BACKGROUND
The National Association of Clinical Nurse Specialists (NACNS) Board of Directors, in consultation with its Education Committee, and faculty and dean members of NACNS, conducted an extensive analysis of the proposal developed by the American Association of Colleges of Nursing (AACN) on the Practice Doctorate in Nursing,1 referred to as the Doctorate of Nursing Practice (DNP). Approximately 54 Deans carried the vote for this major professional paradigm shift (160 for, 106 against) at the October 2004 meeting-only those in attendance were able to vote, despite membership of over 500 schools. If adopted, the DNP is supposed to be completely actualized by 2015.
NACNS discussions have focused on exploring areas of opportunities, concerns, and continuing questions about the proposal. Several documents were reviewed to contribute to the analysis, including the AACN Position Statement on the Practice Doctorate in Nursing,1 the National Organization of Nurse Practitioner Faculty (NONPF) Practice Doctorate Resource Center documents,2 speaker handouts+ from the 2005 AACN Doctoral Education Conference (January 19-12, 2005, San Diego, Calif), discussion forum comments from NACNS members, and several additional publications.3,4 As a result of this analysis, the NACNS Board of Directors developed this paper to contribute to the national dialogue.
OUTCOMES OF THE ANALYSIS
Opportunities Related to the AACN DNP Proposal
* Provides the opportunity for national dialogue among multiple stakeholders about all advanced practice registered nurse competencies, including those of clinical nurse specialists (CNSs), the primary focus of NACNS.
* Provides a forum to discuss the increasingly complex competencies and outcomes needed for nursing practice at the baccalaureate, master's, and doctoral levels.
* Provides a framework for increased dialogue about the complexity and technological culture of patient care.
* Allows the development of advanced nursing practice competencies for increasingly complex clinical, faculty, and leadership roles.
* Provides an educational pathway for nurses seeking advanced practice education without a strong research focus.
Areas of Concern About the Proposal
NURSING PROFESSION
* The AACN Proposal represents a major professional paradigm shift in nursing practice and education that warrants extensive dialogue from stakeholders. Opportunities for collegial dialogue in regional and national meetings should precede a change of this magnitude.
* The proposed DNP potentially creates a divisive change in a profession that has a long history of a lack of professional cohesion.
* It is NACNS' understanding that neither the American Nurses Association (ANA) and the National League for Nursing (NLN) nor the American Academy of Nursing (AAN), flagship organizations that represent nursing practice and education, were invited participants in the deliberations leading up to the Proposal for the DNP.
* There is a lack of consensus from specialty and other professional organizations about how the DNP proposal will complement the nursing profession.
* There are no studies showing that doctorally prepared advanced practice nurses have better outcomes than master's-prepared advanced practice nurses.
EDUCATION
* The competencies and outcomes for the DNP-prepared nurse have not been developed or articulated.
* There is a lack of clarity in the DNP Proposal regarding evolving education pathways to advanced practice nursing and preparation of nursing educators and nurse administrators. As a result, there is much opportunity for inconsistent expectations and degree requirements.
* The nature of additional knowledge infused into the DNP curricula versus the knowledge in the present MSN curricula is not known.
* The impact of adding another degree with more credit hours on already scarce faculty resources is not known.
* Potential nurse scientists may opt for the DNP as opposed to traditional PhD programs, thus the DNP could compete against the PhD for scare resources, reducing the number of nurse scientists and leading to a decreased evidence base for nursing practice. (Apparently, one of the unintended consequences of the practice doctorate in pharmacology (PharmD) degree is that it significantly decreased numbers of PhD-prepared people in the discipline).
* CNSs who seek further education typically seek a PhD in Nursing, desiring increased preparation in research to become PhD-prepared practicing CNSs with increased research capabilities, nurse researchers, or nurse educators.
* The impact on current and future nursing faculty has not been adequately addressed. Future faculty members who hold a DNP may face tenure/promotion difficulties. At academic institutions where no other faculty hold practice doctorates, the DNP-prepared faculty member may be viewed negatively.
* Consistent with nationally approved standards that preceptors must have a degree greater than that of the student, master's-prepared CNSs, as well as other advanced practice nurses, will not be considered qualified to precept doctoral students who are obtaining a practice doctorate.
* The 2004-2005 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing5 provides data from 91 schools reporting PhD programs and 351 schools reporting master's degrees. Some existing CNS programs, as well as other advanced practice nursing programs, may need to close because they are not permitted by state statute to offer doctoral education or may lack the fiscal or faculty resources.
* Based on the existing DNP programs and AACN documents, there is a discrepancy regarding the focus of the DNP, for example, preparation of advanced practice nurses (NP, CNS, CRNA, CNM) to improve the quality of care delivery versus preparation of future nursing educators and nurse administrators.
