The DNP: Pros and Cons The DNP: Pros and Cons from a National Perspective from a National Perspective

Linda L. Lindeke PhD RN CNPLinda L. Lindeke PhD RN CNPAssociate Professor School of Associate Professor School of

Nursing Nursing

Director of Graduate Director of Graduate StudiesStudies

BackgroundBackground

NP graduates enter very NP graduates enter very high-pressure, fast-paced high-pressure, fast-paced and rapidly changing and rapidly changing workplacesworkplaces

Are NPs Are NPs change agentschange agents, or , or marketplace marketplace commoditiescommodities??

One Purpose of the DNPOne Purpose of the DNP

How can we as faculty use the How can we as faculty use the best available evidence to best available evidence to prepare our students for prepare our students for

workplace realities and position workplace realities and position them for success?them for success?

OROR

Where are the “Nightingales” of Where are the “Nightingales” of the 21the 21stst Century? Century?

Extremely-brief history of Advanced Extremely-brief history of Advanced Practice Nursing:Practice Nursing:

Master’s education began in 1950s Master’s education began in 1950s (education, administration, psych-(education, administration, psych-mental health clinical nurse mental health clinical nurse specialist)specialist)

Nurse practitioner master’s programs Nurse practitioner master’s programs began at U of Colorado 1965began at U of Colorado 1965

Certificate NP education at Duke, Certificate NP education at Duke, Mass General; U of MN, Mayo, even Mass General; U of MN, Mayo, even St Cloud Group Health! St Cloud Group Health!

More HistoryMore History

Nurse anesthesia practice and Nurse anesthesia practice and education 100 years old education 100 years old

Nurse midwifery goes back to Nurse midwifery goes back to beginning of role; formal beginning of role; formal education in England education in England

Public health nursing and nursing Public health nursing and nursing administration seen as administration seen as “advanced specialties” (vs “advanced specialties” (vs “advanced practice nursing)“advanced practice nursing)

History, cont.History, cont.

1990s: Commission on Collegiate 1990s: Commission on Collegiate Nursing Education (CCNE) Nursing Education (CCNE) established partnerships with established partnerships with professional organizations to include professional organizations to include graduate education in schools’ graduate education in schools’ accreditationsaccreditations

2000: American Association of 2000: American Association of Colleges of Nursing (AACN) found Colleges of Nursing (AACN) found much variation in PhD programs, much variation in PhD programs, titling, focus (study by Sandra titling, focus (study by Sandra Edwardson et al)Edwardson et al)

External ForcesExternal Forces

Workplace and foundations demand Workplace and foundations demand higher skill level of nursing higher skill level of nursing leadership to solve complex health leadership to solve complex health problems (IOM, PEW, etc)problems (IOM, PEW, etc)

Other professions establish doctoral Other professions establish doctoral practice degrees (PT, Audiology, etc)practice degrees (PT, Audiology, etc)

Other professions enter with Other professions enter with doctorates (Dentistry, Vet Med, Law, doctorates (Dentistry, Vet Med, Law, Psychology)Psychology)

Findings of my own 3 Barriers to Findings of my own 3 Barriers to Practice Studies (1996-2003)Practice Studies (1996-2003)

1.1. Understanding complex legal and Understanding complex legal and regulatory issuesregulatory issues“…“…insistence by some community providers that insistence by some community providers that orders must be signed by physician”orders must be signed by physician”

“…“…a nurse practitioner cannot be a primary a nurse practitioner cannot be a primary care provider”care provider”

4.4. Dealing with confusing Dealing with confusing reimbursement issuesreimbursement issues““Limitations on the amount reimbursed”Limitations on the amount reimbursed”

““I find it difficult to stay on topic of what I find it difficult to stay on topic of what Medicare will and will not allow…”Medicare will and will not allow…”

Barriers, Cont.Barriers, Cont.

