DOCTOR OF NURSING PRACTICE VIS-À-VIS DOCTOR OF PHILOSOPHY IN NURSING

As in the United States, Doctor of Nursing Practice (DNP) graduates in Brazil are expected to be key players to translate new knowledge into practice in order to improve patient safety, quality care, and cost effectiveness.1^-2 The graduates are anticipated to be able to synthesize credible research evidence and apply clinical practice innovations to patient care that is tailored to patients’ needs, while taking into account the complexity of the social, economic, cultural, and healthcare systems.1^-2 Thus, the expectation is for the DNP graduate to be an effective leader in a changing and complex healthcare environment.3 As the role of the DNP evolves and new opportunities emerge, the evolution of the DNP nurse holds promise for the acceleration of evidence-into-practice initiatives.

In the United States, the first nursing practice doctorate program at the entry level was offered in 1979 at Case Western Reserve University in Cleveland, Ohio; but the first DNP program established at the terminal degree level was at the University of Kentucky in 2001.2 In 2004, the DNP was introduced by the American Association of Colleges of Nursing (AACN) as the recommended preparation level for advanced practice RNs (APRNs).2 Since 2006, the number of DNP programs has increased dramatically, whereas the number of Doctor of Philosophy (PhD) programs has grown very slowly. Approximately 350 DNP programs and over 150 PhD programs were offered in the United States in 2018.4 By comparison, 2 DNP programs and 36 PhD programs are currently offered in Brazil.5 The DNP has gained international recognition as another pathway for nurses to advance their degrees. In 2019, Brazil launched its first DNP program with a focus on clinical care management at the Universidade Federal de Santa Catarina.1 The second program followed in 2020 at the Universidade Estadual Paulista "Júlio de Mesquita Filho, in São Paulo.5

To earn a DNP degree in the United States, the completion of a scholarly project is required, in addition to coursework that includes specialty content and an immersive clinical practicum.3 The scholarly work could be demonstration, quality improvement, evidence-based practice, health care policy change, or program evaluation project.6 Upon completion of the program, the DNP candidate should clearly demonstrate how the scholarly work makes (or potentially makes) a significant clinical contribution to healthcare at the unit, organizational, or system level in relation to the eight DNP essentials outlined by the AACN for U.S. graduates.3

The PhD and DNP are both terminal degrees in nursing. Even though both the PhD and DNP are a degree and not a role, it is safe to say that the major role of a PhD-prepared nurse is to generate new knowledge, whereas the role of a DNP-prepared nurse is to translate new knowledge into practice, to lead changes across complex systems, and to improve patient, population, and/or organizational outcomes.3 In the United States, while many PhD nursing graduates are employed in academic institutions or in industry where their primary role is to conduct research, we know less today about the employment status of DNP graduates. Beeber et al. surveyed 155 U.S. DNP graduates and found that 52% worked in acute care, 11% in primary care, 8% in a government agency, 8% in ambulatory care, 5% in health systems/networks, 4% in specialty care, 3% in public health, and the rest (9%) in home health, occupational/student health, retail, anesthesia practice, and long-term care, combined.7 Based on 23 semi-structured employer interviews from the same study, some employers stated that the role of DNP graduates is still in its infancy and did not see their role as different from other APRNs. Also, some employers noted that when DNP graduates are additionally equipped with data mining and analysis skills (which are not typical among DNP-prepared nurses), they can even better expedite the translation of research findings into practice.7 Some employers viewed DNP graduates’ contributions as unique and viewed those graduates as being more equipped with leadership and research translation skills when compared to masters-prepared nurse practitioners.7

Similarly, in a qualitative study, Bowie et al. found that DNP graduates (N=10) reported that they felt confident, prepared, and empowered to lead change within their organization, a finding that was substantiated by supervisors of DNP graduates, reflecting the achievement of an important AACN DNP competency that distinguishes the MSN-prepared APRN from the DNP.8

For both the PhD and DNP nurses to be effective in their career paths, their relationship needs to be bidirectional: practice informs research, and research informs practice. This is an iterative and cyclical process with feedback loops between the patient and/or healthcare system and the researcher and clinician (Figure 1).

Figure 1 -
Role of PhD-prepared nurse vis-a-vis DNP-prepared nurse.

