Doctor of Nursing Practice (DNP): My Personal Pro's and Con's

[Corey Narry]

The Doctor of Nursing Practice or DNP degree has been one of the biggest buzzwords in Advanced Practice Nursing. The mere mention of it creates a stir of emotions and strong opposing opinions perhaps of the same magnitude as the liberal versus conservative views prevalent in our current political climate. Unlike nursing buzzwords that come and go depending on what is en vogue at the moment, current Advanced Practice Nurses (APN's) who hold stronger feelings of opposition rather than agreement with the degree would be foolish to ignore the issue. There are strong indicators that support the argument that this degree is here for good.

For one, Advanced Practice Nursing while a smaller subgroup within the larger nursing milieu has shown tremendous ability to self-regulate and adapt to change. Indeed, the speed at which change have occurred in the APN environment is astonishing. The Nurse Practitioner movement, for instance, borne out of an idea in the 1960's, have now blossomed into a membership of more than 180,000 professionals (Pearson Report, 2011). In that period of time, Nurse Practitioner (NP) training completely transitioned to post-licensure nursing programs leading to a certificate to the current graduate degree offerings at the Master's and Doctoral level. The Centers for Medicare and Medicaid Services (CMS) have even kept up with this change and will only grant provider status to NP's who are trained in a graduate degree program.

One can argue that the number of DNP programs have consistently grown in numbers since the first discussion on building a practice doctorate in nursing began in 2002. The American Association of Colleges of Nursing (AACN) lists 139 institutions with DNP programs around the country, roughly 20% of the total number of member institutions totaling 670 (AACN Program List). Twenty percent may seem small but bear in mind that not all AACN member institutions are offering graduate-level programs that have a potential to be transitioned to DNP. Also, the current program list does not include online DNP programs offered by for-profit institutions that have various locations in different states of jurisdiction. My take home message from these data is that while the recommendation for making the DNP a requirement for entry to practice as an APN is farther from becoming a reality by 2015, the pace at which programs are opening up will continue and the degree is here to stay whether we like it or not.

The DNP was just an idea when I finished my training as an Acute Care Nurse Practitioner (ACNP) in 2003. At the time, academic options were clear to me: pursue a Master's degree with my preferred nurse practitioner focus; get certified in the specialty, and voila, I am all set to practice as an ACNP. The option for further academic advancement at the Doctoral level was also very clear: the next step is a PhD or a DNSc both of which have become identical in content. In fact, numerous faculty members encouraged us to consider returning to the halls of the same university (or maybe even another institution) as a PhD student at some point in our career. The idea had a glamorous appeal to it in my mind at the time and I did entertain the thought of following through. Even to this day, I still struggle with the idea and have not come to a conclusion on what the right Doctoral education path to take. What's worse, this whole DNP agenda threw a curveball in my decision-making process.

As an Acute Care Nurse Practitioner since 2004, I have matured and continue to grow professionally in my knowledge and skills as a clinician. I have stayed in the field of Critical Care as an NP since 2005 and have felt this to be my niche early in my career. In my personal quest both for academic advancement and to grow as a healthcare provider, I do not share the sentiments that the ideal MSN to DNP Bridge should be loaded with clinical content by adding so called "residencies". Don't get me wrong, I feel strongly that clinical content could undeniably be improved in the current manifestations of BSN to MSN or BSN to DNP programs for NP's. But I'm being selfish in my personal goals: since I already practice in a heavily patient care-based setting where knowledge and skills already get tested daily, my needs are different. In other words, I do not need a DNP to get a "residency" in Critical Care because I live and breathe in this specialty day in and day out.

DNP courses that deal with leadership, management, the politics of healthcare, and the financial aspect of providing healthcare can be appealing to individuals in my professional level. This is the reason why there already exist multidisciplinary degree options outside of nursing that addressed this content even before the DNP was conceived. I remember a Cardiothoracic Surgeon I knew who went to a prestigious graduate school of business for a Master's degree in Healthcare Administration. The guy had big dreams of being a division chief or a CEO. A nurse manager in one of the units pursued a Master's degree in Nursing Service Administration because she had high hopes of climbing the ladder ultimately as a Chief Nursing Officer one day. Though I consider myself a clinician foremost, a business degree is a must should I decide to pursue a role in administration. That said, I do not think a DNP is necessary if I was to pursue this direction in my career given the other degree options that already exist.

