The doctor of nursing practice: from start-up to impact.
AIM This article reflects on the progress of the doctor of nursing practice (DNP) degree and its place in health care. BACKGROUND The DNP originated over 10 years ago, long enough for a comprehensive evaluation.
METHOD Rogers' Diffusion of Innovation Theory is used to trace the history of the DNP. Nurse leaders from service and academia (n = 120) share strategies and innovations, and evaluate DNP education with a focus on outcomes and impact.
RESULTS As schools of nursing target DNPs to become faculty to mitigate the shortage, participants agreed it is time to focus on graduating
strong leaders prepared to transform health care.
CONCLUSION A growing number of nurses practicing in diverse roles have earned the DNP from programs that vary considerably in rigor. Demand for the competencies, skills, and experience which DNPs bring to practice is high as organizations adapt to the accountable care environment.
KEY WORDS Doctor of Nursing Practice (DNP)--DNP Education Outcomes--Doctoral Education--Nursing Profession
The doctorate of nursing practice (DNP) began, much like any start-up, to meet the demands of a quickly evolving market. At once exciting and controversial, rich with opportunity and risk, as well as highly visible with respect to both its achievements and shortcomings, the DNP had much in common with other, more familiar start-ups. It entered a market dominated by credentials that were established, effective, and respected: the doctor of philosophy (PhD) and doctor of education (EdD) degrees.
Now, more than 10 years in, it is time to transition from the behaviors of a start-up to those of a successful endeavor thriving as a result of attention to market conditions and demands. It is no longer sufficient to be the next big thing: it is time to deliver clear, added value.
This article shares key themes from a conversation that began at the first annual DNP Impact Conference, sponsored by Johns Hopkins University School of Nursing, in which participants considered the challenges and demands of the market 10 years into DNP education and practice. One hundred twenty nurse leaders from service and academia joined for two days to reflect on the progress of the degree, the graduates who earn it, the curricula that prepare them, and the demands and opportunities in markets that employ them.
BACKGROUND FRAMED BY DIFFUSION OF INNOVATION THEORY
Ideas move over time from what is known as innovation to what is accepted as common practice. The process proceeds through clear phases, and those who adopt the innovation are identified according to the point at which they come aboard (Rogers, 1962). As background to this account of the DNP Impact Conference, Rogers' Diffusion of Innovation Theory is used to trace the 10-year history of the DNP as it penetrated education and practice.
The first to embrace change, according to Rogers (1962), are innovators, risk takers who share an affinity for new things and solutions. In Rogers' model, the innovators represent roughly 2.5 percent of the market. The American Association of Colleges of Nursing (AACN) in 2004, with the help of Case Western University, Columbia University, and other institutions, opened a dialogue about the demands and challenges facing nursing practice and movement toward the DNP began. Innovators participated in this conversation.
The innovation itself was informed by calls from the Robert Wood Johnson Foundation and the Institute of Medicine (1999) for transformational models of care, interprofessional collaboration, and educational reform that would prepare professionals to increase safety and improve quality. The conversation evolved and much is written about the events that followed (Apold, 2008). Innovators drew distinctions between the research doctorate and the practice doctorate in order to inform curriculum development and conversations about scholarship.
Those who next enter the process, according to Rogers (1962), are opinion leaders, trendsetters, and role models attracted to competitive advantage. Comprising roughly 13 percent of the market according to Rogers, these early adopters have the resources to assume risk. In the case of the DNP, early adopters shared, with innovators, a common intent to prepare advanced practice registered nurses (APRNs) with three attributes: a deep foundation in the science and the discipline that would enable them to critique and apply evidence in the provision of direct care, strong leadership knowledge and skill, and the practiced ability to inform and drive policy (Mundinger, Starck, Hathaway, Shaver, & Fugate-Woods, 2009; Potempa, 2011).
Early adopters implemented DNP programs that were diverse in their curricula and pedagogies. For some, the focus centered on achieving expedient translation of evidence to solve important practice problems. This focus enhanced performance in support of the 'Triple Aim": patient experience, quality of life, and value (Berwick, Nolan, & Whittington, 2008).
