Abstract
The goal of Doctor of Nursing Practice (DNP) education is to prepare advanced practice nurse leaders for the practice setting. Accordingly, it is imperative that DNP education is grounded in nursing theoretical knowledge. The purpose of this project was to examine the presence of nursing theoretical knowledge within DNP programs across the United States. A retrospective approach was used to review publicly available information on the webpages of a sample of DNP programs accredited by the Commission on Collegiate Nursing Education (CCNE) to determine if nursing theoretical knowledge guided DNP programs. Demographic information was also collected. A sample of 100 CCNE accredited programs revealed a lack of nursing theoretical knowledge visible within DNP programs. It is unclear how DNPs are being prepared to be practice leaders guided by nursing theoretical knowledge. Nursing leaders must develop policies to assure that nursing knowledge is core in DNP programs.
In the past 15 years, the number of Doctor of Nursing Practice (DNP) programs in the United States has increased from just a handful in 2004 to 354 in 2019 (American Association of College of Nursing [AACN], 2019a). Four drivers fueled movement to advance the DNP: (a) need for educational parity with other healthcare professionals (MD, DDS, PharmD, PsyD, DPT), (b) recognition that the length/credit requirements for advanced practice programs in nursing approached doctoral credit requirements in other disciplines, (c) potential for DNP-prepared clinicians to serve as clinical faculty as a solution to the nursing faculty shortage, and (d) demand for increased knowledge, creativity, and critical thinking skills to negotiate the accelerating changes in healthcare (Marion, O’Sullivan, Crabtee, Price, & Fontana, 2005).
The Institute of Medicine (2009) suggested that to achieve the competencies required of the healthcare professionals of the future, knowledge from many disciplines are required. Most importantly, health professionals must bring their unique perspective and knowledge base from the discipline they represent to the patient care situation. Given the goal of educational parity and that the role of the DNP is to implement the science developed by nurse researchers prepared in PhD, DNS, and other research-focused nursing doctorates, it is imperative that the DNP curricula be grounded in the knowledge of the nursing discipline as is the case with other practice doctorates for which nursing seeks parity such as medicine, law, pharmacy, psychology and physical therapy.
However, it is also important that there is clarity about what is meant by nursing knowledge. The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006) describes nursing knowledge as having a foundation in the natural and social sciences and informed by many disciplines. However, some have critiqued the DNP essentials because of this focus from disciplines outside nursing such as theories and concepts related to organizational and systems development and change, improvement science, collaboration, epidemiology and public health, policy development and advocacy, technology, and diffusion of innovation rather than on scientific underpinnings or the practice of the discipline (Donohue-Porter, Forbes, & White, 2011; Smith, 2019; Smith & McCarthy, 2010). As such, other scholars in nursing suggest that while nurses may be adept at understanding the knowledge of other disciplines, nursing knowledge itself offers a unique disciplinary perspective that is core to the practice of nursing. This nursing knowledge is comprised of nursing philosophies and theories at all levels (grand, middle-range, and situation-specific practice theories), the research related to those theories, and nursing theory-guided practice.
Nurses who are practicing from a nursing disciplinary perspective must be prepared to design and implement models of care that consider thinking across nursing theories as suggested by Smith (2019)—that is, person-environment centered, relationship-based, culturally sensitive, and oriented toward well-being and healing. It has been suggested that “what is missing from healthcare is what nursing can provide when practiced from its disciplinary perspective” (Newman, Smith, Pharris, & Jones, 2008, p. E25). For DNPs to have a voice at the interdisciplinary table, the DNP curriculum needs to be grounded in the disciplinary perspective of nursing so that theories and other knowledge of nursing informs and is translated into advanced nursing practice. As such, the focus of this inquiry was to examine the presence of nursing theory in the mission and vision statements, curricula, and program outcomes of publicly available web pages in a sample of DNP programs across the United States.
Background
The AACN developed curriculum standards for the DNP, The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006). The focus of the curriculum is as follows: “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” (AACN, 2006, p. 3). The DNP essentials include the “foundational competencies that are core to all advanced nursing practice roles” (AACN, 2006, p. 8). In addition, specialty “competencies, content and practicum experiences needed for specific roles in specialty areas are delineated by national specialty nursing organizations” (AACN, 2006, p. 8). Essential II, Organizational and Systems Leadership for Quality Improvement and Systems Thinking underscores the expectations that DNP graduates advance nursing practice through systems leadership focusing on practice, improving health outcomes, and making patient safety a top priority (AACN, 2006). As leaders they are expected to provide care and to translate nursing philosophical, theoretical, and empirical knowledge into practice to improve the health of populations.
