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

A Look at the Issues Considered

As the task force gathered information about existing programs and began to solicit input from various stakeholders about the practice doctorate, it became readily apparent that there were a number of complex issues to be considered and stances to be taken. The issues that the task force debated, sometimes at considerable length, are described below. In each case the stance taken in the position paper and the rationale for that stance is described. The issues that were considered included: (a) how to define practice for the purpose of defining the scope of the practice doctorate; (b) the degree title to be used; (c) whether the benefits to be derived if the practice doctorate were implemented on a large scale would warrant the effort and potential disruption that would be involved; (d) the recommended curricular structure and major content areas of practice doctoral programs, and (e) whether to recommend the practice doctorate as the advanced practice degree (i.e. the desired level of preparation for all advanced nursing practice) or as an advanced, post-master's credential to be attained by only a portion of advanced practice nurses.

The task force deliberated "long and hard" about the way in which practice would be defined for the purposes of the position paper on the practice-focused doctorate. Ultimately, we chose to define practice more broadly than direct, hands-on care, so as also to include management of care for individuals and populations, administration of nursing and health care organizations, and health policy formulation and evaluation. The choice to use an inclusive approach was based, in part, on a long-standing conceptualization of nursing practice as having two related domains: the direct and the indirect, with the latter defined as activities that are carried out in support of the provision of direct care. Nursing practice was defined as:

any form of nursing intervention that influences health care outcomes for individuals or populations, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations, and the development and implementation of health policy. Preparation at the practice doctorate level includes advanced preparation in nursing, based on nursing science, and is at the highest level of nursing practice (AACN, 2004, p. 3).

The decision to define nursing practice more inclusively than hands-on care was also based on recognition that the authority and responsibility to make decisions that influence nursing and health care, and ultimately patient outcomes, often reside at the system level, i.e., with nursing administrators and policy makers. Many of the key stakeholders from whom input was secured by the task force spoke to the advisability of preparing such decision makers and leaders at the doctoral level and in the discipline of nursing. The curricular implication of this broadly scoped definition of practice is that it includes, but does not limit, practice-focused doctoral programs to preparation for the traditional hands-on advanced practice nursing roles of nurse practitioner, clinical nurse specialist, nurse midwife, and nurse anesthetist. Although this decision remains controversial (see Mundinger, 2005), it received overwhelming support among audiences polled by the AACN task force.

The task force concluded that the practice-focused doctorate was needed in nursing, was a valid terminal degree, and should be recognized as a viable and robust alternative to (but definitely not a substitute for) the research-focused doctorate. The two types of programs should be considered to be distinct and complementary, both contributing in important ways to the future of the profession and to health care in general. All of the institutions that currently offer the practice-focused doctorate also offer research-focused doctoral programs. Although there may be some overlap in core content, the purposes, objectives, and requirements of the two types of programs are clearly different. The experience reported by these institutions is that research- and practice-focused programs do not compete for students. Instead, they provide complimentary alternatives into which students appropriately self-select.

As conceptualized by the task force, the practice doctorate represents the highest level of preparation for advanced nursing practice in a specialized practice area; it is not an entry level degree. In order to be respected as a credible terminal degree, the programs that offer the practice-focused doctorate must be demanding and rigorous, and must include content and requirements and expect terminal behaviors that clearly are beyond the level of current master's degree programs. To minimize confusion both within and outside the discipline, it was recommended that one degree title, Doctor of Nursing Practice (DNP), be used for all practice-focused doctorates, and that the Doctor of Nursing (ND) degree be phased out. The four ND programs are in fact at various stages in the process of formalizing changes in degree title to the DNP.

The practice doctorate was viewed as a viable and necessary alternative to the research-focused doctorate because of the many benefits that the availability of high-level preparation in nursing practice was anticipated to provide to the profession, to health care in general, and to the individuals earning the degree. Although the ANCC task force found no formal studies of the accomplishments of nurses with practice doctorates, and several of the programs were too new to have graduates, it was believed that the nursing profession will benefit both clinically and educationally from the addition of more nurses with practice doctorates. In an era in which virtually all health care professions have moved to the doctorate as the terminal practice degree, parity for nursing is not simply a matter of status. Instead, it is increasingly the credential that is needed for credibility in leadership positions. The task force concluded, based upon comments from the administrative experts with whom the task force met, that nurses who have earned the doctoral degree with a practice focus will be more likely than their master's-prepared counterparts to be accorded a place at the table in institutional and health system decision making. The result should be improved ability to effect needed change in nursing practice, health care, and health policy. The availability of a practice-oriented doctorate as a "destination" should help to attract highly able individuals to the field, which will, in turn, benefit from their intelligence, insight, and leadership skills.

