Endorsement of the Doctorate in Nursing Practice (DNP) as the highest level of preparation for clinical practice promises to revolutionize nursing practice and education. But like any revolution, the move toward the DNP in the university setting likely will require courage, risk taking, and careful consideration of strategies and tactics, as universities make the momentous decisions of whether, and how, to put this opportunity into action.

The purpose of this article is to offer some planning perspectives and practical advice, based on relevant literature and experience as a university president and provost, to those who are considering implementation of the DNP. Leaders in this effort must understand key policy and operational issues in higher education as well as complexities of the change process itself.

Before any major change effort is undertaken, one must answer the question of why change is needed. Among the benefits most frequently cited for implementing the DNP are advancement of nursing practice, expansion of the potential pool of nursing faculty, and awarding a terminal degree that is more appropriate for the academic requirements of students and the expectations of the profession. While potential benefits are significant, so are the challenges that must be addressed. Challenges include tackling major internal and external policy issues, maneuvering extensive curricular and budgeting processes inside and outside of the institution, dealing with higher costs to students as well as the additional resources needed by institutions, addressing concerns of the broader professional community, and importantly, carrying out the transition itself.

At the national level, the American Association of Colleges of Nursing (AACN) is working to provide a common framework for program development. Since the organization’s landmark position statement was adopted (AACN, 2004), task forces have been formed to examine important aspects of implementation, such as basic competencies that should be built into every DNP program, development of efficient bridge programs, and ongoing engagement of key stakeholders. Broad programmatic leadership is necessary to provide a strong foundation for expansion of DNP offerings across the country.

While a nationwide dialogue continues, higher education institutions need to decide whether to move in this direction, and if so, to grapple with a myriad of policy and operational issues to assure strong beginnings for their programs. Even at this early stage of development, the DNP movement is mushrooming, with the number of programs increasing from eight to more than 40 in development, at last count (AACN, 2005a).

Key Policy Issues – External

From an institutional perspective, the move to the DNP raises a number of external policy issues. All universities will be expected to meet program and performance expectations ultimately identified by the Association and the Commission on Collegiate Nursing Education (CCNE). Beyond meeting expectations of the profession, both public and private institutions must comply with graduate program policies in their states. For private institutions, which generally have more autonomy from state controls, external policy issues may be less cumbersome. External reviews in these cases focus primarily on issues of academic integrity and institutional capacity.

For public institutions, the policy issues surrounding doctoral education often are much more complex, particularly as they relate to the allocation of public funds for higher education. Organizations like the AACN and others are advocating changes and incentives, both at the national and state levels, needed to ease the critical shortages of practicing nurses and teaching faculty. There is growing recognition that these shortages, if unabated, will have dire consequences for the quality and availability of health care in the US.

Serving the public good alone is not enough to assure support for DNP development in the constrained world of higher education funding, especially if state support is involved. In Ohio, for example, there has been a significant debate for the past decade about how much state funding for doctoral education is appropriate, given the state’s ranking of 43^rd in the nation in per-capita funding for higher education. Several years ago, the state capped doctoral appropriations to halt a perceived pattern of growth in doctoral funding at the expense of undergraduate education. That change restricted any overall growth in doctoral funding per institution, regardless of enrollment trends or needs served. Appropriations for master’s level programs, on the other hand, were not limited. This Ohio example illustrates how a possible change from master’s to doctoral level programs requires a thorough environmental scan and plan for addressing any state-level policy issues relevant to each specific situation.

In states where several institutions of higher education may be considering adoption of the DNP, it may be wise to hold statewide meetings for interested parties and to build a collaborative approach to advocacy. The policy aspect likely will be fairly straight-forward in states where there are one or few nursing programs and programming decisions are left primarily to these higher education institutions.

In the external policy arena, key questions for consideration include:

1. What is the current process in your state for creating change at the university level?
2. How strong is the current relationship between service and education in your geographic area?
3. What is the political context in your state regarding doctoral education?
4. What restrictions and/or considerations may exist from the state’s perspective in changing a program from the master’s to the doctoral level?
5. What opportunities, if any, exist to engage state policymakers and leaders in a review of state support for nursing education, recognizing the discipline’s changing cost structure and market forces?

