Chapter 3

The Essentials of the Doctor of Nursing

Practice: A Philosophical Perspective

Introduction

• The Doctor of Nursing Practice (DNP) is recommended by the American Association of Colleges of Nursing (AACN) as the terminal practice-focused degree in nursing.

• The history of doctoral education is important to understanding the DNP.

• Philosophical inquiry about the nature of nursing discipline and science is key to DNP competencies.

Overview of the DNP Degree

• The DNP is defined as a practice-focused terminal degree in nursing practice.

• Focuses on population outcomes and nursing’s impact on healthcare policy.

• Emphasizes practice, which separates it from theory- and research-focused PhD degrees.

• Graduates must demonstrate scholarly activity via a theory-driven research project demonstrating research in practice.

• Doctoral education in nursing has seen its greatest growth in the past 40 years.

• Due to the small number of nursing-related doctorates available through the 1960s, most nurses pursued doctorates in the basic sciences or education.

• Nursing PhDs did not become popular until the 1970s.

Historical Perspectives (1 of 4)

Historical Perspectives (2 of 4)

• Doctoral education in nursing developed in three phases:– Development of functional specialists—preparing

nurses as teachers and administrators– Development of nurse scientists—questioning the

nature and knowledge base of nursing– Development of doctorates “in and of nursing”—

utilizing answers about nature and knowledge base to improve practice

• A fourth phase emphasizing nursing practice has occurred recently with development of the Doctor of Nursing Science (DNS) degree.

• The DNS was the first practice-focused doctorate designed to focus on clinical expertise.

• Gradually acquired a theory focus and became more like a traditional PhD, again creating the need for a practice-based degree.

Historical Perspectives (3 of 4)

Historical Perspectives (4 of 4)

• The Doctorate of Nursing (ND) was introduced in 1979 to address several needs in nursing:– Reorientation of care toward health status while

maintaining a detection and treatment focus– Reorientation of the nursing community to promote

scholarship and autonomy– Reorientation of professional preparation toward

independent, accountable nurse practitioners

• ND was not as popular or uniform as the DNS or PhD, but needs are reflected in the DNP.

Development of the DNP Degree

• In 2002, the AACN create a task force to evaluate the current status of practice doctorates in nursing.

• The task force developed recommendations and proposed curriculum models via the Position Statement on the Practice Doctorate.

• Position Statement recommended DNP as the terminal practice-focused degree.

• There are currently more than 100 DNP programs in the United States.

DNP Competencies

• In 2006, the AACN developed the Essentials of Doctoral Education for Advanced Nursing Practice to address the competencies at the core of advanced practice.

• The AACN also developed the Practice Doctorate Nurse Practitioner Entry-Level Competencies.

• These two documents provide curriculum standards for all DNP programs.

Essential I: Scientific Underpinnings for Practice

• Essential I describes the scientific foundations for nursing practice.

• Foundations are derived from both natural and social sciences, including biology, physiology, and psychology.

• Nursing science and middle-range nursing theories are also part of the foundations.

Essential II: Organizational and Systems Leadership for Quality Improvement and

Systems Thinking

• Essential II describes preparation in organization and systems leadership that affects healthcare delivery and outcomes.

• Emphasizes organizational assessments, systems issues, and facilitation of organization-wide changes.

• Prepares graduates to assume leadership roles at every level of an organization.

Essential III: Clinical Scholarship and Analytical Methods for Evidence-

Based Practice

• Essential III describes competencies related to evaluation, integration, translation, and application of evidence-based practice.

• Addresses the unique perspective of graduates to merge science and human elements and ask practice-related questions.

• Emphasizes research partnerships, clinical research, and guideline and method design.

Essential IV: Information Systems/Technology and Patient Care Technology for the Improvement and

Transformation of Healthcare• Essential IV prepares graduates to use information

technologies to improve patient care outcomes.• Emphasizes use of expertise to evaluate

documentation programs and the accuracy, timeliness, and appropriateness of healthcare consumer information.

Essential V: Healthcare Policy for Advocacy in Health Care

• Essential V describes the importance of nurses’ involvement in policy and advocacy.

• Emphasizes the relationship of practice and policy.

• Focuses on analysis of policies and proposals from multiple viewpoints and participation on boards and committees.

• Encourages advocacy through organizational leadership.

Essential VI: Interprofessional Collaboration for Improving Patient and Population Health

Outcomes

• Essential VI prepares graduates for interprofessional collaboration within a multitiered healthcare environment.

• Emphasizes collaboration with members of other professions.

• Focuses on development of expertise necessary for assuming leadership roles on collaborative teams.

Essential VII: Clinical Prevention and Population Health for Improving the

Nation’s Health

• Essential VII prepares graduates to analyze population data in order to develop and implement prevention strategies and evaluate population health.

• Emphasizes health promotion and risk reduction from an advanced nursing practice perspective.

Essential VIII: Advanced Nursing Practice

• Essential VIII describes clinical specialization content from a specific domain of advanced nursing practice.

• Prepares graduates to develop therapeutic relationships with patients and other professionals to improve patient outcomes.

• Encourages utilization of advanced clinical decision-making skills, mentoring of others in the profession, and patient education.

Focus on Essential I (1 of 3)

• Basic sciences: Hard and soft sciences that build a scientific basis for practice.

• Discipline of Nursing: Body of knowledge concerned with four aspects of care:– Principles governing life processes and well-being– Patterning of human behavior – Processes by which positive changes are effected– Wholeness of health of human beings as they interact with

the environment

• Nursing science: Methods of inquiry specific to the discipline and their outcomes.

• Nursing Theory: Product of nursing science that attempts to describe, predict, or explain phenomena consistent with nursing’s perspective.

• Middle-range theory: Concrete, narrow areas of nursing knowledge applicable to clinical practice that help direct assessment.

Focus on Essential I (2 of 3)

Focus on Essential I (3 of 3)

DNP Graduates and Nursing Theory• Theory-practice gap exists in nursing due to lack of

understanding and applicability of nursing theories.• Middle-range theories are key to closing the gap due

to their narrow scope.• DNP nurses are well-positioned to close the gap by

utilizing and explaining theory-guided practice.

DNP Graduates and Use of Theories

• Nursing theory is reflective of a broad range of perspectives due to the many disciplines that form the foundation of practice.

• The social component of nursing requires theory selection based on the individual patient or situation.

• DNP nurses must evaluate and apply theories with an overarching goal of ensuring patient-centered care.

Dilution of the Discipline: Philosophical Considerations for DNP Graduates

• Application and integration of interdisciplinary theories adds to the knowledge base, but may dilute nursing as a unique discipline.

• It is essential, therefore, that DNP nurses develop a good understanding of the profession, science, and discipline of nursing.

• Understanding differentiates DNPs from other nurses by promoting theory integration that aligns with concerns of the discipline.

Summary

• The DNP is the AACN recommended terminal practice-focused degree in nursing.

• This recommendation has implications for nursing as a profession, science, and discipline.

• Understanding the scientific underpinnings of practice and the profession itself are essential to applying knowledge to patient care and bridging the theory-practice gap.