Other early adopters asserted that rapid change in the scientific underpinnings of practice mandated greater proficiency with evidence-based practice than master's education could support. Without a practice doctorate, these early adopters argued, nursing would be disadvantaged in health care settings where pharmacists, physicians, and other disciplines enter with practice doctorates. Early adopters stressed that the health challenges of the future would require greater knowledge, confidence, and skill from APRNs and nurse leaders than the current graduate education could provide. They asserted that the practice doctorate could more appropriately prepare nurses to meet these challenges (Fitzpatrick, 2007). This group was challenged to find faculty suited to the teaching and placements for student learning. Moreover, they labored to describe the types of scholarship that would exemplify practice at the highest level.
Members of the Early Majority
According to Rogers (1962), members of the early majority are pragmatic and deliberate; they prize proven and reliable action and can be risk adverse. The early majority, which comprises roughly a third of the market, carefully considered the experiences of early adopters (Bellflower & Carter, 2006). Informed by the outcomes of efforts by innovators and early adopters, and mindful of the assertions of critics, the early majority acted on concerns about the unintended consequences of establishing the practice doctorate (Clinton & Sperhac, 2009). Careful tracking of the numbers of programs, students admitted, and graduates helped monitor unintended and potentially unattractive consequences.
Critics worried that DNP programs would impede the production of nurse researchers by siphoning talented nurses away from PhD programs. They were concerned that the DNP degree would be sought by those who desired the title doctor, without exerting the effort required to earn it. Critics asserted that the DNP would become a lesser doctorate, lacking in rigor, and lamented that academia would come to focus on production and volume rather than high quality education (Cipriano-Silva & Ludwick, 2011; Cronenwett et al., 2011; Dracup, Cronenwett, Meleis, & Benner 2005; Meleis & Dracup, 2005).
The voices of these critics informed the actions of many. Taleb (2012) states that to become antifragile, individuals and systems must develop strategies that will not only counteract the forces that concern critics, but will make their programs stronger by introducing a stress and responding to it effectively. Antifragile late adopters used criticism to create strength in their programs. For example, in response to the concern that the DNP will be the "lite beer" of nursing education, some late adopters hardwired demands for scholarship and rigor into programs. These included final defenses and publication requirements (Brown & Crabtree, 2013). Although aspirational at first, these requirements have led to such outcome measures as numerous publications from DNP graduates, for example, 200 to date from graduates of the Duke University School of Nursing and 160 from graduates of Johns Hopkins University School of Nursing.
Members of the Late Majority
Rogers (1962) describes members of the late majority, those now entering the field fully a decade into the change, as conservative, cautious, and seeking safe, reliable solutions that do not introduce risk. This group, comprising roughly a third of the market, is likely to be implementing change in response to peer pressure.
Today, DNP programs are offered in diverse colleges and communities where material, financial, and faculty resources vary considerably. For this group, the DNP program may be the first doctoral program on campus and, as in the case of the late majority, execution varies considerably. Pedagogies, platforms (online, blended, and face-to-face), approaches to achieving the DNP essentials, and outcomes differ significantly (AACN, 2006; Grey, 2013; Udlis & Mancuso, 2012).
According to Rogers, members of the last group to embrace change are called laggards (1962) because they come late to the table. In the case of the DNP, the change is not far enough along to allow the identification of laggards, but that time is not far off.
CHANGING THE FOCUS
A decade into diffusion of the DNP into education and practice, it is time to move the focus of conversation from the potential of the DNP and the challenges of implementation to a focus on outcomes and impact. The nature of practice scholarship, the outcomes, and the impact in academia and in practice need to take center stage (Nelson, Cook, & Raternik, 2013).