It is appropriate that experts in practice play a central role in educating the nurses of the future. Currently, much of the clinical instruction of undergraduate students is carried out by master's prepared individuals who may not qualify for full faculty status because they have not earned a terminal degree in the discipline. The practice doctorate should provide ideal preparation and credentialing for clinical teaching. With the practice doctorate as an option the attractiveness of academic careers may increase and result in the ability to attract expert clinicians who enjoy teaching, but lack sufficient interest in research to pursue the PhD credential.

The availability of skilled clinicians and administrators with advanced practice preparation at the doctoral level will benefit health care in general, as well as the individual patients to whom they provide care. Such individuals will be exceptionally well prepared to design, deliver, and direct evidence-based practice; to develop improved practice guidelines; to develop practice innovations; and to evaluate the effectiveness of complex interventions. These individuals will be at the forefront of efforts that will improve health care outcomes and patient safety and increase efficiency. Mundinger (2005) predicts that "these clinicians will change health care and profoundly improve the nation's image of nursing" (p. 174).

Finally, individual nurses will benefit from the availability of practice-focused doctoral programs. The curricula will provide advanced competencies for improved management of complex patients and patient populations, and for providing leadership in the practice arena. Given the complexity and sophistication of the content that has to be mastered for advanced nursing practice in today's health care system and the high number of credits that are required to achieve expected competencies, the doctorate will provide a better match of degree requirements to the credential earned, while also allowing the inclusion of important content that simply cannot be fit into master's programs.

Importantly, the availability of practice-focused doctoral programs will allow a better fit of educational preparation to individuals' career goals. Currently many nurses are dissuaded from pursuing doctoral education because they do not envision research-focused careers, but would prefer to attain additional practice expertise. Others enter PhD programs despite their lack of interest in and commitment to research, because there simply are so few options. The disconnect between the educational program and student goals results not only in dissatisfied students and faculty, but also in an incredible waste of scarce resources for both the student and the institution.

In order to differentiate practice-focused from research-focused doctoral programs, and practice doctorates from master's programs, and to make the degree understandable to patients, potential employers, and the public, it is advisable to achieve as much standardization as possible among practice-focused doctoral programs. The balance is to give the degree meaning, while allowing for some variability across institutions and specialties. To that end, an agreed-upon set of core objectives, curricular components, and content areas should be included in all programs. Core competencies should be expected of anyone holding the degree. The curricular model, therefore, should ideally combine a core of courses and experiences to address the competencies expected of all degree graduates. The core should be accompanied by a specialty component comprised of content and objectives that are specific to the specialty and most likely influenced by certifying bodies external to the institution. NONPF, for example, is developing doctoral-level competencies for nurse practitioners.

One of the clearest differences between the practice doctorate and the research doctorate is the lack of a dissertation requirement in the former. Instead of a dissertation, which is the hallmark of research-focused doctoral education, practice-focused programs are characterized by an extensive and integrative practice experience, often termed a residency or "capstone" experience. Tailored to the specialty and interests of the individual student, this practice experience is up to a year in length, and may be even longer for individuals who lack a background of practice experience. A practice-related written product of some kind is expected, and should be defensible when subjected to peer, professional, and possibly public scrutiny. Examples include a portfolio of case studies analyzing patient care provided, an empirical evaluation of a program of intervention, a publishable policy analysis, a business plan for a major clinical project, a publishable analysis of best practices for the care of a particular patient population, or clinical guidelines based on the analysis of published research and other evidence.

Although it was beyond the scope of the task force's charge to recommend specific content, our analysis of the existing programs and the needs of the health care system and the profession yielded recommendations about content areas that should be considered for inclusion in all programs. These include: (a) scientific underpinnings for practice, including emerging areas of science; (b) organizational and systems contexts for care and management; (c) research and analytic methodologies needed to evaluate, apply, and generate evidence; (d) informatics and the use of information technology; (e) health policy analysis and evaluation; and (f) interdisciplinary collaboration. Finally, it was recommended that all programs include at least one area of advanced nursing practice in which students would specialize. We were not specific about the nature of the specialty area(s), recognizing that in some programs specialties might be designed around specific ANP roles, such as nurse anesthetist or pediatric nurse practitioner, while in others the specialties might be based on clinical populations, rather than roles per se.

Current master's programs are arguably too credit-heavy; however, academic and professional credibility requires that the practice doctorate not simply be a renaming of what currently is being offered at the master's level. With regard to both core and specialty content, it is essential that the level of sophistication and complexity of the content provided and the competencies to be demonstrated by graduates be higher and the scope more inclusive. It must be clear that the nurse with a practice doctorate has "attained a greater depth and breadth of knowledge and practice" (Mundinger, 2005, p. 173) than an advanced practice nurse with a master's degree.

Because they prepare nurses for an advanced level of practice that directly or indirectly impacts patients and patient care, practice-focused doctoral programs must be subject to professional accreditation and governmental regulation. To the extent that the graduates are to be certified for a particular level and scope of practice, these programs may also need approval by specialty organizations. The accreditation and approval processes are essentially analogous to those currently in place for master's programs that prepare for specialized practice. However, the requirement of accreditation further differentiates practice - from research-focused doctoral programs.

