A Confusion Regarding the Focus of the DNP
Despite the fact that there is no national agreement on the need for the degree or the outcomes of the degree, several programs have moved ahead to offer a DNP including the University of Tennessee, Rush University, University of Kentucky, Columbia University, and Drexal University.
Table 1 presents the focus of the five different programs as described on each university's website. The University of Tennessee's (2005) DNP provides an advanced practice focus that includes a variety of specialty clinical areas; however, the functional role of these graduates is unclear. Rush University's DNP (n.d.) prepares graduates with expertise in outcomes management and leadership in complex environments. A review of the DNP projects completed by students and posted on the university's web site include such topics as nurse retention, faculty retention, international studies, and reimbursement for nurse practitioners. University of Kentucky's (2005) DNP program prepares expert clinical nurse leaders to change direct care practice or health care systems. Graduates are prepared as experts in designing, implementing, managing, and evaluating health care delivery systems.
Confusion is created when there is one degree proposed for varied outcomes and the functional role is not well articulated. Role refers to a constellation of functions for which an individual is responsible – educator, administrator, clinical nurse specialist, and so forth – and role preparation occurs in an academic setting where an individual learns to perform the circumscribed role functions. Educational preparation for each role is accomplished through completion of a distinct curriculum that prepares graduates to function in the scope of practice of the role.
Curricular content is determined by professional associations who represent experts in the role (Fulton, 2005). As in the situation at the University of Tennessee (2005), what role competencies will a DNP graduate with a gerontology focus have, nurse practitioner or clinical nurse specialist? Is forensic nursing a functional role with distinct competencies or a specialty practice in the functional role of nurse practitioner, clinical nurse specialist, or nursing administrator?
The lack of professional role competencies for the DNP focus areas suggests a lack of buy-in by professional nursing organizations.
In contrast to the clinical, administration/management, and systems focus of the programs at Tennessee, Rush, and Kentucky, the Doctorate of Practice of Nursing (DrNP) at Columbia University School of Nursing (n.d., a; 2005) prepares nurse practitioners for expanding practice in primary care medicine and independently diagnosing and treating disease to fill an anticipated gap in primary care physician services. Milton (2005) questioned this practice focus with content related to medical pathophysiology, algorithms for disease management, assessment for the purpose of diagnosis and treatment of disease, and pharmacology courses with a list of medications to be learned for the purpose of prescriptive authority, and asked, "What makes this degree nursing?"
The focus on disease management suggests the proposed new practice doctorate is not adequately grounded in the science of nursing. To develop a terminal degree in nursing which lacks emphasis on the discipline's philosophical framework and theories halts the progression and evolution of the science (Whall, 2005). Will the graduates of this program assume the practice values and skills of other disciplines, especially medicine? NPs argue that they do not practice medicine. However, when a premier doctorate of practice of nursing program for nurse practitioners advertises that it prepares nurses in the practice of primary care medicine, to independently diagnose and treat disease for the purpose of filling an anticipated gap in primary care physician services, it's hard to argue this is not doing the work of medicine. As further evidence that this NP program prepares graduates to work as physician substitutes, the Columbia School of Nursing Website states that "nurse practitioners are demonstrating that they are able to complement and even substitute for physicians in caring for stable inpatients" (Columbia University, n.d, b, para 9). In addition, the website notes that:
Because of substantial cuts in reimbursements, teaching hospitals are contemplating significant cuts in residency staffs. But who will provide the care now delivered by these physicians? Many in nursing contend that nurse practitioners are ideal replacements. They can perform most of the first-year resident's tasks under physician supervision, while incurring one-half the cost in salary and malpractice insurance. (Columbia University, n.d, b, para 9)
This statement implies that nursing is willing to do physician work for less money and that nursing is using its education resources to address the problem of physician residencies and to save hospitals money. While nurses are busy substituting for physicians and subsidizing medicine, who is substituting for and reimbursing nursing in our current nursing shortage of crisis proportions?
NP programs have grown in academic credit because they are adding to a nursing curriculum the fundamentals of medical practice. To educate nurses as providers of medical care – to attain competencies in another discipline – more content, hence more academic credit is needed, well beyond the typical 40ish academic credits of a master's program that builds on the competencies of the discipline's baccalaureate education. On the other hand, when the focus of the practice is
nursing at an advanced level – nursing practice built on baccalaureate competencies and focusing on expanding nursing knowledge based on nursing science - a more traditional 42 credit hour (semester) graduate program is adequate. Is nursing conflicted and confounded about the focus of our doctoral programs because we have avoided what is likely a painful and contentious conversation about the focus of our master's programs – particularly the advanced practice nursing options of clinical nurse specialist, nurse practitioner, nurse anesthetist, and nurse midwife.
Columbia University awards a Doctorate of Practice of Nursing with the credential DrNP, however, Drexal University developed a Doctorate of Nursing Practice and uses DrNP; same credential, with different meanings. In addition, Drexal has not limited its degree to clinical practice or the nurse practitioner role. Drexal's program offers four tracks under the DrNP: Clinical Scholar in Advanced Nursing Practice, Clinical Scholar in Nursing Education, Clinical Scholar in Nursing and Health Research, and Clinical Scholar in Nursing Leadership and Healthcare Management. Is the clinical scholar in nursing and health research a research-focused track? The Drexal DrNP curriculum includes courses in philosophy of science, the structure of scientific knowledge in nursing, epidemiology and biostatistics, quantitative methods, and qualitative methods. Is this not the drift toward research that occurred among DNS programs?
NONPF implies that knowledge and competencies gained from a PhD program are not necessary to "create, implement, and evaluate practice interventions, health delivery systems, and clinical teaching" (NONPF, 2003, recommendation 4) in stating:
The research emphasis in a nursing practice doctorate program differs from a traditional PhD program. Rather than preparing nurse scientists for research careers, this program shall prepare graduates to use research knowledge and methods to create, implement, and evaluate practice interventions, health delivery systems, and clinical teaching. As well, this program prepares graduates to assume a key role in establishing national practice guidelines and conducting clinical trials" (NONPF, recommendation 4).
The notion that PhD programs are not necessary for effective practice raises questions about the nature of research and inquiry in a practice discipline. First, should PhD programs, with all inherent resources, be reserved for only those nurses who wish to become nurse researchers/scientists (Fitzpatrick, 1989)? That is, is the degree not appropriate or useful for nurses who intend to: (a) improve their own practice; (b) change clinical practice; (c) improve teaching; and/or (d) improve executive nursing administration? Second, are the theory development and testing competencies gained through a PhD too limited for disciplined inquiry in the practice setting such that program evaluation research is not a legitimate type of research to include in PhD programs? Third, while PhD programs in nursing are expected to be congruent with the gold standard of research-intensive preparation, with well-funded faculty mentors who have research intensive careers, is this model of PhD education in nursing not the most appropriate for the preparation of nurse scholars who desire non-academic careers such as administration (Edwardson, 2004)?
We believe that PhD programs can and do prepare nurse scientists for clinical settings and health care administration as well as academia.