It seems to me like the DNP marketing machine has been trying to convince NP's like me to think that we need a DNP in order to learn from courses that focus on translating research evidence into clinical practice. I find this to be untrue and insulting to currently practicing NP's trained under the Master's degree model who use evidence-based practice in providing care to their patients every day. However, a Capstone Project utilizing Translational Research is a great idea in itself and though such an activity can be accomplished outside of academia, the DNP student who conducts this endeavor is provided with structure and mentoring from experts in any field of inquiry they are interested in. This particular aspect of the DNP convinces me of the value in getting this degree.

The last argument I have been trying to contend with is the DNP's future in terms level of acceptance in academic roles in schools and colleges of nursing. There has not been a straight answer on how universities determine academic ranking for DNP-prepared faculty as this continue to vary depending on the institution. In the years I've been at the bedside as a nurse and as an Advanced Practice Nurse, I have acquired a great deal of past experiences and lessons learned that are worthy of being passed on to new generations of nurses who wish to follow the path I took. A role in the academia, though not attractive at the present given the low earning potential, is inevitable in my future. However, I seek assurance that the degree I pursue is held at the highest regard in terms of advancement in the field of nursing education. It is still tempting to forego the DNP for the much respected PhD in Nursing.

[Corey Narry, MSN, RN, NP]

I think it's such a damaging proposition to speak of the DNP as a degree that focuses on "translation of existing evidence to improve patient outcomes" in the face of an APRN majority who do not hold this degree at the present time. I sure hope that the current crop of practicing NP's prepared at the Master's level all practice using current evidence. Saying that a DNP is needed for an NP to learn translational research in clinical practice provides further ammunition for physician lobbyists who have attacked our field citing "weak educational preparation".

[DNP_FNP]

juan de la cruz said:

I think it's such a damaging proposition to speak of the DNP as a degree that focuses on "translation of existing evidence to improve patient outcomes" in the face of an APRN majority who do not hold this degree at the present time. I sure hope that the current crop of practicing NP's prepared at the Master's level all practice using current evidence. Saying that a DNP is needed for an NP to learn translational research in clinical practice provides further ammunition for physician lobbyists who have attacked our field citing "weak educational preparation".

The DNP is not just about developing the skills to translate research into clinical practice. I apologize for failing to clarify this in my previous post. It was created for a variety of reasons, one of which is to better equip NPs for scientific inquiry and research (including data collection, analysis, and dissemination). It was additionally designed to add clinical time for residency (especially useful for the BSN-DNP tracks), improve global system assessment skills and communication, improve leadership skills, add knowledge of clinical informatics, improve healthcare policy and networking skills, and enhance collaborative interprofessionalism. The professional bodies created this degree in response to an Institute of Medicine report citing the aforementioned skills as lacking in health professions curriculum--including nursing. It made sense (to them) to move toward a doctorate if these skills were to be mandated in an already packed master's program. They also felt that it would provide increased parity with other fields.

Rather than discredit the nursing governing bodies, I applaud them for trying to develop a degree that gives us parity with other professionals in our field--pharmacists have a doctorate, physical therapists have a doctorate, occupational therapist have a doctorate. Is having a doctorate in these fields as the level of entry any more ridiculous than requiring one for advanced nursing? Perhaps. I personally think that the entire nation suffers from "credential creep" in most regards, but the profession of nursing has to keep up with what other health professionals are doing or risk even further demerit.

In my humble opinion, the field of nursing has caused most of its own problems in educational standards because we have a variety of different ways to attain one degree. For example: diploma nursing, associate degree nurse, bachelor degree nurse, master's NP, doctoral NP, PhD, DNSc. No other field does this. There should only be one, standardized route. Our political stance would surely be strengthened if there was only ONE way to be a nurse or advanced practice nurse--perhaps we could stop fighting amongst ourselves and put our positive energies into proving that we are excellent providers of health.

In my opinion, that is one of the reasons why many lobbying physicians consider us to have "weak educational preparation". The other reason is obvious--physicians will always maintain that anything less than a "doctor of medicine" is weak educational preparation. Sadly, physicians should not be threatened and nurse practitioners should not try to be threatening. We all need to work together to provide good health outcomes. Nurse practitioners are certainly not physicians. We do have very different backgrounds and physicians do have the greatest knowledge base when it comes to science. That is just fact. Nurse practitioners do not, however, have weak educational preparation. Saying that something is "weak" suggests that you are comparing it to an accepted standard--but nurses aren't physicians. If we start adding physician curriculum into NP preparation, we might as well just go to medical school because the time to required to graduate as an NP would be just about as long. That being said, the DNP does not really change your scope of practice as a nurse practitioner but it will change the way you think about practice.