3. Health care professionals’ and 3. Health care professionals’ and administrators’ lack of administrators’ lack of understanding of NP practiceunderstanding of NP practice““Administrators don’t know laws and regulations Administrators don’t know laws and regulations of NPs---they want “protocols” and of NPs---they want “protocols” and “supervision” that narrows the scope”“supervision” that narrows the scope”

4. Public’s lack of understanding of NP 4. Public’s lack of understanding of NP practicepractice““Public wants to know how a nurse could Public wants to know how a nurse could diagnose & prescribe…seem concerned”diagnose & prescribe…seem concerned”

Context of Graduate Education Context of Graduate Education in Nursingin Nursing

changing demands across health changing demands across health care, health professional and care, health professional and nursing educationnursing education

increased specializationincreased specialization movement to doctoral movement to doctoral

preparationpreparation expanding credits and degree expanding credits and degree

requirementsrequirements

Graduate Programs in Graduate Programs in NursingNursing

Ph.D. ProgramPh.D. Program• Research-basedResearch-based• Generation of new knowledgeGeneration of new knowledge

D.N.P ProgramD.N.P Program• Highest preparation for nursing practiceHighest preparation for nursing practice

M.S. ProgramM.S. Program• Many specialty areas of studyMany specialty areas of study

Post-baccalaureate entry to registered nurse Post-baccalaureate entry to registered nurse credentialcredential• 16 months or so in length; for non-nurses16 months or so in length; for non-nurses• Prepares for registered nursing licensurePrepares for registered nursing licensure• Sometimes offered as a master’s degree (MN Sometimes offered as a master’s degree (MN

at U of M)at U of M)

Post PhD

PhD

(Graduate School)

Professional Doctorate

(DNP)

Academic Degree

Clinical Internship

Professional Master’s (MN)

Baccalaureate in Nursing

(BSN)

Professional Degree

Non-nursing Bachelor’s

Common Coursework

Master of Science (MS)

RN License

National Certification

Clinical Nurse Leader

Certification

Common Coursework

Two Pathways to Doctoral Preparation

AACN and Practice DoctorateAACN and Practice Doctorate

AACN fall meeting 2004 approved AACN fall meeting 2004 approved moving advanced practice education moving advanced practice education to a doctoral levelto a doctoral level

Second motion was approved to set Second motion was approved to set 2015 as the timeline for this to occur 2015 as the timeline for this to occur for APN entry level educationfor APN entry level education

Task forces implemented by AACN Task forces implemented by AACN and other national nursing groups to and other national nursing groups to establish guidelines, competencies establish guidelines, competencies for practice doctorate, & timelinesfor practice doctorate, & timelines

DNP Core Essential CompetenciesDNP Core Essential Competencies

1.1. Scientific Underpinning for PracticeScientific Underpinning for Practice2.2. Organizational and Systems Leadership for Organizational and Systems Leadership for

Quality Improvement and Systems ThinkingQuality Improvement and Systems Thinking3.3. Clinical Scholarship and Analytical Methods for Clinical Scholarship and Analytical Methods for

Evidence-Based PracticeEvidence-Based Practice4.4. Information Systems/Technology and Patient Information Systems/Technology and Patient

Care Technology for the Improvement and Care Technology for the Improvement and Transformation of Health CareTransformation of Health Care

5.5. Health Care Policy for Advocacy in Health CareHealth Care Policy for Advocacy in Health Care6.6. Interprofessional Collaboration for Improving Interprofessional Collaboration for Improving

Patient and Population Health OutcomesPatient and Population Health Outcomes7.7. Clinical prevention and Population Health for Clinical prevention and Population Health for

Improving the Nation’s HealthImproving the Nation’s Health8.8. Advanced Nursing Practice for Specialty RolesAdvanced Nursing Practice for Specialty Roles

““Catch Phrases” of DNPCatch Phrases” of DNP

““Gentle evolution” to create nursing Gentle evolution” to create nursing leaders in practiceleaders in practice

