When we were about to graduate from our NP program at Columbia University back in 1996, we were asked in a survey how many of us would return to school to complete a clinical doctorate if one were available. We were told that the purpose of such a doctorate would be to improve our clinical skills in diagnosis and management of patients in preparation for practicing independently—essentially, it would be an intensive clinical internship.
Within a few years, Columbia was among the first schools to offer a doctor of nursing practice (DNP) program. Some of my colleagues who enrolled described to me the residencies they completed to earn their degree. Arranged by students through their own contacts, the internships were usually conducted under the supervision of physicians and in health care settings where the students were already employed. As in any such placement, some had great experiences that they felt made them better clinicians, while others did not.
DNP programs are proliferating at a rapid rate; there are currently 241 and another 59 in the works, according to the American Association of Colleges of Nursing (AACN). But many don't resemble the clinical doctorate I first heard described. Now the primary focus seems to be on translating evidence into practice. In order to graduate, the NP must do a capstone project, which is usually an educational intervention with staff or a quality improvement project.
Translation of evidence into practice is an important skill. But why are DNP programs making it a primary focus for NPs, who have been educated to diagnose and manage health problems? As currently realized, the DNP is an appropriate and valuable program for a clinical nurse specialist (CNS) or a clinical nurse leader (CNL). According to the National Association of Clinical Nurse Specialists, the role of the CNS is to “influence care outcomes by providing expert consultation for nursing staffs and by implementing improvements in health care delivery systems”; the AACN describes the role of the CNL as putting “evidence-based practice into action to ensure that patients benefit from the latest innovations in care delivery.” A doctorate focused on improving outcomes and quality of care through translating evidence into practice fits well within these roles—it's what these advanced practice nurses do—and it has the potential to improve their practice.
But does it really improve the practice of the NP?
The roles of NPs are grounded in nursing, but they are expressed in activities that were once associated only with medical doctors. Yes, as nurses NPs practice wellness care and treat patients holistically and tend to be very good at listening to and treating patients within the contexts of their lives. But the practice of most NPs is not focused on quality improvement at the systems level. Their practice is evidence based, but it is focused on doing histories and physical exams—with the purpose of diagnosis and management of acute and chronic illnesses, ordering tests, interpreting test results, and prescribing medications and other therapies. Many have admitting privileges and some perform minor surgical procedures, or suturing and fracture repair.
So, if NPs want to increase their clinical expertise, especially in a specialty area, what educational route is available when few DNP programs offer an intensive clinical placement? If they want a credential that indicates clinical education at the doctoral level—what credential says that?
If all NPs are going to be required to have a doctorate by 2015 for entry into practice, then we need to provide one that is relevant to what many, if not most, NPs actually do. I'm not arguing for a new doctoral-level degree or, for that matter, for any new degree. We are already overrun with degrees and specializations and certifications. I'm arguing for a rigorous clinical practice DNP track that provides NPs with the opportunity to hone their diagnostic and clinical skills under the tutelage of expert diagnosticians and clinicians, whether they are medical or nursing doctors.