* Currently, doctoral programs in nursing are not accredited by AACN's Commission on Collegiate Nursing Education (CCNE) or the National League for Nursing Accrediting Commission (NLN-AC), the 2 professional groups that accredit undergraduate and master's degree nursing educational programs. It is assumed that an infrastructure would need to be developed to accredit DNP programs.
PATIENT SAFETY
* Current evidence supports the safety of CNSs and other advanced practice nurses in providing high-quality and cost-effective advanced practice nursing.
* Harm data about care provided by CNSs and other advanced practice nurses prepared at the master's level do not exist according to the American Nurses Association Malpractice Data Bank.
* It is unclear how the proposed DNP will contribute to increased patient safety as there have been no studies done to support this premise.
ECONOMIC ISSUES
* From an academic perspective, the cost and affordability of shifting current master's-level curricula to the proposed DNP have not been determined.
* From a student perspective, costs in relation to increased tuition, time, and reduced income while enrolled in a lengthy program have not been determined. We also do not know if postgraduation salaries for CNSs as well as other advanced practice nurses will offset the increased educational costs.
* From a healthcare employer perspective, it is not known if DNP-prepared advanced practice nurses will be affordable to employers and third-party reimbursers.
DEVELOPMENT OF THE DNP
* The DNP Proposal primarily addresses nurse practitioners.
* AACN sought limited informal input from CNSs, nurse midwives, and nurse anesthetists during the initial discussions of this major professional paradigm shift that affects all advanced practice nurses.
* Decisions to initiate this major paradigm shift were not derived from an extensive nursing practice analysis, but from one group of advanced practice professionals.
* The proposed DNP was developed with limited input from a full range of higher education organizations such as private universities or smaller universities that cannot offer doctoral degrees.
NURSE PRACTICE ACTS
* The regulation of the practice of CNSs, as well as other advanced practice nurses, differs from state to state, and scope of practice will be affected differently depending on the state's nurse practice act.
* Nurse practice acts will need to be opened and modified so as to change language to incorporate doctoral competencies and scope of practice. Opening acts may invite the attention of stakeholders who wish to modify existing components of the acts as well as to block the changes required.
* Variability within state-level regulations exists with respect to using the title "doctor" when providing patient care.
* Certification mechanisms (new exams or portfolio) to satisfy state boards of nursing may need to be developed.
ONGOING/IMPLEMENTATION CONCERNS
* Issues related to grandfathering (a regulatory term) currently certified CNSs must be resolved. It is imperative that this issue be examined and that CNSs along with other advanced practice nurses who are prepared at the master's level be given authoritative assurance that they can continue to practice without additional graduate course preparation.
* The potential loss of employment for CNSs who choose not to pursue the proposed DNP is not known.
* Licensure/certification issues are not articulated and will need to be addressed.
* The practice of CNSs with respect to specialty and subspecialty will need to be examined.
Questions That Require Further Discussion
In addition to the concerns described above, further questions need discussion, such as the following:
* Should it be the will of the profession that the DNP becomes the degree for advanced practice registered nurses, will current advanced practice nurses need to be grandfathered into recognition at the state level of regulation so as to continue to practice with a master's degree?
* Is it the vision of those who developed the proposed DNP that master's-level CNS nursing education be fully replaced by the proposed DNP by 2015?
* How will changes in educational preparation levels affect the numbers of CNSs specifically and all other advanced practice nurses?
a. At a time when there are not enough practicing CNSs to fill existing job vacancies, and with that shortage likely to last for several years, how will increasing the length of education to the DNP level meet healthcare needs?
b. How will nursing education be affected if the proposed DNP is a terminal degree?
c. How many programs will be closed because of a school's inability to be approved to offer doctorates?
d. Who will be the faculty for the proposed DNP programs?
POSITION STATEMENT BASED ON RESULTS OF ANALYSIS
NACNS has significant concerns about the DNP as currently proposed and urges a national dialogue to address the compelling issues that have been raised. NACNS remains neutral about the proposed DNP until our concerns can be resolved and our questions answered. The proposed DNP represents a major professional paradigm shift in nursing practice and education that warrants extensive dialogue from a host of stakeholders. Opportunities for collegial dialogue in regional and national meetings should precede a change of this magnitude.
NACNS recognizes the importance of advanced education and is interested in participating in the national dialogue with other stakeholders and organizations representing CNS members. An exploration of differences in competencies of a master's-prepared CNS and a doctorally prepared CNS, and the educational requirements to support those differences is needed. After meaningful dialogue and pending resolution of critical issues, NACNS will partner with other national organizations to develop a doctoral-level CNS curriculum and to identify additional competencies that could emerge from the additional coursework. The NACNS Statement on Practice and Education (2004) currently provides an excellent framework for master's CNS curricula and could potentially form the basis of doctoral-level CNS curricula.
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