Nichols, Catherine DNP, APRN, BC; O’Connor, Nancy PhD, RN, ANP-BC; Dunn, Deborah EdD, MSN, GNP-BC
Author Affiliations: Nurse Practitioner (Dr Nichols), Women’s Wellness Clinic, Walt Breast Center, Detroit, Michigan; Chairperson, Graduate Nursing Program (Dr O’Connor), Director, Graduate Nurse Practitioner Program (Dr Dunn), School of Nursing, Madonna University, Livonia, Michigan.
The authors declare no conflicts of interest.
Correspondence: Dr Nichols, Women’s Wellness Clinic, Walt Breast Center, 4100 John R St, Detroit, MI 48201 (email@example.com).
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jonajournal.com).
The proliferation of DNP degree programs continues. Little has been published about the utilization and effects on healthcare outcomes of the DNP degree. An initial strategy to gather data on DNP utilization and impact was designed using Donabedian’s1 conceptual model and was initially piloted by surveying chief nursing officers (CNOs) leading Michigan’s public and teaching hospital systems.
The complexity of the US healthcare system has resulted in increasing fragmentation and led to challenges and innovation in care delivery models.2 In the past 14 years, the Institute of Medicine (IOM) reported astonishing deficits in the nation’s healthcare systems and provision of care2-4 including preventable medical errors, lack of chronic condition care, and poor access to timely care.2-4 In the 2011 publication, The Future of Nursing: Leading Change, Advancing Health,4 the IOM called upon nursing to increase education levels of both undergraduate and graduate nurses.
In response to the need for clinical nurses prepared at the doctoral level, DNP programs have been developed and continue to expand in number.6 In January 2013, the American Association of Colleges of Nursing (AACN) reported 221 current colleges and universities across the United States offering DNP degrees with more than 100 programs in the planning stages.5 This surpasses the number of nursing PhD programs now offered across the United States. The AACN also reported nearly double the number of enrollees in DNP programs as compared with those in PhD programs. From 2010 to 2011, the number of DNP enrollees grew from 7034 to 9094.6 The numbers of DNP graduates are steadily increasing as well with 1282 graduating in 2010 and 1595 in 2011.6 The acceptance of the DNP degree by nurses returning to school has presented new challenges as nurse leaders enhance their own knowledge about possible contributions to the care domain and work to develop programs and services to support these opportunities. The employment patterns, utilization, and impact of DNP graduates need to be monitored and reported, because there are few if any published studies to date documenting the market penetration and utilization of DNP-prepared nurses.
The Current Trends in DNP Utilization CNO Survey (Table 1) was developed based on Donabedian’s1 conceptual model to quantify the numbers of DNPs employed in identified organizations and to detail the DNP nurses’ scope of responsibilities.2 Donabedian developed 3 domains of inquiry for analysis: (1) structure, (2) process, and (3) outcome. For this survey, structural elements include the type of DNP practice setting, including inpatient and outpatient. Process elements include the specific types of advanced practice RNs (APRNs) employed in the workplace (nurse practitioner [NP], clinical nurse specialist, certified nurse midwife, certified RN anesthetist, or nurse leader). Outcome elements assessed (1) CNO’s satisfaction with the DNPs’ organizational impact and (2) patient-centered outcomes relevant to the identified DNP position and (3) critical health indicators prioritized by the Michigan Department of Community Health.8 The 13-item survey was constructed to elicit current information regarding DNP practitioner utilization and impact on Michigan Public and Teaching Hospital systems. Survey content validity was established through expert panel review. Approval for this project was obtained from the human subject review committee at Madonna University.
CNO Satisfaction With DNP Employees Organizational Impact
Early literature regarding interest and support for DNP-prepared nurses included 2 studies that influenced the development of this survey. The 1st was a structural study conducted at the University of Kentucky (UK) and cited by the AACN in its 2004 DNP position statement.9 The study was a market analysis survey of 111 top executives in acute, long-term, and public healthcare settings in Kentucky, to determine their interest in hiring a DNP graduate from the UK program. Most (61%; n = 68) of the respondents indicated they would be interested in hiring DNP graduates in the next 5 years, and forecasted at least 80 positions would be available during that time. Nine specific positions were identified by respondents for potential utilization of a DNP graduate are (a) vice president for clinical service, (b) program director, (c) vice president for patient care, (d) chief executive officer, (e) quality improvement director, (f) director of clinical services, (g) clinical information technology specialist, (h) direct care clinician, and (i) faculty member.
The 2nd study informing survey development was from the University of Washington’s School of Nursing.10 In this study, Kaplan and Brown10(p364) propose “capturing the profession’s transition” (to the DNP) from a survey of employers to determine the contributions of DNP graduates. The idea of capturing DNPs’ initial contributions to organizational outcomes by surveying employers was used to design the current CNO survey of DNP impact.
