Overview: The Doctor of Nursing Practice (DNP): Need for More Dialogue

I am honored to have the opportunity to provide the overview for this topic, The Doctor of Nursing Practice (DNP): Need for More Dialogue. I was privileged to work on the development of the curriculum for and teach in the first practice-focused doctoral degree, the Doctorate of Nursing (ND), which was implemented at Case Western Reserve University. The initial six articles are a fitting tribute to Rozella Schlotfeldt, originator and genius behind the ND. Dr. Schlotfeldt, who died recently, provided the spark that ignited the 27 year path to the October 2004 historic vote by the American Association of College of Nursing (AACN) to establish the Doctor of Nursing Practice (DNP) degree as the terminal degree for advanced nursing practice carried out by nurse practitioners, clinical nurse specialists, and nurse administrators by 2015.

Elizabeth Lenz chaired the AACN Taskforce on the Practice Doctorate in Nursing. In her article, "The Practice Doctorate in Nursing: An Idea Whose Time Has Come," Dr. Lenz describes the process used by the taskforce and some of the issues they considered. The issues include the definition of practice (broader than direct hands-on care); practice doctorate status and title (alternative to research-focused doctorate, one title and credential for the practice doctorate); benefits (credibility in leadership positions; ideal preparation for advanced practice nursing, as well as for a faculty position in practice-focused doctoral programs or clinical teaching in any nursing education program); and curricular elements (core competencies, objectives, curricular components, and content areas).

Afaf Meleis, Dean of the School of Nursing at the University of Pennsylvania and Kathleen Dracup, Dean of the School of Nursing at the University of California, San Francisco express their opinion that the DNP is the wrong degree for nursing. In "The Case Against the DNP: History, Timing, Substance, and Marginalization," Drs. Meleis and Dracup present compelling arguments against moving forward with the DNP and encourage us to refocus our attention on the MS and PhD degrees, which are well understood by our public and have thrived. They also describe our history of academic marginalization, argue that the time spent in the development and implementation of the new degree program is wasted, and believe that educating doctorally prepared clinical experts without a research focus is supportive of a dichotomy that has thwarted knowledge development in nursing for decades. The crux of their argument against the practice doctorate is that we are creating a second-class citizenship in universities and enhancing the potential for marginalization of those with practice or research doctorates by others.

Janet Fulton and Brenda Lyons, actively involved in the National Association of Clinical Nurse Specialists, hope their paper will stimulate a dialogue between all stakeholders. In "The Need for Some Sense Making: Doctor of Nursing Practice," they contend that many issues must be addressed before we proceed with such a "major professional paradigm shift." Among the issues they identify are the differences in the practice doctorate proposals from AACN and the National Organization of Nurse Practitioner Faculty (NONPF); the lack of national agreement on the need for a practice doctorate; clear identification of competencies or outcomes of the degree programs; the lack of supporting evidence/rationale for the practice doctorate; and the unknown impact on educational resources. Drs. Fulton and Lyons also point out that having the DNP as the terminal degree for CNSs is highly questionable; economic issues have not been determined; a process to grandfather current master’s prepared advanced practice nurses needs to be identified; the impact on state regulation of nursing practice is not clear; and opening Nurse Practice Acts may create unanticipated problems. They maintain that meaningful, rather than short, scripted, dialogue needs to address the future of doctoral education in nursing in general, and the practice doctorate in particular.

Ann O’Sullivan, President of the NONPF, describes the context for the evolution of the practice doctorate for nurse practitioner education and answers four Ws – Why? What? Where? and When? in "Moving Forward Together: The Practice Doctorate in Nursing." Dr. O’Sullivan explains that, in addition to the AACN, NONPF has been a major force behind the adoption of the practice doctorate. Indeed, since 2001, NONPF has endeavored to delineate the impact of the practice doctorate on nurse practitioner education. In 2005, NONPF issued a draft statement about nurse practitioner competencies for the practice doctorate. Dr. O’Sullivan maintains that "the move to the practice doctorate is no longer a question for advanced practice nursing and particularly for NPs of the future. Just how to bring about the needed changes in the educational systems to facilitate this move is open to continued discussion."

Margaret Flinter, Vice President and Clinical Director of Connecticut’s largest federally qualified health center (FQHC), makes the case for the establishment of one year residencies in primary care for nurse practitioners in "FQHC-based Residency Programs in Primary Care for Nurse Practitioners: Pragmatism Meeting Praxis for the Advancement of the Social Good." She believes that without a practice-based institutional residency, DNP programs will not prepare nurse practitioners to enter and undertake independent practice for which they can be fully accountable. Her premise is that residency training following an educational program allows academic education to be translated into in clinical practice competencies that are fundamental to safe, high quality care. Ms. Flinter also describes the philosophical, practice, legislative, and practical bases for establishment of residencies in primary care and identifies potential funding sources.

Carol Cartwright, a University President, and Charlene Reed, Senior Assistant to the President (and past Provost), raise key policy and operational issues that need to be considered by universities before implementing the practice doctorate in "Policy and Planning Perspectives for the Doctorate in Nursing." They point out that key external policy issues are more complex for public than private institutions. Such issues include the political context regarding doctoral education in each state, restrictions or considerations in changing from a master’s to a doctoral degree program from the state’s perspective, and the potential difficulty of engaging state policy makers and leaders in a review of state support for nursing education. Key internal policy issues focus on consideration of each institution’s mission, resources, and other demands; how each university will view DNP degree-holding faculty; the expectations for those faculty; who will teach in these programs; and how the practice doctorate can be offered when colleges already have resource and faculty shortages? Drs. Cartwright and Reed also address Meleis and Dracup’s concern about marginalization of DNP faculty, whose academic work is consistent with the scholarship of application and integration as described by Boyer (1990, 1996) and Holland (2005). They point out that key strategies for change should include strong administrative support, a collaborative process, motivating vision, persuasive and effective communication, a long-term orientation, rewards and incentives, and supporting structures.

After reading the six articles in this issue, the reader is left with several challenging questions:

• Is there a need for more dialogue between the multitude of stakeholders before nursing moves forward with the DNP as the terminal degree for advanced practice nursing?
• Is the DNP the right degree for nursing at this moment in time?
• Will DNP education alone prepare advanced practice nurses for autonomous roles in primary health care or are residency programs also needed?
• Will DNP-prepared nurse be given a seat at the table in practice and academic settings?
• Can we agree on competencies and educational standards for the DNP?
• How do we educate the public about the DNP degree?
• Should we raise the bar even higher and mandate that the DNP be the degree for entry into professional nursing practice?

The authors of the six articles and I hope that your answers to these questions will stimulate discussion about the practice doctorate with your colleagues, friends, family, and the public. Please send letters to the editor responding to any one or more of the articles so that we can continue to stimulate a full airing of the issues surrounding this historic development in nursing.

Greer Glazer, RN, CNP, PhD, FAAN
E-mail: Greer.Glazer@umb.edu