[Corey Narry, MSN, RN, NP]

DNP_FNP said:

The DNP is not just about developing the skills to translate research into clinical practice. I apologize for failing to clarify this in my previous post. It was created for a variety of reasons, one of which is to better equip NPs for scientific inquiry and research (including data collection, analysis, and dissemination). It was additionally designed to add clinical time for residency (especially useful for the BSN-DNP tracks), improve global system assessment skills and communication, improve leadership skills, add knowledge of clinical informatics, improve healthcare policy and networking skills, and enhance collaborative interprofessionalism. The professional bodies created this degree in response to an Institute of Medicine report citing the aforementioned skills as lacking in health professions curriculum--including nursing. It made sense (to them) to move toward a doctorate if these skills were to be mandated in an already packed master's program. They also felt that it would provide increased parity with other fields.

Rather than discredit the nursing governing bodies, I applaud them for trying to develop a degree that gives us parity with other professionals in our field--pharmacists have a doctorate, physical therapists have a doctorate, occupational therapist have a doctorate. Is having a doctorate in these fields as the level of entry any more ridiculous than requiring one for advanced nursing? Perhaps. I personally think that the entire nation suffers from "credential creep" in most regards, but the profession of nursing has to keep up with what other health professionals are doing or risk even further demerit.

...and the current manifestation of the NP Master's program do not offer these? I have 6 graduate credits in Research, 3 graduate credits in Health Care Policy, Business, and Professional Adjustment Issues, 3 graduate credits in Theories and Concepts of Stress and Coping in Acute Illness in my Master's degree ACNP program. I'm not in the camp that complains about these courses - they are helpful to a future provider but adding more to these in a BSN to DNP program is completely unnecessary.

As far as I can tell from looking at current DNP programs, the additional clinical time that was intended initially never materialized. The bottomline for me is that nursing tried to achieve degree parity with other healthcare professions but wanted it all by adding equal parts of all the IOM recommendations without addressing the pressing need for more clinical content that many graduates of NP programs self-admit is true.

DNP_FNP said:

In my humble opinion, the field of nursing has caused most of its own problems in educational standards because we have a variety of different ways to attain one degree. For example: diploma nursing, associate degree nurse, bachelor degree nurse, master's NP, doctoral NP, PhD, DNSc. No other field does this. There should only be one, standardized route. Our political stance would surely be strengthened if there was only ONE way to be a nurse or advanced practice nurse--perhaps we could stop fighting amongst ourselves and put our positive energies into proving that we are excellent providers of health.

...and the DNP added a layer to that power struggle in the nursing profession to justify one camp over another as we are doing now. Was that a completely necessary consequence of our quest to achieve parity with other healthcare professionals? perhaps, but the planning and the fleshing out of an actual product (the DNP) could have been arrived at in much better ways than what we have done so that the choice between MSN and DNP is easier to make.

DNP_FNP said:

In my opinion, that is one of the reasons why many lobbying physicians consider us to have "weak educational preparation". The other reason is obvious--physicians will always maintain that anything less than a "doctor of medicine" is weak educational preparation. Sadly, physicians should not be threatened and nurse practitioners should not try to be threatening. We all need to work together to provide good health outcomes. Nurse practitioners are certainly not physicians. We do have very different backgrounds and physicians do have the greatest knowledge base when it comes to science. That is just fact. Nurse practitioners do not, however, have weak educational preparation. Saying that something is "weak" suggests that you are comparing it to an accepted standard--but nurses aren't physicians. If we start adding physician curriculum into NP preparation, we might as well just go to medical school because the time to required to graduate as an NP would be just about as long. That being said, the DNP does not really change your scope of practice as a nurse practitioner but it will change the way you think about practice.

You are preaching to the choir here. Most of the readers of this thread are NP's or other types of APRN's or nurses interested in becoming any of the APRN specialists.

[PG2018]

The DNP does not add parity. Perhaps you have never examined the curricula of doctoral physician, pharmacist, dentist training, et al.

Like it or not, physicians are at the pinnacle of healthcare. Their education does not include doctoral training in leadership, systems, or anything similar.

To say you are as clinically prepared as someone with a degree in medical science with three plus years of residency training in a specialty is to get you laughed from a room. To be judged as equal, which won't happen, we must enter the race as well prepared clinicians, and although we manage somehow our raining is largely a disservice to our cause.