A 3rd published study11 that informed survey construction was conducted at the University of Alabama. Researchers examined the newly developed role of the clinical nurse leader (CNL). The aim of the study was to determine if CNL graduates were being utilized to the fullest extent of the “9 components outlined by the AACN’s vision.”11 While not pertinent to the DNP role, the idea of using the stipulated role components of a newly developed role to assess its uptake and impact was informative to this survey construction paralleling the stipulated DNP role components.
CNO Satisfaction With the DNPs’ Organizational Impact
CNO satisfaction with the DNPs’ impact on the organization was addressed through CNO evaluation of DNP impact on healthcare indicators, DNP role types and their specific organizational impact, and current employment trends of DNPs. Of the 5 APRN/DNP role types, only the NP and CNO/leader role type were reported as DNP positions.
This measure was evaluated by CNO perception of specific patient benefit in their organization. A potentially hopeful finding for the indigent and healthcare-naive populations was the resounding 100% agreement of respondents to an increase in access to care provided by the DNP. Another promising finding was the 50% positive response of the likelihood of hiring a DNP in the future, based on their current experience. This suggests the DNP is having a positive effect on Michigan’s healthcare systems overall.
Critical Health Indicator Outcomes
To elicit the impact of outcomes of DNP practice related to critical health indicators in surveyed organizations, the instrument contained an embedded list of Michigan’s leading health indicators, as prioritized by the Department of Community Health.8 These were selected to identify the impact of the DNP-prepared nurse in healthcare organizations and on population health. Survey questions included open-ended responses regarding the impact on populations as perceived by the CNO respondent. The resulting survey (Table 1) can be used by CNOs to systematically gather data on DNP utilization in their organizations, and it can be targeted to any state’s population health indicators or identified organizational priorities.
In a preliminary Internet-based exploration of 17 CNOs leading Michigan’s public and teaching hospitals, only 6 (35%) reported employing DNPs. The CNOs endorsed 8 of the 9 identified position titles (extracted from the UK study) that would necessitate DNP preparation within their institutions (see Document, Supplemental Digital Content 1, http://links.lww.com/JONA/A285).
In considering DNPs’ impact on health outcomes, CNOs identified those that were targeted to 1 or more of Michigan’s leading health indicator, for example, (1) support for increasing access to healthcare and (2) providing care for those with coronary heart disease.8
The small group of Michigan CNOs who completed the survey showed in their open-ended responses that knowledge of actual DNP practice and its potential impact on targeted outcomes are little known among senior administrators (see Document, Supplemental Digital Content 1, http://links.lww.com/JONA/A285). This is the 1st known study probing where, how, to what degree, and in what capacity DNPs are being employed. Although the response rate was low, the information obtained was valid, sound, and very useful. It is encouraging that CNOs affirmed support for advancing education among nursing employees, albeit mostly reported as general support for any type of healthcare degree pursued, not exclusively DNP education. DNP-prepared APRNs are being called upon by the IOM to fill the void in primary care, and this study reports an interest in utilization of these practitioners for this role plus other roles that can contribute to healthcare quality and access.
Ironically, although the majority of the respondents stated they would likely hire a DNP in the future, only 2 DNP/APRN roles were reported as having benefited the institution. Seventy-five percent of respondents stated that the NP benefited the system the most, with only 1 other reported APRN/DNP role, the nurse executive, benefiting the institution with a 50% response rate. This may represent a true self-selection of DNP utilization by nurse executives. When forced to choose a position from a list of advanced practice and executive positions, however, it was remarkable the CNOs were not reporting that they would likely hire a DNP to do their job. Again, this exposes the lack of consistent understanding of these executives regarding the value of a DNP-prepared nurse. Validating this deficit of knowledge are the actual narratives plainly stating a lack of understanding in the qualitative data (see Document, Supplemental Digital Content 1, http://links.lww.com/JONA/A285).
Limitations include that this was a convenience sample in this study with a limited sample size. The majority of respondents represented inpatient hospital care settings, whereas few respondents represented the outpatient care sector. This study should be replicated in other states and practice settings to monitor the impact and ongoing utilization of DNP graduates. Additional methods such as telephone follow-up interviews may assist in collecting the targeted and qualitative data, especially the impact on health outcomes.
Conclusion and Implications for Nurse Leaders
The DNP degree was developed to enable the nursing profession to prepare professionals as advanced practice providers of care and as senior leaders within health organizations.9 Assessing the adoption and support of DNP-prepared nurses among CNOs is essential to promulgating this level of practitioner into healthcare systems. This survey supports that CNOs are not well versed in the clinical outcomes of DNP practice or the population health outcomes that may be impacted by DNP-prepared providers. Continued research and dissemination of information regarding these issues are essential to support the growth and support of roles for DNP nurses and the widespread recognition of their impact.
The authors would like to acknowledge the helpful comments of Dr Diane Burgermeister on earlier versions of this manuscript.
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4. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011.
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