Practice Made Perfect

A revolution is occurring in the worlds of advanced practice nursing and graduate nursing education. And it’s one that many nursing leaders believe is long overdue.

In October 2004, the American Association of Colleges of Nursing (AACN) issued a landmark position statement endorsing a new type of terminal degree: the Doctor of Nursing Practice (DNP). As the name implies, this new doctoral degree option—unlike the traditional research-focused PhD in nursing—is a practice-focused doctorate designed for advanced practice nurses (APNs), such as nurse practitioners, clinical nurse specialists, nurse-midwives and nurse anesthetists.

Until recently, most practicing APNs received their educational preparation at the master’s degree level. If they then went on to pursue doctoral degrees, it was usually because they wanted to teach and conduct research, rather than focus on clinical practice. But now, AACN and its member educational institutions are calling for moving the level of preparation necessary for advanced nursing practice from the master’s degree to the doctorate by the year 2015.

According to AACN, “the changing demands of the nation’s complex health care environment require that nurses serving in specialty positions have the highest level of scientific knowledge and practice expertise possible. Research. . .has established a clear link between higher levels of nursing education and better patient outcomes. In 2005 the National Academy of Sciences called for nursing to develop a non-research clinical doctorate to prepare expert practitioners who can also serve as clinical faculty. [Our] work to advance the DNP is consistent with this call to action.”

While the DNP is still a relatively new concept, a handful of these programs already existed well before the AACN published its position statement. The association notes that the first such program was established in 1979 at Case Western Reserve University in Cleveland, Ohio. Other early DNP programs were offered by the University of South Carolina, the University of Colorado, Rush University, the University of Kentucky and other institutions.

At last count, 68 schools of nursing across the country currently offer DNP programs, and over 100 more are considering starting them. Most are hybrid programs, blending online learning with classroom time on campus. Others are 100% on-campus programs while a few are completely online.

Raising the Standard

What exactly is the DNP—also known as the practice doctorate in nursing—and how does it differ from the PhD? According to AACN, the practice doctorate is designed to prepare graduates for the highest level of nursing clinical practice by enhancing their skills in areas that will improve patient outcomes, such as evidence-based practice, quality improvement and systems thinking. The DNP also teaches APNs the business skills they need to successfully manage their practice and prepare for leadership careers that support clinical practices, like organizational management and health care administration.

The AACN made its decision to advocate for a higher standard of educational preparation for advanced practice nurses after commissioning a task force to study the issue. One of the key benefits of the DNP is that it raises APNs to the same level as other clinical practitioners, explains Jeanette Lancaster, PhD, RN, FAAN, immediate past president of AACN and the Sadie Heath Cabaniss professor and dean at the University of Virginia School of Nursing.

“Dentists, pharmacists and other [clinical] professionals have terminal degrees that are doctorates, [such as DDS, PharmD, etc.],” she points out.

“In nursing, the curriculum has been moving to a higher level, even though [advanced practice] nurses still graduate on the master’s level,” Lancaster continues. “To meet the demands [of today’s health care environment], additional courses were added, [to the point where] many master’s programs in nursing required 50 hours of coursework. The fact was that [the nursing profession] was giving a master’s degree for the same amount of work that earned a doctorate degree in many other disciplines.”

Does this mean that if you are already an advanced practice nurse, you will be required to go back to school and earn a DNP degree? No, says AACN. Although the profession is preparing to transition to the DNP by 2015, current APNs holding only a master’s degree will be allowed to continue their practice as long as state laws do not change. Individual state legislatures or state boards of nursing could mandate that clinical practitioners hold a DNP, but so far no states have introduced such proposals. And master’s degrees in nursing will still be available after 2015, although their focus may change as more institutions begin offering the DNP.

Nevertheless, Lancaster believes many current master’s-prepared APNs will choose to enhance their professional credentials by earning a practice doctorate. “I think a lot of [them] will go back [to school to get their DNP],” she says. “Any time the profession moves the standard to a higher level, nurses want to get that. Many [APNs] could attend part-time [so that they can still devote time to their practice].”

DNPs for Educators

One minority advanced practice nurse who did go back is Michael E. Zychowicz, DNP, RNFA, NP-C, FAANP. He was also one of the earliest, earning his DNP in 2006 from Case Western Reserve University’s Frances Payne Bolton School of Nursing. And he is also one of a surprisingly large number of DNP graduates who hold positions as nursing faculty.

Zychowicz is a nurse practitioner who maintains a private practice. But he is also an associate professor at Mount Saint Mary College in Newburgh, N.Y., where he teaches nursing and nurse practitioner courses. Why did he choose the practice doctorate as his terminal degree instead of the more traditional PhD? The answer is simple: He wanted a doctoral degree that would benefit both aspects of his career.

For More Information To learn more about the Doctor of Nursing Practice degree, visit the DNP section of the American Association of Colleges of Nursing (AACN) Web site at www.aacn.nche.edu/DNP. There you’ll find: • The complete AACN Position Statement on the Practice Doctorate in Nursing. • The DNP Roadmap Task Force Report, which outlines the process for transitioning the level of preparation necessary for advanced nursing practice from the master’s degree to the DNP by the year 2015. • A list of nursing schools that offer Doctor of Nursing Practice programs. • Answers to frequently asked questions (FAQs) about the DNP.

“I am a full-time educator, so I had to get a terminal degree as part of my obligation to teach. At that time, I had to do a lot of reflection on what my professional career goals were. I had to decide which one of all the different terminal degree options was the best for me,” Zychowicz says. “After I researched the options, I felt the DNP was in alignment with my goals to continue both teaching and being an advanced practice nurse. The courses helped me both as an educator and a clinician.”