Based on these convictions, the DNP Impact Conference was convened to provide the opportunity for innovators, early adopters, and members of the early majority to engage in thoughtful and critical conversation with an eye to increasing the quality and impact of programs and graduates. Members of the late majority and laggards had the opportunity at the conference to hear about the experiences of and reflections of schools that implemented DNP programs on the leading, as opposed to the trailing, edge. Critics could pose thoughtful questions to inform program improvements across all groups. Successful approaches and strategies could be disseminated broadly to inform the development of new programs and the refinement of existing ones.
The inclusion of leaders from academia and service assured a close connection between what is needed of the DNP across diverse health care systems and how DNP graduates are prepared to fully contribute, now and in the future. These assertions were the reasons to convene the conference and to create this report.
DNP Impact Conference Structure
The two-day conference was open to leaders from universities and schools of nursing that offer DNP programs as well as executives, administrators, and leaders from the service sector who employ DNP graduates; 120 nursing and industry leaders actively participated. Formal presentations were punctuated by opportunities for participants to discuss experiences, concerns, practices, and outcomes.
The objectives of the conference were as follows: a) to engage in dialogue about DNP education to date, b) to invite feedback from those who employ DNPs, c) to learn about best practices in education and practice of DNPs, d) to achieve cross-pollination of those best practices, and e) to advance the impact of DNP education and practice.
KEY THEMES FROM THE CONFERENCE
Several themes arose from the speakers and participants and are cited as personal communications and noted accordingly. A summary of key themes is presented in Table 1.
The difference between DNP and PhD had to be made clear when the practice doctorate was first introduced (Fulton & Lyon, 2005; Loomis, Willard, & Cohen, 2007; O'Sullivan, Carter, Marion, Pohl, & Werner, 2005). Participants emphasized that now, more than 10 years in, the difference is clear and well understood. Participants were eager to move past this discussion toward a substantial focus on outcomes and impact.
The DNP Is Not a Role
The DNP is a credential and not a role. To have earned the DNP is to have mastered the essentials and to be prepared to apply them in a variety of roles, including those of midwife, nurse practitioner (many specialties), clinical nurse specialist, administrator, executive, policy maker, advocate, informatician, analyst, and more (AACN, 2006). Thus, the DNP credential refers to a set of knowledge and skills to be applied across different roles and settings in service of improving care, quality, cost, and outcomes (J. Sebastian, PhD, personal communication, July 8, 2014).
The DNP Could Be a Threat to Nursing
At its inception, the DNP degree was framed as potentially threatening to the profession in several important ways (Dracup et al., 2005; Meleis & Dracup, 2005). The degree could attenuate and dilute the quality of doctoral education for nurses; it might become a shortcut to the title of Doctor pursued by less committed nurses; it could reduce the applicant pool and brain trust that would pursue the PhD; and finally, it might impede the production of good nursing science and harm the practice of nursing and the health of the nation. During the conversation at the conference, various aspects of this critique were evaluated; themes of the conversation are presented below.
CONCERN ABOUT QUALITY ENDURES Conference participants from schools preparing to open DNP programs were interested in learning how to offer quality education. These concerns centered on strategies to elevate the practice and scholarship of the post-master's DNP and effective means to graduate practice-ready DNPs from post-baccalaureate programs.
Participants from schools that have graduated students (largely postmaster's programs) were interested in benchmarking and metrics. These schools could report completion rates and numbers of graduates but shared an appetite for more robust metrics.
Participants discussed challenges encountered providing DNP education. Many were challenged to find the correct practicum opportunities and preceptors; to set and maintain a high standard of scholarship and practice; to find faculty with the proper credentials; to provide strong advising to the DNP; to improve the quality of writing; and to establish a foundation for analytics that would support rigorous evaluation of DNP projects, all within the two-year curriculum, which has become the benchmark.
Participants from schools preparing post-baccalaureate DNPs sought information about curriculum design, clinical placements, scale of programming, and examples of outcomes that provide evidence that students are prepared to practice at the highest level. This group was looking for effective practices. They could, in fact, be considered early adopters of a different program rather than late adopters of the DNP. Regardless, they were looking for information and strategies to emulate.