Clearly, the DNP debate has given the nursing community a vehicle both for creating a shared vision for the future and for working together to advance the profession. Collaboration and consensus development also must reach external stakeholders, including the general public. The public needs to understand that this move is being undertaken to promote high-quality patient outcomes and to assure that advanced practice nurses have the high level of scientific knowledge and practice expertise needed to meet the current and future demands of the health care environment.

Key Policy Issues - Internal

Before taking its message to external stakeholders, however, each nursing education program needs to carefully weigh the decision about recommending implementation of the DNP in the context of its own mission, resources, and demands. Above all, this decision must be consistent with the organizational mission and based on strong evidence of the school’s strengths, capacity, and market forces. Along with its stakeholders, the dean and faculty need to weigh alternatives and seek consensus on a path for moving forward. This can be a challenging process, particularly as universities are continually called upon to do more with less.

One way of looking at the DNP decision is through the lens of "anchoring ideologies," which individuals use to put their institution’s mission into practice (Tierney, 1999). This organizational identity gives meaning and affiliation to the work its members undertake, punctuates how the organization is different from others, and reveals why its work is important. If the practice doctorate is to be a viable choice, it must fit the organization’s purpose and identity, especially at this time of limited resources and scarce human capital.

Once a decision is made to pursue the DNP, planners need to navigate the broader university environment, especially complex staffing and financial issues that already challenge most colleges of nursing. According to a recent AACN study, severe faculty shortages are hindering efforts to address the nation’s nursing shortage. In the past year alone nearly 3,000 qualified students, who eventually might fill faculty roles, were turned away from graduate nursing programs (AACN, 2005b).

In the internal policy arena, key questions for consideration include:

1. How will the university community view DNP-qualified individuals?
2. Given the lack of existing professionals with this credential, who will teach in these programs?
3. How can the new mission of the DNP be embraced when units already are unable to meet student demand due to shortages of faculty and other resources?

Each institution must determine the requirements and expectations of faculty members. However, we expect that much of the higher education community will embrace DNP-qualified individuals whose scholarship likely will extend beyond traditional definitions of teaching and research (Boyer, 1990; Boyer, 1996). Of particular relevance are Boyer’s concepts of the scholarship of application, which explores how knowledge can be applied to consequential problems, and the scholarship of integration, which seeks to interpret, make connections across the disciplines and bring new insights to bear on original research.

Development of the practice doctorate also is in keeping with the emerging model of the engaged university, which is gaining favor as colleges and universities break out of traditional molds (for examples see Ramaley, 2002a; 2005; Ward, 2002). The engaged university is responsive to, and respectful of, community-identified needs, opportunities, and goals in ways appropriate to its mission and academic strengths (Ramaley, 2002b). This interaction is intentional, far-reaching, and mutually beneficial—enriching learning and discovery functions of the academic institution while enhancing community capacity.

Holland (2005) summarized new traditions of scholarly excellence that also support development of the practice doctorate. These traditions include balanced attention to the multiple scholarly roles of discovery, interpretation, and application; research-based approaches to teaching and learning; strategic perspective that anticipates changing academic needs and societal knowledge needs; an intentional and evolving research agenda engaging many collaborative partners; and responsiveness to and engagement in regional and local issues and conditions.

From our understanding of the profession’s vision, we expect the DNP will expand the pipeline for teaching faculty over time. This may vary according to each institution’s culture, expectations of faculty, and tenure and promotion policies. Scholarship clearly is not the exclusive domain of Ph.D.-qualified professionals: many advanced practice nurses, who hold the master’s degree, are advancing practice through publication today.

Across the nation there is a groundswell of support for changing promotion and tenure guidelines to accommodate broader definitions of scholarship. Among institutions cited as moving in this direction include: Portland State University, the University of Illinois, the University of Pittsburgh, and California State University-Monterrey Bay (Ramaley, 2005).

At Kent State, the faculty senate recommended aligning university policies with Boyer’s broad concept of scholarship—encompassing discovery, integration, application, and teaching—a decade ago and now is considering additional changes that would incorporate the scholarship of engagement. These policies support faculty who are engaged in this work and will encourage individuals who are practice-based in their experience and orientation to find careers in academe. By expanding the pipeline to the doctorate and encouraging broader definitions of scholarship, the profession is building multiple pathways to university teaching, instead of assuming this role exclusively for research-based doctoral programs.