Probably the most controversial of the decisions made by the task force was the recommendation to upgrade the degree requirement for advanced nursing practice from the master's to the practice doctorate. The reason for this stance was the firm belief that the doctorate is the appropriate degree to reflect the extent and level of difficulty and sophistication of preparation required for specialized, advanced practice in today's health care system. The intent of this recommendation was in no way to devalue or make obsolete the master's credential that is currently the accepted preparation for advanced practice nursing. Rather, it was designed to underscore the complexity of knowledge that must be mastered in order to practice at the highest level. The intent was to be forward-looking and to set a high standard, with the full realization that the shift to the doctorate as the preferred preparation for advanced nursing practice will be difficult, requiring a transition period of approximately ten years. Although a dual-level system will undoubtedly be in existence for a considerable period of time, the goal is to move to the doctorate as the sole advanced practice degree.

Currently the majority of DNP programs have focused attention on a phased-in approach that begins with the post-master's level of education. With the exception of the former ND programs, which tend to have multiple entry points, most practice-focused programs presently admit only students who have already earned master's degrees. Such students generally bring to their doctoral education a wealth of practice experience. Although the doctoral program objectives and expected competencies build upon this level of preparation, they are designed clearly to extend beyond it.

Ultimately it is anticipated that there will be multiple entry points and routes to the practice doctorate as illustrated by Marion, O'Sullivan, Crabtree, Price, and Fontana (2005). For some students who are advanced practice nurses with extensive experience in complex practice arenas, the transition to the doctorate can ideally be streamlined in a way that acknowledges and provides efficiently for validation of terminal competencies. However, since most institutions set minimum credit and residency requirements at the doctoral level, it is unrealistic to expect that a high quality program could be any less than a year in length. The nurse entering the program without master's preparation or with limited advanced practice experience will require more time to achieve the desired level of competency.

The issues and challenges raised by this recommendation are admittedly many, and it continues to be debated (Dracup, Cronenwett, Meleis, & Benner, 2005). At the individual level nurses who are already practicing as advanced practice nurses will need to decide whether to pursue the doctorate. Although compensation may not increase markedly with the added degree, even the most experienced nurse should benefit from practice-focused doctoral education, because it leads to additional competencies and an expanded world view. Both of these competencies should enrich and improve practice. An expanded repertoire of employment opportunities may become available as employers become aware of the value added by the capabilities of this level of graduate. As noted above, the opportunities for employment in academia should be excellent, given impending faculty shortages. Whether or not faculty who have earned a practice doctorate (versus the PhD) will be tenurable will depend on institutional policy and individual scholarly productivity.

Institutional challenges cannot be ignored. Nearly all institutions desiring to offer the degree will face the challenge of providing faculty to teach the core and specialty courses, as well as appropriate practicum experiences. Some institutions have chosen to admit some of their own faculty in the first cohort of students, while others are precluded from doing so and are planning inter-institutional collaborations that will allow faculty from one institution to enroll at another. Some are taking advantage of programs that are offered online. The recommendation to upgrade the degree requirement for advanced practice may create some difficulties for some institutions currently offering the master's degree in nursing, particularly smaller schools that are not chartered to offer doctoral degrees. There is interest in developing models of inter-institutional collaboration that will encourage partnerships between such schools and those that can offer the doctorate. As with any new degree program, institutional resistance to innovation may require skillful negotiation in order to secure approval. The existence of profession-wide positions and standards by AACN and other professional organizations should be helpful in this regard.

Some educators have expressed the fear that the existence of DNP programs will siphon off badly needed enrollment in PhD programs and compromise the development of the science (e.g., Dracup & Brian-Brown, 2005; Dracup, Cronenwett, Meleis & Benner, 2005). As reported in the survey of institutions that offer both research- and practice-focused doctorates, that fear has not materialized. For example, at the University of Kentucky applications to the PhD program increased after the initiation of the DNP program was announced. A likely explanation is that the two types of programs are attracting students from two distinct applicant pools, with different interests and goals.

The move to the practice doctorate as the desired credential for advanced nursing practice has been criticized as contributing to the confusion about nursing education that is experienced by the public, other health professionals, even nurses themselves. Dracup and Brian-Brown (2005) have argued that in the midst of considerable debate and disagreement about requirements for entry into practice, the master's degree has remained a "beacon of clarity…the degree required for all advanced practice and faculty roles" (p. 279). Notwithstanding the statement is clearly debatable – given the long-standing existence of generic master's programs and the requirement in many institutions that faculty be doctorally prepared – the practice doctorate could actually result in improved degree clarity if it is established as the only practice-focused doctorate and ultimately as the only preparation for advanced practice.

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