faculty would likely be one group who would move forward with the adoption of formal education sooner than other NPs. If we look at movement from post-basic certificate to a Master’s degree, we see faculty members were the innovators – seeking enrollment for the advanced degree in the first eighteen months after it was available to them.
Myth: Doctorally-prepared NPs will have different practice skills than master’s prepared NPs.
Reality: Doctorally-prepared NPs will have enhanced practice skills.
Knowledge, affective, and psychomotor skills obtained at the Master’s level and used routinely will be the basis of the additional skill and knowledge that can be obtained at the doctoral level. For example, physically examining an ear for otitis media will not be enhanced with a doctoral degree. However, what one does with the findings and how one approaches a patient regarding the cause and treatment measures required may be improved through the emphasis of the course work and clinical experiences during the practice doctorate. The practice doctorate will, however, enhance the NP’s essential practice skills in areas such as evidence-based practice, systems, and leadership.
Keep the dialogue going regarding the practice doctorate...
The move to the practice doctorate is no longer in question for advanced practice nursing, and particularly for NPs of the future. How to bring about the needed changes in the educational systems to facilitate this move is open to continued discussion. As in the past, NP faculty can count on NONPF to lead the way in setting the standards for educational program and in formulating the competencies for the graduates of these emerging programs. This is an exciting time in the history of nursing education. NPs will at last be on parity with the other health professions and can continue to demand a place at the policy table.
These changes will not come about without some anxiety and concern. The existing NPs have charted new directions in the care of people. Often it was the NPs who cared for the poor, most sick, and disenfranchised people of our society, and who expanded the scope and depth of practice. Yet, the evidence from the practices of the early NPs supports their role and practice as having a positive impact on outcomes (Feldman, Ventura, & Crosby, 1987; Laurent et al., 2005; Mundinger et al., 2002). We shall expect no less of these new doctorally-prepared NPs. They will possess more knowledge and skill than in the past, and this new expertise will be demanded by the changing health care system.
Where are you going with your career? Will you use this opportunity to enhance your skill and knowledge in a formal way? How one answers these questions will determine the amount and kind of change one can expect in his or her future career. Keep the dialogue going regarding the practice doctorate, and visit NONPF’s Web-based Practice Doctorate Resource Center (www.nonpf.org/cdhome.htm).
Ann L. O’Sullivan, PhD, CRNP, CPNP, FAAN
Ann L. O'Sullivan, PhD, FAAN, CRNP, CPNP, is a Professor of Primary Care Nursing with joint appointments in the School of Nursing and School of Medicine at the University of Pennsylvania. She received her BSN, MSN, and PhD from the University of Pennsylvania and completed post-master’s education as a Pediatric Nurse Practitioner as part of the Robert Wood Johnson (RWJ) Nurse Faculty Fellows Program at the University of Maryland. She completed the three-year RWJ Executive Nurse Fellows Program in 2001. Since 1972, Dr. O'Sullivan has served on the faculty of the University of Pennsylvania, where she and two colleagues began the Family Nurse Clinician Program in 1973. She is currently the Program Director of the Pediatric Nurse Practitioner Program and Co-Director of the Center for Urban Health Research. Dr. O'Sullivan has also practiced at The Children's Hospital of Philadelphia (30% of her time) since 1980.
Michael Carter, DNSc, RN, FAAN
Michael Carter, DNSc, RN, FNP, FAAN holds the BSN and MNSc from the University of Arkansas for Medical Sciences and the DNSc from Boston University. He is certified by the American Nurses Credentialing Center as a Family Nurse Practitioner. He served as Dean of the University of Tennessee Health Science Center College of Nursing for 18 years during which time he lead the development of one of the early practice doctorates in nursing. He continues to teach in that program today as a University Distinguished Professor.
Lucy Marion, PhD, APRN, FAAN
Lucy Marion, PhD, APRN, FAAN, is currently Dean of Nursing and Professor at the Medical College of Georgia. She received her BSN and MN from the University of South Carolina. She earned her PhD in Nursing Science from the University of Illinois at Chicago, and she became a certified family nurse practitioner in 1980. She is a past president of the National Organization of Nurse Practitioner Faculties (NONPF) and has chaired the NONPF Practice Doctorate Task Force since 2001. She was recently appointed to the U.S. Preventive Services Task Force.
Joanne M. Pohl, PhD, APRN, BC, FAAN
Joanne M. Pohl, PhD, APRN, BC, FAAN is Associate Dean of the Office for Community Partnerships and Associate Professor at The University of Michigan, School of Nursing. She obtained her PhD from the University of Michigan, her MSN from Wayne State University, and her BS from Southern Connecticut State College. She is president-Elect of National Organization of Nurse Practitioner Faculties. She is also the Primary Investigator and Director of The National Network for Nurse Managed Health Centers. Dr. Pohl has been an educator, researcher, and practitioner for over 25 years serving in faculty positions in Michigan. She has been actively involved in advancing the education, research, and clinical practice for nurse practitioners nationally.
Kathryn E. Werner, MPA
Kathryn E. Werner, MPA is the Executive Director of the National Organization of Nurse Practitioner Faculties (NONPF). She holds a BA in English from the College of William and Mary and a Master of Public Administration from George Mason University. She has been with NONPF for 10 years and has served as staff liaison to the organization’s curriculum and competency development task forces. She currently supports the NONPF Practice Doctorate Task Force and competency subcommittee.
Article published September 30, 2005
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