CONCERN ABOUT DIMINISHING THE BRAIN TRUST REMAINS active Data provided by the AACN (2014), and reproduced in Figure 1 illustrate a sustained rise in the number of doctoral programs, including both PhD and DNP education (Kirschling, 2013). However, interpretations of those data vary.
DNP programs are increasing the number of graduates each year at a rate that exceeds the increase in PhD graduates. Many participants conclude that is because the DNP is the right terminal degree for a nurse in practice. Participating leaders from academia and service interpret AACN data as indicating that the DNP is drawing new nurses to doctoral education. Some, on the other hand, assert that the lower rise in the PhD student graduations indicates that the DNP is drawing nurses away from research careers as predicted.
The Context Is Changing
Transition from a fee-for-service model to accountable care creates significant risk and opportunity for health care providers and for the industry. Whereas hospitalization and utilization of specialty services drove payment in a fee-for-service model, primary care and preventing hospitalization are essential in accountable care. New skills, knowledge, methods, and collaborations will be needed to create bridges to the new practice environment (D. Chin, MD, personal communication, July 9, 2014).
All speakers agreed there is a good fit between the DNP essentials and the practice environment, as well as the readiness to respond rapidly and effectively to new compensation and demand. The goals of health reform under the Affordable Care Act of 2010 (improve care delivery systems through accountable care organizations, medical care homes, etc.; emphasize health education and prevention; expand access to health care insurance for millions of Americans; and replace the fee-for-service payment system that rewards overutilization with a value-based payment system that rewards quality and efficiency) were described as closely aligned with the DNP essentials (P. Beurhaus, PhD, personal communication, July 9, 2014).
Tools and Competencies for DNP Scholarship
The DNP essentials (AACN, 2006) provide scaffolding upon which to build both educational programs and DNP practice that are well suited to this new and changing context (P. Buerhaus, personal communication, July 9, 2014). Participants debated several key points about tools and competencies, and the conversation continues.
Speakers and discussants found they had many questions about the nature of scholarly work products that demonstrate mastery of the essentials and readiness for the demands of practice. In particular, they questioned whether scholarly work by a DNP graduate differs from that of the master's-prepared nurse. Discussants spoke about many different examples of scholarship and considered several questions.
* Does a search of the evidence demonstrate practice that is appropriate for doctoral study?
* Does planning an activity demonstrate practice that is appropriate for doctoral study?
* Does assisting a faculty member or a PhD student demonstrate practice that is appropriate for doctoral study?
* Will group activities demonstrate practice that is appropriate for doctoral study?
* What are the activities and work products of practice scholars that demonstrate mastery of higher level thinking beyond that of the master's prepared nurse? The merit of specific activities was questioned, including:
** Conducting a thorough search of evidence
** Developing a comprehensive strategic plan
** Publishing case studies
** Assisting faculty members or PhD students with research
** Carrying out group projects
** Assembling a portfolio
* Do we require the same scholarly work products from the postbaccalaureate student as we require from a postgraduate student? If no, how do we defend that? If yes, how do we achieve that?
* To what degree should we require the DNP to execute analytics for outcomes measurement? Is this something that can be delegated, for instance, to a statistician? If yes, how do we defend that? If no, how do we achieve that? If we require the DNP to conduct robust evaluation, how do we prepare them and support them within a two-year program of study?
* How do we differentiate between the DNP-NP and the MSNNP? How do we change expectations in clinical? How does the education differ? Is the availability and quality of placements sufficient if nearly twice the clinical hours are required for graduation? How do the educators differ? Who will precept this DNP, and who will pay for preceptorships?
Pressing Need to Prioritize Quality of Education Over Volume of Graduates
The workforce in both nursing education and nursing practice continues to gray; mature nurses are drawn from hospital to ambulatory care to meet growing outpatient demand; and talented nurses are drawn to advanced practice and administrative positions. The net effect of these trends is a striking reduction in nurses at the bedside, even as acuity and complexity in the hospital are on the rise. So, while it is reassuring that schools of nursing have increased the number of graduates over the past decade, this is no time to become complacent.
