NEPHROLOGY NURSING JOURNAL ■ November-December 2006 ■ Vol. 33, No. 6 685

Doctor of Nursing Practice: The Time is Now

The American Association of Colleges ofNursing Calls for Requiring the DNP for Entryinto Practice for Nurse Practitioners

I recently enrolled in Doctor of Nursing (DNP) pro-gram at the University of Arizona. During orientation, Ilearned that the amount of healthcare information dou-bles every 5 years. That fact gave me pause as it shouldanyone. We practice in a scholarly environment that ismoving at a mind-numbing speed. The increasing com-plexity of healthcare demands the best possible prepara-tion for licensed independent providers. Accordingly, theAmerican Association of Colleges of Nursing (AACN) hasproposed that the DNP be the terminal clinical degreeoffered in nursing (for the full report, see http://www.aacn.nche.edu/DNP/pdf/DNP.pdf). It is expected to be therequirement for entry into practice for nurse practitionersby 2015. The DNP is a clinical practice degree; it is nei-ther a replacement nor a substitution for the PhD in nurs-ing, which emphasizes development of nurse researchers.The focus of the DNP is to create expert nurse clinicians.

Doctoral Level Education is the Standard forIndependent Healthcare Providers

The AACN is not alone in appreciating the need fordoctoral level education for clinical practice. A clinicaldoctorate has become the standard for many healthcareprofessions that once required MS-level preparation suchas pharmacy (PharmD), physical therapy (DPT), and audi-ology (AuD). The necessity of a doctorate has long beenaccepted in medicine, podiatry, and dentistry. There is nodebate about the need for doctoral level education forphysicians and dentists. Should the bar be any lower fornurse practitioners? The fact is that the call for doctorallevel education for nurse practitioners is also arising fromoutside our profession. In a 2005 report entitled“Advancing the Nation’s Health Needs: NIH ResearchTraining Programs,” the National Academy of Sciencesendorsed the clinical doctorate in nursing stating, “theneed for doctorally prepared practitioners and clinical fac-ulty would be met if nursing could develop a new non-research clinical doctorate, similar to the MD andPharmD in medicine and dentistry” (National ResearchCouncil, 2005).

The DNP Will Prepare NPs for the Challengesof the 21st Century

As envisioned by the AACN, the DNP curriculum willrequire a global increase in the amount of scientific edu-cation and clinical training of nurse practitioner students.The proposed curriculum will provide advanced instruc-tion in pathophysiology, pharmacology, informatics, sta-

Implications of Doctorate inNursing Practice - Still ManyUnresolved Issues for NursePractitioners

The Doctorate in Nursing Practice (DNP) is a sug-gested practice degree to prepare nurse practitioners(NP) to assume full leadership roles in clinical practice,clinical teaching, and research applications, with the abil-ity to deliver exceptional, high quality care and leader-ship in increasingly complex health care delivery sys-tems. The DNP implies NPs will be provided parity withmedical doctors, pharmacists, and dentists (Steefel,2005). However, there is no indication from these pro-fessionals that this theory will materialize in everydayclinical practice.

Practice-focused doctoral degree programs in nursingwere first offered in 1979. Since then, many programshave been developed to offer an alternative to theDoctor of Philosophy (PhD), which has historically beena research- focused degree. There currently exists pro-grams for Doctor of Nursing (DN), Doctor of NursingScience (DNS, DSN, or DNSc), and now a Doctor ofNursing Practice (DNP, DrNP). In October 2004, theAmerican Association of Colleges of Nursing (AACN)voted to establish the DNP degree as the terminal degreefor NPs by 2015 (Glazer, 2005). This shift has createdmany controversies and implications to the practice ofadvanced practice nursing. The most significant issues toNPs that the practice doctorate creates are the need forstandardized education, which includes addressing thepresent status of NPs with masters degrees, standardizednomenclature and titling for NPs, definitive identifica-tion of practice guidelines, changes in billing and codingprocedures, and the necessary education of the publicand the healthcare industry.

Dr. Ann O’Sullivan, president of the NationalOrganization of Nurse Practitioner Faculty (NONPF),maintains that the move to the practice doctorate is nolonger in question for NPs of the future. The question ishow to bring about the transition and the needed changein the educational system to facilitate this move (Glazer,2005). The current curriculum for NPs is being changedand expanded on an ongoing basis. Many NP programs

Christy Price Rabetoy, Department EditorControversies in Nephrology NursingControversies in Nephrology Nursing

The Controversies in Nephrology Nursing department focuses onexploring ethical and clinical issues within the nephrology clinic practicein a point/counterpoint format. Address correspondence to: Christy PriceRabetoy, Department Editor, through the Nephrology Nursing Journal;East Holly Avenue/Box 56; Pitman, NJ 08071-0056; (856) 256-2320; orby emailing her at christycpr@comcast.net. The opinions and assertionscontained herein are the private views of the contributors and do notnecessarily reflect the views of the American Nephrology Nurses'Association.

