Essentials of Doctoral Education for Advanced Medical Practice

Essentials of Doctoral Education for Advanced Medical Practice

Essentials, Doctoral, Education, Advanced, Medical, Practice

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.

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;

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)

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 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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