Speakers and discussants caution that the need for a great volume of graduates must not be allowed to compromise the quality of the preparation of those graduates. Participants agree that providing quality education and producing DNPs with strong skill sets will be critical if the profession is to navigate the transition from fee-for-service to accountable care. New roles will evolve and new competencies in analytics and advocacy will be required.
Early concern about outcomes, which projected that DNP programs would be less committed than PhD programs to rigor and scholarship, are now met with mixed response. Some conference participants from postgraduate DNP programs report accomplishments and scholarship that directly relate to the triple aim to deliver quality care, improve outcomes, and reduce cost (Terhaar & Sylvia, in press). These outcomes include: diverse clinical and operational outcomes, reduced length of itinerary, reduced recurrent events following discharge, reduced readmission, decreased agitation, decreased sedation, decreased intensive care unit days, decreased mean transfer time, increased dietary and exercise education, and increased provider knowledge. Examples of outcomes from scholarly projects at one institution are presented in Table 2.
The dissemination of findings is important but conference participants report this remains largely an aspirational goal. Publications from graduates have begun to penetrate the literature and important findings are being disseminated. Conference participants who lead baccalaureate-to-DNP programs report they are graduating "amazing novices" who will transform the work, workforce, and health of the public given the time and opportunity to do so. Additional metrics describing readiness for practice, quality of care, and quality of outcomes are not yet available.
Time of Significant Opportunity
Leaders from the service side emphasized that the DNP has the knowledge, skill, and flexibility required for today's health care system. Moreover, they find that the DNP essentials are a good fit for systems in flux that are characterized by great uncertainty and great opportunity.
* Health care organizations are engaged in expansive, complex change and require the skill set of the DNP to navigate unfamiliar waters. Informed, practiced, courageous leadership within diverse teams will be vital. Education must be rigorous and educators must engage in rapid-cycle performance improvement to assure graduates are prepared for the challenges of this practice environment. Under these conditions, the DNP will possess the skill set for the time (K. Haller, PhD, personal communication, July 8, 2014)
* Workforce planning and development will be critical to the success of any health care organization. Any enterprise would be well advised to weave DNPs throughout their long-term strategic plans. For the purpose of adapting, innovating, and succession planning, the DNP will be integral to the successful strategy and financial stability (T. Williams, personal communication, July 8, 2014)
* In order for organizations to thrive in the context of accountable care they will require knowledge, capabilities, and proficiency with large datasets. Organizations will need new knowledge workers and infrastructure as well as the ability to make data-based decisions across primary, tertiary, rehabilitative, urgent, and palliative care. The well-prepared DNP can meet this growing need (L. Dunbar, PhD, personal communication, July 8, 2014)
* DNP education cannot take the easy path. DNPs need to be able to drive improvement and fully participate in collaboration informed by data, evidence, and improvement science. The education needs to be rigorous to prepare graduates to lead significant change (L. Wood, DNP, personal communication, July 8, 2014)
* DNP programs must prepare graduates to function successfully and contribute significantly to a practice environment that is highly collaborative and highly interprofessional. Teaming is key (M. J. Assi, DNP, personal communication, July 8, 2014)
Innovators within the profession have conceptualized a practice doctorate with tremendous potential to improve outcomes and achieve the triple aim of improving care, quality, and cost. DNPs must exploit the opportunity to establish nursing as a full partner making measurable, relevant contributions that directly and substantially contribute to the health of individuals, the strategic intent of organizations, and the wellness of the communities they serve. Academics can change health care by educating DNPs with strong basic science, translation, implementation, teaming, writing, collaborating, and leadership capabilities that are based on evidence and suited to the evolving market. Ongoing dialogue between service and academia will lead to useful course corrections and the insight necessary to seize this opportunity and all its associated potential.
Nationally, the profession is considering barriers and facilitators of the move to the postbaccalaureate DNP (Auerbach et al., 2014). The authors propose a keen focus on the outcomes of DNP education and practice. Such data will inform academic programs and help establish the value proposition as well as meaningful benchmarks for performance moving forward.