The essentials were built upon a generalist foundation in nursing attained through the baccalaureate or entry-into-practice master’s degree in nursing. The curricular path for the DNP differs depending on whether the student has a baccalaureate or master’s degree in nursing. For this reason, there are two curricular pathways: the postbaccalaureate and the postmaster’s options. There are eight essentials: (a) Scientific Underpinnings for Practice, (b) Organizational and Systems Leadership for Quality Improvement and Systems Thinking, (c) Clinical Scholarship and Analytical Methods for Evidence-Based Practice, (d) Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care, (e) Health Care Policy for Advocacy in Health Care, (f) Interprofessional Collaboration for Improving Patient and Population Health Outcomes, (g) Clinical Prevention and Population Health for Improving the Nation’s Health, and (h) Advanced Nursing Practice (AACN, 2006). Through the elaboration of these eight areas, curricular standards are set for DNP programs throughout the United States (AACN, 2006). The first and eighth essentials, scientific underpinnings for practice and advanced nursing practice, are specific to nursing knowledge and, as such, must be foundational for the DNP curriculum. AACN is in the process of revising the essentials. At the time of this publication, proposed changes by the Essentials Task Force have been unveiled and public comment is being considered (AACN, 2020).
Nursing Theoretical Knowledge and DNPs
Smith and McCarthy (2010) suggested the narrative related to the first essential (AACN, 2006) includes references to nursing science, middle-range theories, and concepts to guide nursing practice. Specifically, one competency is to “develop and evaluate new practice approaches based on nursing theories and theories from other disciplines” (AACN, 2006, p. 9). While these references are encouraging, in the totality of the first essential, the predominant focus is on knowledge from other disciplines, “natural and social sciences.” There is very little reference to the growth in nursing theories or nursing science, whereas the emphasis on the growth of knowledge in other areas such as genetics and genomics is emphasized (Smith & McCarthy, 2010, p. 49). DNP graduates are being prepared as leaders, advanced practice nurses, and practice scholars and as a result must be prepared with knowledge of the ontology, epistemology, and praxis of the nursing discipline (Smith & McCarthy, 2010, p. 46). This knowledge provides the unique perspective of the discipline related to human wholeness, person-environment-health interrelationships, health as well-being, well-becoming, and human flourishing in living and dying, and caring-healing relationships (Newman et al., 2008; Smith, 2019; Willis, Grace, & Roy, 2008).
Donohue-Porter et al. (2011) agree that the essentials offer a lesser focus on the knowledge of the discipline of nursing and instead focus on quality, safety, and evidence-based practice and policy. They argued that this content, while important, has lessened and eclipsed the inclusion of nursing theory within nursing curricula. Furthermore, they warned that advanced practice curricula are “moving alarmingly closer to a medical model of practice” (Donohue-Porter et al., 2011, p. 5) and that practice models developed from nursing theory can differentiate nursing practice from medical practice. Finally, they stated that the primacy of evidence-based practice has reduced nursing actions to a “narrow form of empirics” (Donohue-Porter et al., 2011, p. 5). This suggested the need for inclusion of multiple epistemologies within DNP curricula.
Milton (2005) argued that the advanced study of practice within a discipline requires the study of discipline-specific theories and frameworks incorporating philosophical principles and concepts that guide practice (p. 114). “The structure of nursing theories guides nursing’s use of knowledge, research and practice approaches” (Milton, 2005, p. 115). While many supporting the need for a practice doctorate often asserted that important content missing from curricula in advanced practice was practice management, health policy, information technology, risk management, evaluation of evidence, and advanced diagnosis and management, few acknowledged the expansive work on nursing theory-guided practice and the differences these models have made in health and quality of life. It is essential for those pursuing the practice doctorate to build on the basic knowledge of nursing theory in order to develop and test nursing theory-guided practice models.
Burman et al. (2009) reasoned that the increased knowledge for advanced practice in the DNP programs needed to be focused on theory and research from nursing rather than shared content of assessment, pharmacology, pathophysiology, diagnosis, and treatment of disease. They emphasized the importance of an intensive focus on the disciplinary core of health promotion.
