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The Essentials of Doctoral Education for Advanced Nursing Practice

October 2006

TABLE OF CONTENTS

Page Introduction

Background 3 Comparison Between Research-Focused and Practice-Focused

Doctoral Education 3 AACN Task Force on the Practice Doctorate in Nursing 4 Context of Graduate Education in Nursing 5 Relationships of Master’s, Practice Doctorate, and Research Doctorate Programs 6

DNP Graduates and Academic Roles 7 The Essentials of Doctoral Education for Advanced Nursing Practice 8 I. Scientific Underpinnings for Practice 8 II. Organizational and Systems Leadership for Quality Improvement and Systems Thinking 9 III. Clinical Scholarship and Analytical Methods for Evidence-Based Practice 11 IV. Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care 12 V. Health Care Policy for Advocacy in Health Care 13 VI. Interprofessional Collaboration for Improving Patient and Population Health Outcomes 14 VII. Clinical Prevention and Population Health for Improving the Nation’s Health 15 VIII. Advanced Nursing Practice 16 Incorporation of Specialty-Focused Competencies into DNP Curricula 17 Advanced Practice Nursing Focus 17 Aggregate/Systems/Organizational Focus 18

ADVANCING HIGHER EDUCATION IN NURSING

One Dupont Circle NW, Suite 530 · Washington, DC 20036 · 202-463-6930 tel · 202-785-8320 fax · www.aacn.nche.edu

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Curricular Elements and Structure 18 Program Length 18 Practice Experiences in the Curriculum 19 Final DNP Project 19 DNP Programs in the Academic Environment: Indicators of Quality in Doctor of Nursing Practice Programs 20 Faculty Characteristics 20 The Faculty and Practice 20 Practice Resources and Clinical Environment Resources 21 Academic Infrastructure 21 Appendix A Advanced Health/Physical Assessment 23 Advanced Physiology and Pathophysiology 23 Advanced Pharmacology 24 Appendix B DNP Essentials Task Force 25 References 27

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Introduction

Background Doctoral programs in nursing fall into two principal types: research-focused and practice- focused. Most research-focused programs grant the Doctor of Philosophy degree (PhD), while a small percentage offers the Doctor of Nursing Science degree (DNS, DSN, or DNSc). Designed to prepare nurse scientists and scholars, these programs focus heavily on scientific content and research methodology; and all require an original research project and the completion and defense of a dissertation or linked research papers. Practice-focused doctoral programs are designed to prepare experts in specialized advanced nursing practice. They focus heavily on practice that is innovative and evidence-based, reflecting the application of credible research findings. The two types of doctoral programs differ in their goals and the competencies of their graduates. They represent complementary, alternative approaches to the highest level of educational preparation in nursing. The concept of a practice doctorate in nursing is not new. However, this course of study has evolved considerably over the 20 years since the first practice-focused nursing doctorate, the Doctor of Nursing (ND), was initiated as an entry-level degree. Because research- and practice-focused programs are distinctly different, the current position of the American Association of Colleges of Nursing (AACN, 2004) [detailed in the Position Statement on the Practice Doctorate in Nursing] is that: “The two types of doctorates, research-focused and practice-focused, may coexist within the same education unit” and that the practice-focused degree should be the Doctor of Nursing Practice (DNP). Recognizing the need for consistency in the degrees required for advanced nursing practice, all existing ND programs have transitioned to the DNP. Comparison Between Research-Focused and Practice-Focused Doctoral Education Research- and practice-focused doctoral programs in nursing share rigorous and demanding expectations: a scholarly approach to the discipline, and a commitment to the advancement of the profession. Both are terminal degrees in the discipline, one in practice and one in research. However, there are distinct differences between the two degree programs. For example, practice-focused programs understandably place greater emphasis on practice, and less emphasis on theory, meta-theory, research methodology, and statistics than is apparent in research-focused programs. Whereas all research- focused programs require an extensive research study that is reported in a dissertation or through the development of linked research papers, practice-focused doctoral programs generally include integrative practice experiences and an intense practice immersion experience. Rather than a knowledge-generating research effort, the student in a practice- focused program generally carries out a practice application-oriented “final DNP project,” which is an integral part of the integrative practice experience.