DNP is the terminal practice degreeDNP is the terminal practice degree PhD will be enhanced by this PhD will be enhanced by this

initiativeinitiative Many issues will be clarified state-by-Many issues will be clarified state-by-

state and institution-by-institutionstate and institution-by-institution Many issues have not yet been Many issues have not yet been

discussed or addressed but discussed or addressed but implementation proceedsimplementation proceeds

Local/regional ActivitiesLocal/regional Activities

Tri-College University Nursing Consortium. Tri-College University Nursing Consortium. (NDSU) launched DNP Fall 2005 (NDSU) launched DNP Fall 2005

U of Wisconsin changed structure to allow U of Wisconsin changed structure to allow practice doctorate for audiology; slow with practice doctorate for audiology; slow with DNPDNP

U of MN established practice doctorate Jan U of MN established practice doctorate Jan 0707

MNSCU obtained legislative approval to MNSCU obtained legislative approval to amend MN regulations to permit “applied amend MN regulations to permit “applied doctorates”doctorates”

Several DNP programs in MN, WI, IA, SDSeveral DNP programs in MN, WI, IA, SD

Many Concerns!!!Many Concerns!!!

Funding for longer program for Funding for longer program for studentsstudents

Faculty shortage and qualificationsFaculty shortage and qualifications Faculty and school resourcesFaculty and school resources Workplace readiness (salary, Workplace readiness (salary,

positions)positions) Regulatory concerns (titling, etc)Regulatory concerns (titling, etc) Alienation of nurses who “did Alienation of nurses who “did

everything right”everything right” Faculty fatigue…we’ve come so far…Faculty fatigue…we’ve come so far…

do we have energy for yet another do we have energy for yet another major change?major change?

DNP Leadership ProjectDNP Leadership Project

The capstone or architecturally, the The capstone or architecturally, the finishing stone on a structurefinishing stone on a structure

OR: “backbone” project ( for post-MS OR: “backbone” project ( for post-MS students)students)

“ “Systematic Investigation of a Practice Systematic Investigation of a Practice Issue”Issue”

Project development, implementation and Project development, implementation and evaluationevaluation

Formats vary considerably from program Formats vary considerably from program to programto program

Current ProgressCurrent Progress

Model curriculum plans disseminated Model curriculum plans disseminated & ongoing development in the & ongoing development in the literature and at national, regional, literature and at national, regional, local conferenceslocal conferences

AACN and the National Association of AACN and the National Association of Nurse Practitioner Faculties (NONPF) Nurse Practitioner Faculties (NONPF) set up websites of documents & set up websites of documents & FAQsFAQs

The DNP Reaches the “Tipping The DNP Reaches the “Tipping Point”Point”

The US health system is in disarrayThe US health system is in disarray Nursing leaders must be at the table Nursing leaders must be at the table

representing practice for representing practice for interdisciplinary policy and interdisciplinary policy and knowledge developmentknowledge development

The Doctor of Nursing Practice The Doctor of Nursing Practice degree will enhance the profession degree will enhance the profession and improve the nation’s healthand improve the nation’s health

2010 Trends: The “tipping point” 2010 Trends: The “tipping point” has been reachedhas been reached

Over 200 schools beginning practice Over 200 schools beginning practice doctorate; 50 others strongly doctorate; 50 others strongly consideringconsidering

Huge differences between programs!Huge differences between programs! ““Clinical” defined differently in Clinical” defined differently in

various programsvarious programs Many faculty supported to complete Many faculty supported to complete

their DNP programtheir DNP program DNPs and Health Care Reform…a DNPs and Health Care Reform…a

great match!great match!

Engaging NP/DNP Engaging NP/DNP students with students with

workplace realities for workplace realities for practice improvementpractice improvementand enhancing their and enhancing their

leadership knowledge leadership knowledge and skills will and skills will

increase their success increase their success as NPsas NPs

This is what they look like!!This is what they look like!!

Florence Nightingale:

Nurse, Scientist, Policy-maker, Educator, Systems Designer

?? The “first DNP”?