In clarifying the difference between the DNP and PhD, AACN stated that the practice doctorate would have less of a focus on theory and metatheory (Fulton & Lyon, 2005). Some (Arslanian-Engroren, Hicks, Whall, & Algase, 2005; Whall, 2005) have asserted that the DNP as proposed could disconnect nursing practice from its metatheoretical and theoretical roots, leaving it ungrounded in the discipline. “Without a clear definition of our metatheoretical space, we risk blindly adopting the practice values of other disciplines, which may not necessarily reflect those of nursing” (Arslanian-Engoren et al., 2005, p. 315). It is clear that both the PhD and DNP require a deep understanding of nursing theory; the focus of the PhD is on theory development and testing with research, while the focus of the DNP is on the application and testing of theory in practice (AACN, 2006).
Others critique the current education for advanced practice. Meleis and Dracup (2005) assert that DNP programs should offer a reconceptualized model of advanced practice nursing focusing on advancing or translating knowledge and that practice is the core of this knowledge. “All doctoral education must be designed to help define, generate, develop, translate and test the substantive base of knowledge in nursing” (Meleis & Dracup, 2005, p. 4). Without an extensive and intensive study of nursing knowledge within DNP programs, this would not be possible.
Fulton and Lyon (2005) expressed concern that faculty teaching in DNP programs may lack preparation in nursing theory resulting in graduates who will not have a strong foundation in nursing knowledge. These graduates may go on to faculty careers, further exacerbating the problem. The danger is educating a generation of practice leaders without grounding in the knowledge of the discipline.
Trends in DNP Programs
The AACN Reports of Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing (available from https://www.aacnnursing.org/News-Information/Research-Data) reveal a pattern of significant growth in DNP programs in the United States. Between 2008 and 2018 the number of practice-focused doctoral programs nearly quadrupled from 92 to 354. The total enrollment in DNP programs in 2018-2019 was 32,678. From 2014 to 2018 there was an average increase of 3,446 DNP students per year and 959 DNP graduates a year (AACN, 2019a, p. 52). This is in contrast to the number of research-focused doctoral programs, with only a 22% increase in 11 years from 116 to 141. Between 2014 and 2018, there was an average decrease of 104 PhD (research doctorate) students enrolled per year and an average increase of only 21 PhD graduates per year (AACN, 2019a, p. 50). This trend might be viewed as a double-edged sword. The increasing number of doctorally prepared nurses overall is encouraging because we are educating more advanced practice nurses and leaders, at a higher level; however, the decreasing PhD (research doctorate) enrollment is a concern since 80% of these graduates become the academic leaders and researchers of the future (Ketefian & Redman, 2015).
The additional risk of declining research doctorates is a diminished amount of new nursing knowledge developed in PhD programs for translation into the interprofessional practice setting by the leaders in advanced nursing practice, the DNPs.
Table 1 summarizes the AACN survey data of the enrollments and graduations in postbaccalaureate and postmaster’s DNP programs in 2018-2019 (AACN, 2019a). By far, the highest enrollment in the postbaccalaureate DNP programs is in the nurse practitioner concentrations, while the postmaster’s programs enrolled the highest number in the leadership concentration, with the nurse practitioner and unspecified major categories following with about 1,500 fewer enrollees. The unspecified concentration for the postmaster’s is a surprise but is probably indicative of programs preparing students with the DNP Essentials without a focus on a concentration. This contributes to confusion related to the exit competencies of DNP graduates. Nursing administration/management programs enroll about five times the number of students in the postmaster’s DNP programs as compared to postbaccalaureate programs, suggesting that master’s prepared nurse administrators may be selecting DNP programs rather than PhD programs for their doctoral education. Both nurse practitioner and nurse anesthesia students have large enrollments in the postbaccalaureate programs, probably because there is a clear message from AACN, specialty groups, and certifying bodies that the doctoral degree is or will be required for certification.
Enrollment and Graduations in Doctor of Nursing Practice Programs by Major Areas of Study 2018-2020 (AACN, 2019a, p. 83).
Other published data from AACN (2019a), not in Table 1, indicate that the highest enrolled nurse practitioner majors are family NPs in both postbaccalaureate and postmaster’s programs with psychiatric-mental health as the next highest in both. However, it is important to note that for postmaster’s programs, the highest enrollment is in the category of “previously certified as NPs” (AACN, 2019a, p. 84), indicating that most postmaster’s programs are not preparing students with entry-level NP competencies. The split between full-time and part-time enrollment in DNP programs is 54% full-time and 46% part-time. For DNP postbaccalaureate programs, 63% of students are full-time and 37% part-time. In contrast, in postmaster’s DNP programs, 41% of students are full-time and 59% part-time.