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AACN Task Force on the Practice Doctorate in Nursing The AACN Task Force to Revise Quality Indicators for Doctoral Education found that the Indicators of Quality in Research-Focused Doctoral Programs in Nursing are applicable to doctoral programs leading to a PhD or a DNS degree (AACN, 2001b, p. 1). Therefore, practice-focused doctoral programs will need to be examined separately from research-focused programs. This finding coupled with the growing interest in practice doctorates prompted the establishment of the AACN Task Force on the Practice Doctorate in Nursing in 2002. This task force was convened to examine trends in practice-focused doctoral education and make recommendations about the need for and nature of such programs in nursing. Task force members included representatives from universities that already offered or were planning to offer the practice doctorate, from universities that offered only the research doctorate in nursing, from a specialty professional organization, and from nursing service administration. The task force was charged to describe patterns in existing practice-focused doctoral programs; clarify the purpose of the practice doctorate, particularly as differentiated from the research doctorate; identify preferred goals, titles, and tracks; and identify and make recommendations about key issues. Over a two-year period, this task force adopted an inclusive approach that included: 1) securing information from multiple sources about existing programs, trends and potential benefits of a practice doctorate; 2) providing multiple opportunities for open discussion of related issues at AACN and other professional meetings; and 3) subjecting draft recommendations to discussion and input from multiple stakeholder groups. The final position statement was approved by the AACN Board of Directors in March 2004 and subsequently adopted by the membership. The 2004 DNP position statement calls for a transformational change in the education required for professional nurses who will practice at the most advanced level of nursing. The recommendation that nurses practicing at the highest level should receive doctoral level preparation emerged from multiple factors including the expansion of scientific knowledge required for safe nursing practice and growing concerns regarding the quality of patient care delivery and outcomes. Practice demands associated with an increasingly complex health care system created a mandate for reassessing the education for clinical practice for all health professionals, including nurses. A significant component of the work by the task force that developed the 2004 position statement was the development of a definition that described the scope of advanced nursing practice. Advanced nursing practice is broadly defined by AACN (2004) 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. (p. 2)

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Furthermore, the DNP position statement (AACN, 2004, p. 4) identifies the benefits of practice focused doctoral programs as:

• development of needed advanced competencies for increasingly complex practice, faculty, and leadership roles;

• enhanced knowledge to improve nursing practice and patient outcomes; • enhanced leadership skills to strengthen practice and health care delivery; • better match of program requirements and credits and time with the credential

earned; • provision of an advanced educational credential for those who require advanced

practice knowledge but do not need or want a strong research focus (e.g., practice faculty);

• enhanced ability to attract individuals to nursing from non-nursing backgrounds; and

• increased supply of faculty for practice instruction.

As a result of the membership vote to adopt the recommendation that the nursing profession establish the DNP as its highest practice degree, the AACN Board of Directors, in January 2005, created the Task Force on the Essentials of Nursing Education for the Doctorate of Nursing Practice and charged this task force with development of the curricular expectations that will guide and shape DNP education. The DNP Essentials Task Force is comprised of individuals representing multiple constituencies in advanced nursing practice (see Appendix B). The task force conducted regional hearings from September 2005 to January 2006 to provide opportunities for feedback from a diverse group of stakeholders. These hearings were designed using an iterative process to develop this document. In total, 620 participants representing 231 educational institutions and a wide variety of professional organizations participated in the regional meetings. Additionally, a national stakeholders’ conference was held in October 2005 in which 65 leaders from 45 professional organizations participated. Context of Graduate Education in Nursing Graduate education in nursing occurs within the context of societal demands and needs as well as the interprofessional work environment. The Institute of Medicine (IOM, 2003) and the National Research Council of the National Academies (2005, p. 74) have called for nursing education that prepares individuals for practice with interdisciplinary, information systems, quality improvement, and patient safety expertise. In hallmark reports, the IOM (1999, 2001, 2003) has focused attention on the state of health care delivery, patient safety issues, health professions education, and leadership for nursing practice. These reports highlight the human errors and financial burden caused by fragmentation and system failures in health care. In addition, the IOM calls for dramatic restructuring of all health professionals’ education. Among the recommendations resulting from these reports are that health care organizations and

