The Need for Advanced Clinical Education for Nurse Practitioners Continues Despite Expansion of Doctor of Nursing Practice Programs

We read with great interest Mundinger and Carter’s exposition of how, in their view, Doctor of Nursing Practice (DNP) education has lost its way and what consequences might result. In “Potential Crisis in Nurse Practitioner Preparation in the United States,” they note that the DNP arose to address the demand for more deeply skilled nurse practitioners (NPs) ready to respond proactively to a rapidly changing health care environment and the complex care needs with which patients present (Mundinger & Carter, 2019). Mundinger and Carter (2019) argue that these new NP skills were meant to be primarily clinical, yet, as of 2018, only 15% of DNP programs focus on providing advanced clinical training, while the overwhelming majority focus on administration and leadership. Mundinger and Carter attribute the growth in this nonclinical focus to an ill-advised decision by the American Association of Colleges of Nursing (AACN) to define nursing practice to include both nonclinical and clinical care. The consequences, they argue, are very concerning for the future of NP education, especially clinical doctoral education.

We share the concern of Mundinger and Carter (2019) about the future of NP education within the context of expanding DNP programs. DNP programs clearly can be an appropriate and desirable vehicle for producing NPs with advanced clinical training. But, despite the continued expansion of DNP programs, the need for expanding advanced clinical training for NPs continues.

Despite the proliferation of DNP programs across the country, there is almost no evidence that their output has led to any appreciable impact on the quality of care delivered by NPs (Auerbach et al., 2015; Avery & Howe, 2007; Berkowitz, 2014; Burman et al., 2009; Paplham & Austin-Ketch, 2015; Pritham & White, 2016). This is not surprising given that so many of the DNPs programs are not clinically focused. To the contrary, there seems to be some limited evidence that, in fact, NP programs are not meeting the need for NPs with more advanced clinical training. There are relatively few studies examining the NP readiness for practice out of educational programs, but the extant literature suggests that there a number of challenges including a lack of perceived readiness to practice, reported knowledge gaps, clinical skills gap, and role ambiguity (Faraz, 2016; MacKay, Glynn, McVey, & Rissmiller, 2018). We know very little about the role of DNP-prepared NPs in clinical practice and if they are even being used differently than masters-prepared NPs (Beeber, Palmer, Waldrop, Lynn, & Jones, 2019).

This is especially troubling as an increasing number of NPs are entering specialty practice. While the NP role was originally conceived to help fill primary care needs in vulnerable communities (Safriet, 1992; Silver, Ford, & Day, 1968), research shows that NPs are increasingly entering specialty and subspecialty practices (Martsolf et al., 2018; National Center for Health Workforce Analysis, 2014). The proportion of specialty physician practices employing advanced practice providers including NPs grew by 22% between 2008 and 2016 (Martsolf et al., 2018). By 2025, an estimated 30% of all nonprimary care clinicians are expected to be advanced practice nurses, including NPs, up from 19% in 2010 (National Center for Health Workforce Analysis, 2014). Currently, the vast majority of NPs have graduated from family NP programs and are certified as family NPs (AACN, 2018; American Association of Nurse Practitioners, 2019). These family NPs are increasingly migrating to specialty practices without commensurate training that DNP programs could provide. Yet, DNP programs are doing relatively little to respond to this need.

Health systems administrators, in contrast, are acting on this need as they are continuing to develop and expand NP residency and fellowship programs in both primary care and specialty practice (Martsolf, Nguyen, Freund, & Poghosyan, 2017). NP residency and fellowship programs are generally designed as compensated, 12-month post-NP licensure programs offering hands-on clinical experiences in population-based focus and specialty practice areas (MacKay et al., 2018). A recent study that identified 70 such programs across the country found them focused on helping both new NPs transition into primary care and specialty practice and experienced NPs transition into new specialty areas (Martsolf et al., 2017). The vast majority of these programs are organized and administered by delivery system actors such as academic medical centers and community health centers (Martsolf et al., 2017). Thus, it is the health systems that are in fact responding to the need for advanced clinical preparation. Nursing schools, on the other hand, as Mundinger and Carter (2019) argue, have doubled down on creating nonclinically-focused DNP programs.

Fifteen years after the AACN position statement on the clinical doctorate was issued, the goal of DNP education remains an unfinished project (AACN, 2004). The DNP degree is providing future NPs with advanced skills in quality improvement, practice management, information technology literacy, and leadership; they are giving them a toolkit for advancing quality practice and becoming leaders in health system change. One would think that the demand for NPs with these skills would be significant given the growth in value-based payment models and outcomes accountability affecting clinical practice (Nichols, O’Connor, & Dunn, 2014). Only time will tell. However, the system-wide demand for NPs with greater clinical breadth and depth is unequivocal. Can, will, and how should DNP programs deliver?