The Practice Doctorate in Nursing: An Idea Whose Time Has Come

Elizabeth R. Lenz, PhD, RN, FAAN

Disclosures

Online J Issues Nurs. 2005;10(3) 

In This Article

Background

Certainly a practice doctorate in nursing is not a new idea. Nearly 20 years ago Schlotfeldt (1978) and her colleagues operationalized the dream of making the doctorate the entry-level degree in nursing when the first practice-focused Doctor of Nursing (ND) program opened at what is now Case Western Reserve University (CWRU). Eclipsed in priority and popularity by the research-focused PhD, by 2000 the ND was offered by only four institutions (CWRU, Rush University, the University of Colorado, and the University of South Carolina). Its original conceptualization as an analog to the MD had blurred and changed to an advanced practice focus. Nevertheless, the ND made an important contribution to the discipline by providing a practice-focused degree that represented a type of doctoral preparation that is distinctly different from the research-focused academic doctorate (PhD) or nursing's professional research-focused degree (the Doctor of Nursing Science – DNS, DSN or DNSc).

The idea that the two types of programs are distinctly different and should not be evaluated by identical criteria is consistent with the recommendations of a task force of the AACN that reviewed and recommended the indicators of quality for research-focused nursing doctoral programs (AACN, 2001). By that time the idea that the nursing discipline should offer both research- and practice-focused doctoral degrees had resurfaced actively, and was beginning to stimulate considerable discussion and activity. Three additional schools of nursing were then planning, and later opened, practice-focused doctoral programs: The University of Tennessee Memphis, The University of Kentucky, and Columbia University.

Several trends and events in the practice arena and in nursing and health professions education are detailed in this section. Practice trends include the increasing complexity of health care and the resulting requirement for increased knowledge for advanced practice; education trends include the trend toward practice doctorates in the health professions, the increase in credit requirements at the master's level in nursing, and the tremendous need for nursing faculty who are well prepared for clinical teaching.

Regarding the practice arena, in addition to the ever-spiraling complexity and sophistication of health care, particularly in acute care settings, several studies and reports documented problems with health care delivery and patient safety (e.g., Institute of Medicine, 1999, 2001, 2003). These trends suggested an increasing need for insightful and visionary nursing leadership in practice with the educational credentials necessary to be accorded a place at the table in high level health care management and policy decisions.

Much of the early discussion about educational preparation for advanced practice nursing has focused on nurse practitioners. Mundinger and colleagues (Mundinger, 2005; Mundinger, Cook, Lenz, Piacentini, & Smith, 2000) at Columbia University mounted a powerful argument that although master's-prepared nurse practitioners (NPs) practice effectively and achieve primary care patient outcomes that are equivalent to those of MDs (Mundinger, Kane, Lenz, Totten, Tsai, Cleary, et al., 2000), doctoral education is the optimal level of preparation to provide cross-site, full-scope practice in primary care. In order to ascertain the extent to which actively practicing NPs perceived gaps in their formal education and to identify potential areas for curricular emphasis, Columbia University researchers conducted a national mailed survey. Results from 2303 NPs revealed that although formal education provided the basis for their skills in patient diagnosis and management (in a majority of cases supplemented by subsequent on-the-job training), gaps existed in relation to cross-site practice, credentialing, use of information technology, evidence as a basis for practice, policy, synthesis and application of knowledge at a high level, and multiple aspects of practice management. Although they expressed a desire for more education about these topics, few anticipated obtaining more formal education; because they did not believe existing research-focused doctoral programs to be particularly relevant (Lenz, Mundinger, Clark, Hopkins & Lin, 2000). These findings about perceived gaps in knowledge and the need for additional education are consistent with themes from focus group sessions conducted by the National Organization of Nurse Practitioner Faculties (NONPF) (Marion, personal communication, 2003).

With respect to education, several patterns converged. First, it became increasingly apparent that a major trend in other health disciplines was underway to move the terminal practice degree to the doctoral level. In some cases the doctorate had been newly established as the educational level that will be required for entry into practice (for example, the PharmD in pharmacy, DPT in physical therapy, and AuD in audiology). Nursing remained one of the few health-related disciplines for which a doctorate is not regarded as the highest and desired practice credential.

Secondly, it became increasingly apparent that nursing may be under-credentialing its advanced practice graduates. As the knowledge requirements for advanced practice nursing in today's complex clinical environment have increased steadily, the credit requirements for master's programs and the clinical hour requirements for credentialing have also increased (the phenomenon is often termed "credit creep") to the point where they far surpass master's credit requirements in many other disciplines. They are equivalent to or surpass requirements for doctoral programs in other fields, even clinical disciplines. It is not uncommon for master's programs that prepare nurse practitioners to require in excess of 50 semester credits of didactic courses and clinical practica. An alternative strategy that has been used to keep the credit requirements to a reasonable number is to under-credit clinical practica, allowing credit hour to practicum clock hour ratios to increase well beyond the traditional 1:3 or 1:4. At the same time that credit hour requirements have been escalating, the number of nurse practitioner programs has also escalated, with programs sometimes opening with insufficient numbers of qualified faculty and other resources; concerns about their quality have mounted.

A trend in nursing education that has served to increase the demand for doctorally prepared nurses with expertise in nursing practice is the tremendous shortage of faculty. As was predicted by Berlin (2002) faculty shortages, which are already seriously compromising the discipline's ability to respond to the shortage of bedside nurses, are expected to worsen as more and more faculty reach retirement age. Unfortunately, the enrollments in and graduations from PhD programs in nursing have remained quite steady, so are insufficient to replace the number of faculty who are scheduled to retire in the near future. A practice-focused doctorate appeals to a sizable number of master's-prepared, experienced, and expert clinicians who desire the doctoral credential that many universities recommend or require for their faculty, but who do not wish to pursue a research-focused doctoral degree.

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