This is a very exciting time for our nursing profession, as we now have a large cadre of DNP graduates who can help close the gap between the generation of scientific knowledge and its application in the healthcare setting, and also to translate research findings into practice in order to transform healthcare and to improve the quality of patient care and patient outcomes. 3^,8 Still, questions remain about future projections for the supply of DNP and PhD graduates to meet workforce needs in clinical practice and academia. Growth in the number of PhD graduates is lagging compared to the groundswell of DNP graduates in the United States; this difference can partly be explained by the recommendation from the AACN in years past that U.S. APRNs should earn their DNP by 2015.2 Similarly, clinical faculty in schools of nursing are urged ‒ and in some cases may be required ‒ to earn a doctoral degree. These developments have in large part stimulated the surge in DNP program enrollment. Also, DNP programs are clinically-focused and less costly and time consuming compared to PhD programs. The need to increase enrollment in PhD programs is thus urgent, given that continued productivity in nursing scholarship is vital to address contemporary health problems and patient-centered concerns through knowledge development that can then be transformed into action.

New roles have emerged for DNP graduates. In lieu of clinical positions, U.S. DNP graduates have sought faculty positions in academic institutions to teach in undergraduate and graduate nursing programs, including DNP programs. This may stem from the shortage of PhDs in academia (due to the convergence of decreasing numbers of PhD graduates and increasing numbers of retiring faculty) as well as the requirement that nursing faculty have a doctorate. Although these DNP graduates fill a need, faculty development will still be required to prepare them for the teaching role and scholarship that many academic institutions require for non-tenure track clinical faculty. Recognizing this issue, some DNP programs are now offered with an education focus in contrast to an APRN clinical focus. Significantly, novel PhD-DNP dual degree programs have been developed to prepare nurses for the clinician-scholar role at several U.S. universities including the Johns Hopkins University in Maryland which expects its graduates to be “…prepared to conduct clinical research, teach, mentor, and implement innovations to enhance patient outcomes”.9 At Case Western Reserve University in Cleveland, Ohio, students in its DNP/PhD program will take “…courses in both programs concurrently… Students will complete a DNP project and PhD dissertation, with the potential for the DNP project to serve as a pilot study for the PhD dissertation. Students would have the opportunity to complete course requirements for both the DNP and PhD in nursing degrees (55 credits) in three years, after which they would complete their proposal development, candidacy exam, proposal defense, DNP project and final PhD dissertation.”10

Finally, asking some important questions can help us in working toward DNP programs that are responsive to the changing needs of patients and healthcare systems. For example, should a course be offered that guides DNP and PhD students to strategically collaborate within clinical contexts or in formal academic-practice partnerships? Can similar partnerships evolve between DNPs in community settings and PhDs in academia, and can such partnerships be modeled from the academic-practice partnerships between health care institutions/medical centers and schools of nursing? Or are new models needed? Additionally, could joint nurse-scientist positions be encouraged to help bridge the gap between academic institutions and clinical settings and to shorten the time between knowledge generation and implementation in practice?11 In the context of the growth of DNP programs in the U.S. and the development of two new programs in Brazil, addressing the above questions can further the advancement of nursing science, operationalize nursing leadership, and optimize patient outcomes. Globally, the demand for more highly qualified nurses is underscored by today’s aging demographics, increased chronic disease prevalence, and complex healthcare systems. DNP and PhD nurses together offer vital contributions to the healthcare workforce and the improvement of future care.

REFERENCES

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• 3. American Association of Colleges of Nursing. The essentials of doctoral education for advanced nursing practice [Internet]. 2006 Oct [cited 2020 Sept 30]. Available from: Available from: https://www.aacnnursing.org/education-resources/aacn-essentials
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• 8. Bowie BH, DeSocio J, Swanson K.M. The DNP degree: Are we producing the graduates we intended? J Nurs Adm [Internet]. 2019 [cited 2020 Sept 30];49(5):280-5. Available from: Available from: https://doi.org/10.1097/nna.0000000000000751
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• 9. Johns Hopkins School of Nursing. The Johns Hopkins school of nursing launches DNP/PHD dual degree [Internet]. 2017 [cited 2020 Sept 30]. Available from: Available from: https://nursing.jhu.edu/news-events/news/news/the-johns-hopkins-school-of-nursing-launches-dnpphd-dual-degree
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• 10. Frances Payne Bolton School of Nursing. Case Western Reserve University. Dual doctorate PhD/NP [Internet]. 2020 [cited 2020 Sept 30]. Available from: Available from: https://case.edu/nursing/programs/dual-doctorate-phddnp
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• 11. Carter EJ, Hessels A, Cato K, Sun C, Cohen B, Rivera R, et al. Evaluation of the joint nurse scientist role across academia and practice. Nurs Outlook [Internet]. 2020 May [cited 2020 Sept 30];68(3):261-9. Available from: Available from: https://linkinghub.elsevier.com/retrieve/pii/S0029655419302428
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Publication Dates

• Publication in this collection
  20 Nov 2020
• Date of issue
  2020