[RN-APNstudent]

Every time I try and find a good article/posting about DNP, all I seem to come across is MSN prepared NP's showing nothing but negativity towards the idea of NP's being doctorate prepared. It's very disappointing that I cannot read a good conversation on here, without the few NP's (or soon to be) explaining why the DNP is just so awful and unnecessary. There has been talk for years that the DNP will soon be entry level for those pursuing advanced practice nursing, and I understand that may be threatening to some who are already in the field or in the MSN program. What I do not understand though is why it has to be a competition- we are all in this field for the same reasons. The doctorate in nursing practice program may not be perfected at this point, and everybody understands that. But if people wishing to pursue advanced nursing feel that they will be better secured in their field by going ahead and obtaining a doctorate before its required (if and when) - and they wish to pursue higher education- then why are people being so hateful towards it!? If you don't agree with what a doctorate program for nurses has to offer- then simply don't do it!!!!

[IsabelK]

I have a DNP. I do feel that it has provided me with a much greater depth of understanding about both my clinical practice and how to look at research and use it effectively. No academic program is perfect but I have few complaints about mine.

Physicians are not the pinnacle of health care. They are members of a larger team of providers. They are one profession in a myriad number of players. Physicians must stop seeing themselves as the kings of the moutain and nurses must present a united front.

I would also question why any nurse who is as negative about our profession as some participants are here became nurses.

I worked hard for my credentials. And yes I am Dr. Nurse.

[CraigB-RN, MSN, RN]

I'd have to ask were you an NP already when you got your DNP or did you have a "generic" MSN?

[RN-APNstudent]

IsabelK I love everything about your post!!!

[IsabelK]

CraigB-RN said:

I'd have to ask were you an NP already when you got your DNP or did you have a "generic" MSN?

I went from ASN/RN to BSN to MSN/ANP to DNP.

I have been an ANP, and board certified, for 4 years. Worked for 2 years as a night hospitalist, then switched to days in consulting/primary care (we do either in my office) and went back to school. My ANP program was not as hard as my DNP program.

[IsabelK]

RN-APNstudent said:

IsabelK I love everything about your post!

Thank you.

[Jules A, MSN]

RN-APNstudent said:

Every time I try and find a good article/posting about DNP, all I seem to come across is MSN prepared NP's showing nothing but negativity towards the idea of NP's being doctorate prepared. It's very disappointing that I cannot read a good conversation on here, without the few NP's (or soon to be) explaining why the DNP is just so awful and unnecessary. There has been talk for years that the DNP will soon be entry level for those pursuing advanced practice nursing, and I understand that may be threatening to some who are already in the field or in the MSN program. What I do not understand though is why it has to be a competition- we are all in this field for the same reasons. The doctorate in nursing practice program may not be perfected at this point, and everybody understands that. But if people wishing to pursue advanced nursing feel that they will be better secured in their field by going ahead and obtaining a doctorate before its required (if and when) - and they wish to pursue higher education- then why are people being so hateful towards it!? If you don't agree with what a doctorate program for nurses has to offer- then simply don't do it!!

I'm not sure why you object to others adding their comments just because they don't support your opinion. No worries because until a DNP presents with more clinical and prescribing knowledge or increases my income I will not do it but that doesn't mean I can't add my opinion on an open forum. At present the "clinical hours"which to my understanding are spent on a "project" is not what I consider clinical hours.

While it is apparent the schools are pushing the DNP, imagine that?, I personally remember the rumblings that LPNs were going to be obsolete as far back as the early 80s and yet they are still working and so are ADNs for that matter. I have absolutely no feeling of being threatened work wise from DNPs because I have a solid background, plenty of connections in my field and the physicians I work for think the DNP is unnecessary given there is no additional focus on pharm or clinical skills. Physicians are imo at the pinnacle of healthcare and they are the ones who hire and work with me.

I do have concerns over the large number of inexperienced new grads both DNP and MS who will be practicing as NPs in upcoming years from the variety of schools that seem to be popping up out of the woodwork. There are great NPs and lousy ones just like physicians but for me I take it personally when it is a NP and think we need to strive to improve our clinical acumen and to me at this time the DNP does not do that in the NP arena. I am not anti-nurse. I loved being a RN and love being a NP. What I am is anti-inexperienced and incompetent NPs especially those who are calling themselves "Dr". Simply put I think our NP education should include more clinical time and more pharmacology hours or mandatory fellowships before we start patting ourselves on the back for elevating our profession.

[RN-APNstudent]

Your concerns seem to be aimed (and maybe should be voiced toward) the decision makers at the board level. As far as LPN and ADN nurses- in my state (Michigan) it's very rare to see LPN's anywhere but nursing homes, and they make considerably less money than RN's. BSN's are also becoming the majority in any acute care hospital, yes they still hire adn's but unless you know somebody or are working on your BSN- good luck. There will always be controversy and differing opinions regarding the different levels of nursing/advanced practice nursing..certain groups will always be bitter toward other groups and that won't ever change.