Racial-ethnic diversity of graduates of DNP programs is limited. In postbaccalaureate programs, 72% of graduates are White, with only 10% Black/African American, 7% Asian, 5% Hispanic or Latino, and less than 1% American Indian or Alaskan Native. In postmaster’s programs, 65% of DNP graduates are White, with 19% Black/African American, 7% Asian, 4% Hispanic or Latino, and 1% American Indian or Alaska Natives (AACN, 2019a, p. 85).
Distance education is incorporated into both postbaccalaureate and postmaster’s DNP programs. About 40% of postmaster’s DNP programs have between 51% and 99% of the program offered through distance education and about 32% are fully distance-accessible. So nearly 75% of all postmaster’s DNP programs have over half the curriculum offered through distance education. The postbaccalaureate DNP programs utilize distance education less frequently, with 41% offering from 51% to 99% of the curriculum through distance education and only 11.6% fully at a distance (AACN, 2019a, p. 16).
Employment commitment data for PhD and DNP graduates suggest that nearly half (48%) of graduates of research (PhD/DNS) programs are seeking faculty positions, while 8.5% of practice doctorate (DNP) graduates are committed to seeking academic appointments. However, about 42% of graduates of DNP programs indicate that they do not know where they will seek employment or have no employment commitment. Some (Danzey et.al., 2011) have argued that the DNP graduates may be able to shrink the nursing faculty shortages by accepting academic appointments (AACN, 2019b, p. 86). If DNP graduates cannot find employment in the practice sector, it is logical that with the current and predicted nursing faculty shortages, they would apply to open positions in schools of nursing. If this is the case, it is essential DNP education is grounded and that the DNP graduates are well-versed in nursing theoretical knowledge.
Method
This inquiry used a retrospective approach to review publicly available information on the webpages of a sample of DNP programs in the United States accredited by the Commission on Collegiate Nursing Education (CCNE). More specifically, we examined mission and vision statements, the curricula, course descriptions, and completed DNP projects (when accessible) of programs to determine if nursing knowledge guided the DNP programs. Additionally, we collected demographic information related to location (region of country), focus (role or concentration), how the programs were offered, and number of total credits.
Data Collection
As this was a survey of publicly available information, this study did not require institutional review board approval. Using the CCNE-accredited programs list from November 2019, a list of random numbers was used to obtain a sample of 100 programs to review. The only inclusion criterion was that the program was CCNE-accredited. The list of 100 schools was evenly divided so that each member of this team collected the information on 25 schools. Each person on the team used a standardized checklist as detailed in the figure to collect the data to determine if programs included nursing theoretical knowledge as evidenced by what was visible on the programs’ websites. Data collection occurred over 3 months. The team met via conference call three times during data collection to assure that we were all following the same process and to review questions and discuss emerging findings. When there were challenges in either locating or interpreting the information, the team met to review and discuss. For example, if it was not always clear if a program was hybrid or face-to-face, when we met we reviewed the information together and came to consensus over how to categorize the data.
Descriptive information collected on DNP Programs.
Results
The demographic location of each school was readily available and easy to access on the website of all 100 schools. The results of data selection related to demographic location indicated that in this sample the South Region had the largest number of accredited DNP programs with 35 DNP programs, followed by the Midwest Region with 25, North Region with 21, West Region with 13, and the North Atlantic Region with 6 (see Table 2).
Demographic Location of Selected DNP Programs.
The curriculum information of each DNP program was not consistently easy to access on the website of the 100 schools. In fact, for some programs, it was necessary to complete an admission form to obtain this information. The results indicated that 92/100 programs offered postmaster’s DNP programs and 68/100 programs offered BSN to DNP programs. Many programs offered both tracks. The specialties offered ranged from the high of 60 for NP programs to a low of 5 for the CNS specialty. Postmaster’s programs were most typically available as both full-time or part-time, while the BSN to DNP was more often full-time. In terms of format for delivery of the curriculum, 40 programs offered face-to-face instruction, while only 29 offered online programs only, and 31 programs offered a hybrid method for course delivery (see Table 3). There was variation in course credits required for the BSN to DNP ranging from 74-124 credits and postmaster’s DNP total credits ranged from 34-55 credits.
Curriculum Demographics of Selected DNP Programs.
Only 1 out of 100 schools explicitly suggested the program was guided by nursing knowledge and that program’s curriculum was informed by a variety of nursing theories within caring science. Seventeen out of 100 selected DNP programs offered a nursing theory course; two programs had nursing outcomes clearly describing nursing theory. Any course description with nursing philosophy or nursing theory was counted in this category (see Table 4).
Scholarship of Selected DNP Programs.