Another attractive benefit of the DNP, he adds, was that “the program recognized the work that I had already done on my master’s and the level I had already achieved. That’s somewhat different from the structure of a PhD. Typically, PhD programs do not recognize any [previous] courses you have completed. Students start from square one.”

Zychowicz says the program at Case Western Reserve offers a choice of two tracks to the DNP for candidates who already hold a master’s degree. One is designed for clinical leaders and the other for educational leaders.

“I chose to go through the clinical leadership track because I am teaching clinicians,” he explains. “The program included several research courses. These were doctoral-level research courses that prepared me for my dissertation. The curriculum also had courses geared toward practice management issues.”

Zychowicz attended the hybrid program “just short of full time.” Some classes required him to travel to Cleveland to attend intensive week-long sessions on campus with follow-up study online. As more students from the New York area began to enroll in the program, the university actually sent a professor to New York to teach the class.

Although Zychowicz completed his program in three-and-a-half years, the amount of time it takes to earn a DNP degree varies, depending on such factors as the structure of the program, whether students attend full or part time, and whether or not students already have master’s degrees and experience as clinical practitioners. A number of schools offer a fast-track BSN-to-DNP option, which takes longer to complete than a stand-alone DNP program, but does have the advantage of getting minority nurses into the DNP pipeline sooner.

“From a clinical perspective, I think if I had entered into the DNP program right after earning my bachelor’s degree, it would have allowed me to enter practice at a more advanced level,” Zychowicz believes.

How does he weigh the benefits now that he’s earned his practice doctorate? “It has enhanced my research level,” he says. “The DNP also gives me more visibility [in the practice setting]. Now, I have a doctoral degree. People don’t just call me Mike. They call me Dr. Zychowicz. It gives an implied respect within the clinical arena.”

Choosing a DNP Program

With more and more nursing schools adding practice doctorates to their graduate-level offerings, students have a wide variety of DNP programs to choose from. Zychowicz, for example, interviewed with one school where the DNP was designed to train nurses for hospital administration positions. Some DNP programs have clinical specialty options, such as pediatrics or geriatrics. And a growing number of DNP programs—such as those at the University of Washington School of Nursing, the University of South Alabama College of Nursing and Thomas Jefferson University—have courses or entire concentrations that focus on cross-cultural health and providing care to medically underserved populations.

How do you decide which type of program will best meet your needs—or if a DNP degree is even right for you in the first place?

“Students really need to think about what they want to be in their career,” Lancaster answers. “When [the University of Virginia] started [our] DNP program last August, many students were asking, ‘Do you think I should get a DNP or a PhD?’ Both are positive moves, but that choice really depends on what you want to do. If you want to spend your career in funded research, then you definitely need to get the PhD. If you are committed to clinical practice and you enjoy teaching and direct patient care more [than research], you may want to get the DNP.”

Because most educational institutions prefer to hire faculty who are doctorally prepared, earning a DNP would enable more APNs with an interest in teaching to attain faculty positions. Not every nursing school is a research-focused school that requires tenured faculty members to produce new research, Lancaster points out.

“Even research institutions have a percentage of faculty who are highly prepared master’s-level nurses,” she adds. “In the future, these will be DNPs.”

Zychowicz strongly advises nurses who are shopping around for a DNP program to visit several campuses. As you’re being interviewed, he says, take the opportunity to interview the school as well. “[Look at] how the program will fit your individual goals. Look at the courses offered. I would ask [admissions committees] how they think the program would help me meet my career goals.”

Because many recently established DNP programs are still so new, accreditation procedures are just beginning and most programs have few or no alumni to speak with. Therefore, prospective students may have to do a little extra research to determine the quality of various programs. If the nursing school is fully accredited, chances are the DNP program will also be accredited.

One way to assess whether or not a particular DNP program would be a good fit for you is to look at the faculty, says Zychowicz. “Do some research on the faculty members. Find out what their background is. Does that background fit well with the goals you have as a student? Just looking at the faculty can be very interesting. Some faculty members are really the quiet heroes of nursing and those are the ones you want to find.”

For many students, however, the choice may come down to simple logistics. Where is the program located? Is a part-time or online program available? How long does it take to complete the program? And, because graduate school tuition can be expensive, how much does it cost?

DNP vs. PhD

For APNs whose careers are focused solely on clinical practice, there’s no question that earning a DNP will help them advance to a higher level of responsibility and professional respect. But for those who, like Zychowicz, want to balance their careers between practice and teaching, the degree may have one possible disadvantage, Lancaster cautions. Even though the practice doctorate is designed in part to train APNs to become clinical faculty, DNP-prepared educators may finder it harder to land tenure-track positions than those who have PhDs.

Zychowicz admits to experiencing some prejudices when he was interviewing for teaching positions. “Many institutions may not fully accept the DNP as being equal to the PhD,” he explains. “[During one interview,] I did have some concerns about how they viewed the degree and my ability to do research. I have done research, both in my teaching position and in my doctoral program. Still, it was questioned.”

Those doubts will begin to subside, Zychowicz believes, as the nursing profession becomes more familiar with the concept of the practice doctorate. If you look at the content and rigor of DNP curricula, he argues, it is very similar to that of other terminal degrees. The word just needs to spread among educators.

“As more is known about the degree and as more universities have a DNP program in place, attitudes will change,” Zychowicz says. “After all, who is going to teach the DNP students? As more DNPs graduate and become both educators and practitioners, the [bias against DNPs] will go by the wayside.”