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groups promote health care that is safe, effective, client-centered, timely, efficient, and equitable; that health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement, and informatics; and, that the best prepared senior level nurses should be in key leadership positions and participating in executive decisions. Since AACN published The Essentials of Master’s Education for Advanced Practice Nursing in 1996 and the first set of indicators for quality doctoral nursing education in 1986, several trends in health professional education and health care delivery have emerged. Over the past two decades, graduate programs in nursing have expanded from 220 institutions offering 39 doctoral programs and 180 master’s programs in 1986 to 518 institutions offering 101 doctoral programs and 417 master’s programs in 2006. Increasing numbers of these programs offer preparation for certification in advanced practice specialty roles such as nurse practitioners, nurse midwives, nurse anesthetists, and clinical nurse specialists. Specialization is also a trend in other health professional education. During this same time period, the explosion in information, technology, and new scientific evidence to guide practice has extended the length of educational programs in nursing and the other health professions. In response to these trends, several other health professions such as pharmacy, physical therapy, occupational therapy, and audiology have moved to the professional or practice doctorate for entry into these respective professions. Further, support for doctoral education for nursing practice was found in a review of current master’s level nursing programs (AACN, 2004, p. 4). This review indicated that many programs already have expanded significantly in response to the above concerns, creating curricula that exceed the usual credit load and duration for a typical master’s degree. The expansion of credit requirements in these programs beyond the norm for a master’s degree raises additional concerns that professional nurse graduates are not receiving the appropriate degree for a very complex and demanding academic experience. Many of these programs, in reality, require a program of study closer to the curricular expectations for other professional doctoral programs rather than for master’s level study. Relationships of Master’s, Practice Doctorate, and Research Doctorate Programs The master’s degree (MSN) historically has been the degree for specialized advanced nursing practice. With development of DNP programs, this new degree will become the preferred preparation for specialty nursing practice. As educational institutions transition from the master’s to DNP degree for advanced practice specialty preparation, a variety of program articulations and pathways are planned. One constant is true for all of these models. The DNP is a graduate degree and is built upon the generalist foundation acquired through a baccalaureate or advanced generalist master’s in nursing. The Essentials of Baccalaureate Education (AACN, 1998) summarizes the core knowledge and competencies of the baccalaureate prepared nurse. Building on this foundation, the DNP core competencies establish a base for advanced nursing practice in an area of specialization. Ultimately, the terminal degree options in nursing will fall into two

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primary education pathways: professional entry degree (baccalaureate or master’s) to DNP degree or professional entry degree (baccalaureate or master’s) to PhD degree. As in other disciplines with practice doctorates, some individuals may choose to combine a DNP with a PhD. Regardless of the entry point, DNP curricula are designed so that all students attain DNP end-of-program competencies. Because different entry points exist, the curricula must be individualized for candidates based on their prior education and experience. For example, early in the transition period, many students entering DNP programs will have a master’s degree that has been built on AACN’s Master’s Essentials. Graduates of such programs would already have attained many of the competencies defined in the DNP Essentials. Therefore, their program will be designed to provide those DNP competencies not previously attained. If a candidate is entering the program with a non- nursing baccalaureate degree, his/her program of study likely will be longer than a candidate entering the program with a baccalaureate or master’s in nursing. While specialty advanced nursing education will be provided at the doctoral level in DNP programs, new options for advanced generalist master’s education are being developed. DNP Graduates and Academic Roles Nursing as a practice profession requires both practice experts and nurse scientists to expand the scientific basis for patient care. Doctoral education in nursing is designed to prepare nurses for the highest level of leadership in practice and scientific inquiry. The DNP is a degree designed specifically to prepare individuals for specialized nursing practice, and The Essentials of Doctoral Education for Advanced Nursing Practice articulates the competencies for all nurses practicing at this level. In some instances, individuals who acquire the DNP will seek to fill roles as educators and will use their considerable practice expertise to educate the next generation of nurses. As in other disciplines (e.g., engineering, business, law), the major focus of the educational program must be on the area of practice specialization within the discipline, not the process of teaching. However, individuals who desire a role as an educator, whether that role is operationalized in a practice environment or the academy, should have additional preparation in the science of pedagogy to augment their ability to transmit the science of the profession they practice and teach. This additional preparation may occur in formal course work during the DNP program. Some teaching strategies and learning principles will be incorporated into the DNP curriculum as it relates to patient education. However, the basic DNP curriculum does not prepare the graduate for a faculty teaching role any more than the PhD curriculum does. Graduates of either program planning a faculty career will need preparation in teaching methodologies, curriculum design and development, and program evaluation. This preparation is in addition to that required for their area of specialized nursing practice or research in the case of the PhD graduate.