Is the Burden Worth the Benefit of the Doctorate of Nursing (DNP) for NPs?

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NEPHROLOGY NURSING JOURNAL ■ November-December 2006 ■ Vol. 33, No. 6686

Is the Burden Worth the Benefit of the Doctorate of Nursing (DNP) for NPs?

tistics and research methodologies, genetics, evidence-based practice, diagnosis and management of illness, andpreventive healthcare. There is also content in healthcaresystems and health policy. In addition to preparing the NPto be a highly competent independent provider, the DNPwill enable the NP to possess the skills necessary to be athoughtful consumer of healthcare research, a vital skillfor healthcare professionals. The ability to comprehendareas such as research, genetics, and informatics is nowfundamental in the technology-driven world of 21st cen-tury healthcare.

Grandfathering for NPs Currently in PracticeHistorically, licensure requirements for NPs have var-

ied greatly from state to state. In many states, an ADNnurse could work as an NP. Over time, a consensus devel-oped among most state boards of nursing requiring mas-ters-level education and national certification. This evolu-tion caused considerable anxiety and anger in many NPs.Boards of nursing grandfathered-in NPs who did not meetthe new educational requirements. The move to requirethe DNP for entry into NP practice will follow this samepattern of grandfathering.

The DNP Has ArrivedThe reality is that the DNP is here. Twenty universities

are enrolling DNP students. Over 100 schools of nursingare developing DNP programs. This is the natural pro-gression of NP education. This evolution is driven by thecomplexity of healthcare sciences, the increasing autono-my of NPs, and the move of NPs into more and more spe-cialized roles. To remain relevant in healthcare, NPs musthold doctoral level training. The DNP should beembraced by the nursing community. It is what is best forus as a profession and what is best for those we serve, ourpatients.

David C. Smith, MS, RN, NPAdult Nurse Practitioner (Nephrology)Scottsdale HealthcareScottsdale, AZMember, ANNA’s Desert Vista Chapter

ReferenceNational Research Council. (2005). Committee for Monitoring

the Nation’s Changing Needs for Biomedical, Behavioral,and Clinical Personnel, Board of Higher Education andWorkforce. Advancing the Nation’s Health Needs: NIH ResearchTraining Programs. Washington, DC: The NationalAcademies Press.

currently exceed the usual and required credit load andduration for a typical master’s degree, raising additionalconcerns that professional nurse graduates are notreceiving the appropriate degree for a very complex anddemanding academic experience (The Essentials ofDoctoral Education for Advanced Nursing Practice,2006). Formulating curricula to standardize the educa-tion provided to basic entry level nurses, entry level con-sideration of students who are not nurses, and graduatenurses with varying degrees and varying levels of expe-rience and expertise is an enormous challenge to theindividuals establishing curricula and to the nurse edu-cators. An additional challenge is the fact that the nurs-ing faculty shortage is limiting college enrollment. NPswho practice in specialty care areas and may decide toreturn for doctorate preparation also have the issue offinding appropriate preceptors for residency programsand preceptorships.

It has been recommended by AACN to standardizeterminology and titling to include research doctorate(PhD) and practice doctorate (DNP) for doctorate pre-pared nurses (AACN, 2004). There is no recommenda-tion for practitioners who carry prior licensure as NPswhich will lead to significant confusion with the presenceof multiple titles and levels of education.

The contribution to health care systems of education-ally prepared individuals with DNPs is not established.Regulations in many states require collaboration with aphysician to practice as an NP. The expectation of DNP-prepared nurses is that they practice as autonomoushealth care providers, therefore current restrictions willlead to licensing and practice conflicts with the DNP. Tobetter support the graduates of DNP programs, thereshould have been a survey of the clinical needs, clinicalagencies, consumers, employers and current NPs to clar-ify the desired outcomes and competencies needed ofthese graduates.

The DNP is a degree that is suggested to have a highlevel of functionality in the health care systems. The pathto establishing this degree in the current nursing envi-ronment has many implications and concerns to currentNPs. There has been significant exploration into positionstatements, standardization of education, practice impli-cations and uniformity in credentialing and titling in therecent past. There is continued need for further stan-dardization of basic nursing entry level educationrequirements, uniformity of practice and billing stan-dards, research on the effectiveness of doctorate pre-pared clinical providers, and evaluation of acceptance bythe health care environment and the consumers. Moredata should have been gathered prior to nursing recom-mending a change in the status quo. The idea of theDNP may be popular with some nurses, but it may fos-ter and promote yet another controversial issue for nurs-es to debate and other health care providers to criticize.

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