Discussion and Recommendations
Based on our review of a sample of DNP websites, there is a lack of nursing theoretical knowledge visible within DNP programs. As we reviewed and cross-referenced the DNP essentials, specifically, Essential I, Scientific Underpinnings for Practice, we were concerned about the lack of consistency on how DNP programs applied nursing theory to the education of advanced practice nurses. There were few nursing theory courses; however, theories from leadership, informatics, policy advocacy, and translational sciences seemed to dominate the coursework within programs. It is important to note that in other practice disciplines there is a scaffolding of theory courses and application of theories in practice, with baccalaureate courses offering a survey of theories and doctoral levels focusing on greater depth in application of the theories to guide practice. It is logical to expect that those enrolled in a program preparing nurses for the highest level of practice would be gaining greater depth in the study and application of nursing theories in advanced practice leadership.
The purposes of the AACN (2015) The Doctor of Nursing Practice: Current Issues and Clarifying Recommendations, Report from the Task Force on the Implementation of the DNP was to find patterns and trends in the variability of DNP programs given the explosion of programs and to give guidance for future direction of DNP programs; however, it is not clear that this has been the result. Based on our review, DNP programs build curricula around knowledge and skills from disciplines outside nursing that are then applied in practice. The disciplinary knowledge—that is, knowledge of nursing theories and the research related to them—is not evident. There are only a few programs with any visible content related to nursing knowledge and the difference it makes in outcomes related to health, well-being, and healing.
While in the AACN 2015 White Paper, there was much discussion of the DNP scholarly product from the perspective of what each DNP project should include; the mention of providing a foundation for future practice scholarship was the only possible link to nursing theory-guided practice. We could not obtain information on how nursing knowledge was applied to DNP projects, as only a few programs gave examples of the titles of these projects.
The focus of the courses offered even in clinical DNPs was on leadership, policy, disease prevention, medical management, and quality improvement as suggested by several authors (Donohue-Porter et al., 2011). While DNP programs should produce highly skilled, competent advanced practice nurses, they should also offer a unique nursing perspective complementary to the unique perspective of other healthcare professionals. With the lack of focus on nursing theoretical knowledge evident in the programs reviewed, it is unclear how DNPs are being prepared to be practice leaders consistent with the goals of The Essentials of Doctoral Education for Advanced Nursing Practice. The clarity around the nursing disciplinary perspective of the education is paramount, assuring that nursing knowledge is translated into practice.
Smith and McCarthy (2010) emphasized the need to ground practitioners in nursing science given the “persistent challenge of distinguishing between technical and professional levels of practice” (p. 50). The AACN’s Vision for Academic Nursing (AACN, 2019b) provides direction for future nursing education. There is much emphasis in the vision document on advancing diversity and inclusion in nursing education and practice, transitioning to competency-based education and assessment, and increasing collaboration between education and practice through expanding and more formalized academic-clinical partnerships. Faculty development and career advancement as well as exploring and adopting opportunities for resource efficiencies were also a focus of the vision. It was not evident that nursing practice grounded in nursing disciplinary knowledge was strongly stated as core to the overall vision. This is troubling because if DNP education is not grounded in nursing theoretical knowledge, as was evident in our review of DNP programs, nursing risks losing a unique professional practice and has the potential to become indistinguishable and thus replaceable. Nurse leaders must create policies to assure that DNP programs integrate the application of nursing theories in practice within the curriculum so advanced practice nursing can translate this knowledge into practice. More importantly, these standards are important to gain parity with other health professionals.
The limitations of this study are that we only sampled 100 CCNE-accredited programs. We used the websites to gather publicly available information, and while this generally provided us with information we were seeking for this inquiry, we were able to review only a few DNP projects, which may have reflected an integration of nursing knowledge. Interviews with key stakeholders at the schools of nursing may have provided additional insights not readily available on the webpages and should be the focus of future work.
Conclusion
Our study illuminated the limited focus on nursing knowledge within the curricula of DNP programs. As noted, a critical review of the essentials appeared to focus more extensively on the requisite knowledge from disciplines outside nursing such as theories and concepts of organizational and systems development and change, improvement science, collaboration, epidemiology and public health, policy development and advocacy, technology, and diffusion of innovation. This knowledge is important to the education of all health professionals. However, without an extensive and intensive grounding in nursing knowledge as described by several nurse scholars (Newman et al., 2008; Smith, 2019; Willis et al., 2008), advanced nursing practice, nursing’s distinctive focus on the health, well-being, and quality of life of those we serve, is diminished and our unique professional practice is in jeopardy.