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The Essentials of Doctoral Education for Advanced Nursing Practice

The following DNP Essentials outline the curricular elements and competencies that must be present in programs conferring the Doctor of Nursing Practice degree. The DNP is a degree title, like the PhD or MSN, and does not designate in what specialty a graduate is prepared. DNP graduates will be prepared for a variety of nursing practice roles. The DNP Essentials delineated here address the foundational competencies that are core to all advanced nursing practice roles. However, the depth and focus of the core competencies will vary based on the particular role for which the student is preparing. For example, students preparing for organizational leadership or administrative roles will have increased depth in organizational and systems’ leadership; those preparing for policy roles will have increased depth in health care policy; and those preparing for APN roles (nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives) will have more specialized content in an area of advanced practice nursing. Additionally, it is important to understand that the delineation of these competencies should not be interpreted to mean that a separate course for each of the DNP Essentials should be offered. Curricula will differ in emphases based on the particular specialties for which students are being prepared. The DNP curriculum is conceptualized as having two components:

1. DNP Essentials 1 through 8 are the foundational outcome competencies deemed essential for all graduates of a DNP program regardless of specialty or functional focus.

2. Specialty competencies/content prepare the DNP graduate for those practice and

didactic learning experiences for a particular specialty. Competencies, content, and practica experiences needed for specific roles in specialty areas are delineated by national specialty nursing organizations.

The DNP Essentials document outlines and defines the eight foundational Essentials and provides some introductory comments on specialty competencies/content. The specialized content, as defined by specialty organizations, complements the areas of core content defined by the DNP Essentials and constitutes the major component of DNP programs. DNP curricula should include these two components as appropriate to the specific advanced nursing practice specialist being prepared. Additionally, the faculty of each DNP program has the academic freedom to create innovative and integrated curricula to meet the competencies outlined in the Essentials document. Essential I: Scientific Underpinnings for Practice The practice doctorate in nursing provides the terminal academic preparation for nursing practice. The scientific underpinnings of this education reflect the complexity of practice

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at the doctoral level and the rich heritage that is the conceptual foundation of nursing. The discipline of nursing is focused on:

• The principles and laws that govern the life-process, well-being, and optimal function of human beings, sick or well;

• The patterning of human behavior in interaction with the environment in normal life events and critical life situations;

• The nursing actions or processes by which positive changes in health status are affected; and

• The wholeness or health of human beings recognizing that they are in continuous interaction with their environments (Donaldson & Crowley, 1978; Fawcett, 2005; Gortner, 1980).

DNP graduates possess a wide array of knowledge gleaned from the sciences and have the ability to translate that knowledge quickly and effectively to benefit patients in the daily demands of practice environments (Porter-O’Grady, 2003). Preparation to address current and future practice issues requires a strong scientific foundation for practice. The scientific foundation of nursing practice has expanded and includes a focus on both the natural and social sciences. These sciences that provide a foundation for nursing practice include human biology, genomics, the science of therapeutics, the psychosocial sciences, as well as the science of complex organizational structures. In addition, philosophical, ethical, and historical issues inherent in the development of science create a context for the application of the natural and social sciences. Nursing science also has created a significant body of knowledge to guide nursing practice and has expanded the scientific underpinnings of the discipline. Nursing science frames the development of middle range theories and concepts to guide nursing practice. Advances in the foundational and nursing sciences will occur continuously and nursing curricula must remain sensitive to emerging and new scientific findings to prepare the DNP for evolving practice realities. The DNP program prepares the graduate to:

1. Integrate nursing science with knowledge from ethics, the biophysical, psychosocial, analytical, and organizational sciences as the basis for the highest level of nursing practice.