The challenge of expanding doctoral education at a time of personnel shortages and resource constraints remains a vexing one. We expect that many nursing faculty and academic units already feel somewhat overworked in trying to respond to seemingly insatiable and multiple demands, often with insufficient personnel strength and other resources. Presidents recognize this dilemma and want to work hand in hand with the provost and nursing deans and faculty to support well-developed proposals that are consistent with the institutional mission and capacity, and societal needs. Criteria frequently used in prioritizing programs include: trends for national and local demand, student outcomes, faculty strength and productivity, enrollment generation, and external validation (Dickeson, 1999).

For schools already preparing advanced practice nurses at the master’s level, there are real downsides to a negative decision on the DNP. After 2015, preparation at the master’s level will cease. Beyond a potential loss of student credit hours generated, these programs tend to be a strong component of a unit’s identity and public image, attracting a large, national, and highly qualified applicant pool. Consequences of a lack of support should be detailed as well.

University administrators and faculty must be cognizant of these financial and political forces as they work through their own governance, budget, and planning processes. Studying the experiences of institutions that have successfully made such bold transitions may be particularly helpful. Potential resources include early adopters in higher education now implementing the DNP and health-related disciplines, such as pharmacy and physical therapy, which have implemented a practice doctorate.

Lessons on Change

As a final piece of advice, we suggest planners consider several strategies found to be important to the change process. Among the most frequently cited ingredients for successful change are strong administrative support, a collaborative process, a motivating vision, persuasive and effective communication, a long-term orientation, rewards and incentives, and necessary supporting structures (see summary in Eckel and Kezar, 2003).

Research has shown that active support by those with authority over budgets, personnel, and institutional priorities facilitates change. This is especially true in the case of a resource-intensive decision like implementing the DNP. Several strategies for winning support of senior administration have already been noted, including building a strong proposal, identifying and proposing solutions to policy issues, and building consensus with multiple stakeholders.

The role of leadership in change extends far beyond the presence of a willing president or provost. Higher education long has operated under a model of shared governance, with faculty holding primary responsibility for academic matters. We concur leadership is a collaborative process, involving multiple stakeholders in both developing and implementing the transition to the DNP. This must include gaining buy-in not only from the nursing administration and faculty, but also the broader university community, local and state leaders in the field, and policy makers.

Within the change literature, one of the processes most often identified as leading to success is the creation of a motivating vision. Because change introduces uncertainty and perceptions of risk, a compelling vision is needed to communicate the reasons for change and for the specific directions proposed. It can serve as a beacon for the organization and its members. Some faculty, already straining to meet student and market demands for their programs, may view the DNP with resignation instead of excitement. We believe academic programs cannot be mandated to greatness, and viewing the DNP from a compliance mentality will not result in desired outcomes. Advocates need to create an empowering vision, stressing advantages and opportunities of the DNP, instead of focusing on the negative consequences of failing to move in this direction.

It is imperative that the case and process for change are communicated effectively to stakeholders. A communication strategy should be developed to reach out to specific audiences through a variety of approaches and media. The value of a vigorous debate and open, careful consideration cannot be underestimated. Effective communications not only support well-informed decision making; they foster relationships and build support for the resulting decisions and strategies.

Another factor evident in the literature is that change generally does not happen overnight. Many change efforts have failed due to a lack of long-term perspective (Ramaley, 1995). Common missteps identified include offering incentives only for short-term gains, failing to develop strategies for maintaining stakeholders’ attention over time, and experiencing turnover in leadership before change takes root. In effect, deliberate action is needed to anchor changes in the organization.

Wisely, the AACN has approved a 10-year transition period, warding off any short-term mentality or approaches. Even with this wide window of opportunity, nursing educators and leaders should be proactive in beginning discussion of policy issues and exploring their choices as soon as possible. Long lead times of two years or more can be needed to secure final approval of radical curricular revisions.