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About the Authors Mary F. Terhaar, DNSc, FIN, FAAN, is professor and associate dean for Academic Affairs, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio. Laura A. Taylor, PhD, RN, ANEF, is associate professor, Daniel K. Inouye Graduate School of Nursing and Family Nurse Practitioner Program, Uniformed Services University of Health Sciences, Bethesda, Maryland. Martha L. Sylvia, PhD, MBA, RN, is associate professor in the College of Nursing and director of population health analytics, Medical University of South Carolina, Charleston, South Carolina. This work was accomplished with funding from the Maryland Health Services Cost Review Commission Nursing Support Program II. For more information, contact Dr. Terhaar at email@example.com.
Table 1: A Summary of Key Themes from the DNP Impact Conference Themes Perspectives Confusion The DNP is a credential and not a single role. Academic Rigor DNP education is offered in many colleges and universities; still, concerns about rigor and scholarship endure. Context Accountable care is creating demand for the competencies, skills, and experience DNPs bring to practice and education. Scholarship Questions about the scholarly work products of the DNP persist. Charge for Academics The most important thing for educators to do right now is to make strong, well-prepared nurses and DNPs for the demands of the practice environment. Charge for DNPs Robust evaluation and high-quality dissemination of findings need to become priorities for the profession. Opportunity Current conditions present significant opportunities for the profession. Dialogue Ongoing dialogue between academe and service will help assure curricula prepare graduates prepared to meet current and future market demands. Table 2: Select Outcomes from DNP Scholarly Projects Student Capstone Title Outcome(s) Cynthia Patton, Increasing Efficiency Reduced the mean number of DNP, FNP in Evaluation referrals per patient from of Chronic Cough 3.33 to 1.22 (p< .001) Reduced length of itinerary from 126.93 days to 12.9, t(67) = 5.94, p < .001. Deborah Croy, Improving Provider Increased medication DNP, FNP Adherence to Non-HDL-C prescription or Guidelines recommendation by 30% (p = .004) Increased dietary education by 28% (p = .000) Increased exercise education by 41 % (p = .000) Mary Marshman, Developing a System of Decreased recurrent TIA by DNP Care for the Transient 100% (p = 0.217) Ischemic Attack Patient Decreased Stroke by 72% (p = 0.093) Decreased LOS by 6.8 h from 40 h to 33 h Moved 25% of the population to observation Nilufeur Reducing Heart Failure Reduced 30-day heart McKay, DNP Readmissions failure readmissions by 21.6% Gail Pietrzyk, Shaping Collaborative Increased conduct of DNP Practice: Senior Leader debriefings in the OR from Behaviors and Unit 15% to 50% Teamwork Improved all Senior Leadership scores on the SAQ Christina Di Improving Continuous Provider knowledge of OSA Napoli, DNP Positive Airway increased by 23.8% Pressure Compliance Among Patients Intervention group twice as likely to comply with CPAP regimen Juliane Sedation in the ICU: Decreased agitation as Jablonski, Changing Traditional measured by increased time DNP, CCNS Patterns of Practice per day at target RASS score (mean difference 0.12, p = 0.02) Decreased continuous sedation as measured by mean percent time with continuous sedation (mean difference 0.18, p = 0.01) Maintain comfort as measured by mean percent time with target BPS of 3-5 (mean difference 0.03, p = 0.16) Increase daily activity sessions measured by mean percent of ICU LOS (mean difference 0.17, p = 0.001) Decrease time in ICU days to first activity session (mean difference 1.1 days, p = 0.312) Scott Newton, Rapid Access to Decreased mean transfer DNP Tertiary Care: time by 22% Mitigating Barriers Impacting Clinical, Financial, and Operational Outcomes
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|Author:||Terhaar, Mary F.; Taylor, Laura A.; Sylvia, Martha L.|
|Publication:||Nursing Education Perspectives|
|Date:||Jan 1, 2016|
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