2. Use science-based theories and concepts to: • determine the nature and significance of health and health care delivery

phenomena; • describe the actions and advanced strategies to enhance, alleviate, and

ameliorate health and health care delivery phenomena as appropriate; and • evaluate outcomes.

3. Develop and evaluate new practice approaches based on nursing theories and theories from other disciplines.

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Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking Organizational and systems leadership are critical for DNP graduates to improve patient and healthcare outcomes. Doctoral level knowledge and skills in these areas are consistent with nursing and health care goals to eliminate health disparities and to promote patient safety and excellence in practice. DNP graduates’ practice includes not only direct care but also a focus on the needs of a panel of patients, a target population, a set of populations, or a broad community. These graduates are distinguished by their abilities to conceptualize new care delivery models that are based in contemporary nursing science and that are feasible within current organizational, political, cultural, and economic perspectives. Graduates must be skilled in working within organizational and policy arenas and in the actual provision of patient care by themselves and/or others. For example, DNP graduates must understand principles of practice management, including conceptual and practical strategies for balancing productivity with quality of care. They must be able to assess the impact of practice policies and procedures on meeting the health needs of the patient populations with whom they practice. DNP graduates must be proficient in quality improvement strategies and in creating and sustaining changes at the organizational and policy levels. Improvements in practice are neither sustainable nor measurable without corresponding changes in organizational arrangements, organizational and professional culture, and the financial structures to support practice. DNP graduates have the ability to evaluate the cost effectiveness of care and use principles of economics and finance to redesign effective and realistic care delivery strategies. In addition, DNP graduates have the ability to organize care to address emerging practice problems and the ethical dilemmas that emerge as new diagnostic and therapeutic technologies evolve. Accordingly, DNP graduates are able to assess risk and collaborate with others to manage risks ethically, based on professional standards. Thus, advanced nursing practice includes an organizational and systems leadership component that emphasizes practice, ongoing improvement of health outcomes, and ensuring patient safety. In each case, nurses should be prepared with sophisticated expertise in assessing organizations, identifying systems’ issues, and facilitating organization-wide changes in practice delivery. In addition, advanced nursing practice requires political skills, systems thinking, and the business and financial acumen needed for the analysis of practice quality and costs. The DNP program prepares the graduate to: 1. Develop and evaluate care delivery approaches that meet current and future needs of

patient populations based on scientific findings in nursing and other clinical sciences, as well as organizational, political, and economic sciences.

2. Ensure accountability for quality of health care and patient safety for populations with whom they work.

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a. Use advanced communication skills/processes to lead quality improvement and patient safety initiatives in health care systems.

b. Employ principles of business, finance, economics, and health policy to develop and implement effective plans for practice-level and/or system-wide practice initiatives that will improve the quality of care delivery.

c. Develop and/or monitor budgets for practice initiatives. d. Analyze the cost-effectiveness of practice initiatives accounting for risk and

improvement of health care outcomes. e. Demonstrate sensitivity to diverse organizational cultures and populations,

including patients and providers. 3. Develop and/or evaluate effective strategies for managing the ethical dilemmas

inherent in patient care, the health care organization, and research.

Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice Scholarship and research are the hallmarks of doctoral education. Although basic research has been viewed as the first and most essential form of scholarly activity, an enlarged perspective of scholarship has emerged through alternative paradigms that involve more than discovery of new knowledge (Boyer, 1990). These paradigms recognize that (1) the scholarship of discovery and integration “reflects the investigative and synthesizing traditions of academic life” (Boyer, p. 21); (2) scholars give meaning to isolated facts and make connections across disciplines through the scholarship of integration; and (3) the scholar applies knowledge to solve a problem via the scholarship of application (referred to as the scholarship of practice in nursing). This application involves the translation of research into practice and the dissemination and integration of new knowledge, which are key activities of DNP graduates. The scholarship of application expands the realm of knowledge beyond mere discovery and directs it toward humane ends. Nursing practice epitomizes the scholarship of application through its position where the sciences, human caring, and human needs meet and new understandings emerge. Nurses have long recognized that scholarly nursing practice is characterized by the discovery of new phenomena and the application of new discoveries in increasingly complex practice situations. The integration of knowledge from diverse sources and across disciplines, and the application …