For example, analysis by the nursing faculty can take a semester or more. Consultation is needed—early and often—with the professional community, nursing education colleagues across the state and the nation, and state officials who ultimately will approve or deny program recommendations. Beyond the nursing college or school, support of chief academic and financial officers and the president is needed to ensure adequate resources will be provided and advocacy will occur at higher levels of review. In cases of radical changes like the DNP, this advance work is essential before entering the generally time-consuming (and often more bureaucratic) curricular and budgeting processes in higher education. Once the nursing faculty has decided to recommend implementation of the DNP, the curriculum changes must be written and entered into formal review processes at the unit, university, and state levels. Even after approval occurs, considerable time is needed to put necessary resources in place, notify current and potential students, incorporate changes in university catalogs and other legal documents, plan for phasing in and out of courses and other educational experiences, and transitioning to the new program.

Rewards and incentives are essential in order to encourage and support individuals in redirecting their efforts from existing activities to new or additional ones. Incentives can range from public recognition to increased opportunities for professional development and travel to recognition in tenure and promotion policies. If there is confidence that the right policies and practices in faculty personnel are in place, faculty will feel more assurance that they are not taking on undue risk in devoting their time to new initiatives.

The nursing profession takes great pride in being regarded as an innovator, which provides a strong motivation to succeed. Through its communication about the DNP, the AACN reflects the profession’s pride and confidence in being on the leading edge of a new vision for the future (AACN, 2004).

Simply put, change cannot be achieved and sustained without sufficient resources and support structures. To keep pace with changing program needs and emerging opportunities, institutions must constantly assess both the adequacy and appropriateness of their planning and priority-setting processes. There must be transparency about the processes of governance, budget and planning; what data is expected and how it will be used; and how decisions are made.

The move to the DNP is a resource-intensive decision, which in most cases will require additional resources as well as redeployment of existing ones. This may include realigning faculty roles and reassigning faculty time, reallocating resources within the nursing college and other academic units, and generating increased revenues. DNP advocates need to develop realistic and thorough plans, including strategies and tactics for meeting resource requirements, to increase their chances for a positive conclusion.

The DNP revolution is only beginning but holds great promise for the health of the profession and society at large. We applaud the profession for making this bold and visionary move and for framing the issue in a context that resonates deeply with the higher education community, namely that of fostering student success. In collaboration we will ensure students are well prepared for current and future demands of the health care environment, leading to positive outcomes for patients and programs alike.

Authors

Carol A. Cartwright, PhD
E-mail: carol.cartwright@kent.edu

Carol A. Cartwright, PhD, has served as President of Kent State University since 1991. Previously, she was Vice Chancellor for Academic Affairs at the University of California at Davis and Dean for Undergraduate Programs and Vice Provost at The Pennsylvania State University. As President of Kent State University, Dr. Cartwright oversees one of the nation's largest university systems, with eight campuses serving more than 35,000 students and employing more than 4,600 full- and part-time faculty and staff. She is a member of the board of trustees of the Woodrow Wilson International Center for Scholars, the board of directors of National Public Radio, and the national board of the First Ladies' Library. She has chaired or served on the boards of three national higher education associations and recently completed a two-year term as chair of the National Collegiate Athletic Association (NCAA) Executive Committee. Dr. Cartwright served on the Governor’s Commission on Higher Education and the Economy, and is a member of the Ohio Business Development Coalition commissioned to improve Ohio’s economic growth. She holds Doctor of Philosophy and Master of Education degrees in Special Education from the University of Pittsburgh, and the Bachelor of Science degree in Early Childhood Education from the University of Wisconsin-Whitewater.

Charlene K. Reed, PhD
E-mail:creed2@kent.edu

Charlene K. Reed, PhD, is Secretary to the Board of Trustees and Senior Assistant to the President at Kent State University. Previously, she was Assistant Dean for Administration and Strategic Initiatives and Assistant Professor of Education and Assistant to the President at The University of Akron. She holds the Doctor of Philosophy degree in Education, a Master of Educational Administration-Higher Education degree and a Bachelor of Arts degree in Mass Media/Communication from The University of Akron. She has more than 20 years experience in university administration, with concentrations in institutional governance, finance, planning and resource development. Dr. Reed has played an active role in academic program development and review, serving on self-study teams for regional accreditations and the accreditation of teacher education, and as a member of an institutional academic policy committee. She served as finance officer for the Council for the Advancement of Higher Education Programs and has been active in the National Association of Presidential Assistants in Higher Education, the Association for the Study of Higher Education, and the American Educational Research Association.