The doctor of nursing practice (DNP) degree was introduced by the American Association of Colleges of Nursing (AACN) and their affiliate member schools in 2004 as the preferred preparation level for advanced practice RNs (APRNs). APRNs are currently defined as those nurses who are practicing in 1 of 4 roles: certified nurse practitioners, certified nurse midwives, clinical nurse specialists, and certified RN anesthetists.1 In addition to APRNs, several universities offer DNP degrees, either post–master's degree or BSN-to-DNP, for nurses in indirect care roles, such as healthcare administration or informatics.2 Between 2006 and 2017, the number of DNP programs across the United States grew from 20 to 303. In 2017, there were 25 289 students enrolled in DNP programs of study.2 The overarching purpose of the DNP degree is to prepare APRNs to be effective leaders in a changing complex healthcare environment. In their 2010 report on the Future of Nursing, one of the Institute of Medicine/National Academy of Medicine (NAM) recommendations was that nurses needed to be better prepared to lead change to advance population health.3 In addition, the report recommended that nurses collaborate as full partners with physicians and other health professions in redesigning the American healthcare system. In a similar report, to meet the challenges of a national nursing faculty shortage, the National Research Council of the National Academies expressed the need to develop a nonresearch clinical doctorate to prepare expert practitioners who could also serve as clinical faculty.4 Many leaders in nursing assert that to be a full partner advanced practice nurses need to be prepared at the doctoral level with skills in healthcare policy, interprofessional collaboration (IPC), translating evidence into practice, and improving patient care quality.5,6 Thus, the essential curriculum elements identified by AACN include these topics as well as population health, information technology, and systems leadership for quality improvement.7
One ongoing question remains: Are DNP graduates using their newly acquired knowledge and skills to transform healthcare delivery systems? In other words, is the vision of nursing and other healthcare and academic leaders resulting in the desired goals of better patient outcomes and improved care delivery systems?
In a commissioned study by AACN, the RAND Corporation conducted a national survey of 400 nursing schools and interviewed 29 deans and/or directors of DNP programs.8 Generally, most of nursing's academic leaders believed the DNP provided good value in preparing graduates for leadership roles within healthcare systems.8 The study reported that academic leaders expressed concern that many employers did not understand the role or value of the DNP-prepared nurse. However, until there is evidence that DNP graduates are influencing outcomes across healthcare systems, nursing leaders may not value DNP preparation.
What is needed now is evidence that DNP-prepared nurses are adding value. Therefore, the purpose of this current study was to answer the following questions: 1) How do recently graduated DNPs describe their current practice? 2) How do supervisors of recently graduated DNP nurses describe the DNP's current practice? 3) Do nurse and supervisor descriptions of the practice of recently graduated DNPs reflect the AACN DNP Essentials7 and, if so, how?
Background and Significance
The US healthcare system has become increasingly complex over the past decade and currently has deficits across several critical domains. Challenges include a widening gap in equity of services, burnout among providers, cost containment, patient safety, and applying the most recent evidence in practice.9-13 Working toward solutions in these areas requires collaboration and bridge building across both professionals and consumers. Many medical and nursing schools have added interprofessional team building exercises to enhance interdisciplinary communication and patient outcomes. However, a Cochrane review of IPC studies has revealed that there is not yet sufficient evidence to demonstrate a significant effect of IPC on patient outcomes.14 Nonetheless, preparing advanced practice nurses with the skills to work collaboratively across complex systems to provide equitable and cost-effective care may provide healthcare organizations with the human capital necessary to achieving better population health outcomes.
There has long been a substantial gap (up to 17 years) between the generation of scientific knowledge and its application in healthcare settings.15 And while this gap may have diminished with the availability of online journals, a significant time lag for applying current knowledge to clinical practice remains.16 The requirement for translational research that incorporates evidence into practice and utilizes quality improvement methodologies is an important piece of the foundation for the DNP degree.6
Nursing is not alone in the call for a shift in the education of healthcare providers. The NAM has recently identified the need to design high-value healthcare models, using science, technology, and innovation as the underpinnings for healthcare delivery.9 Knowledge needed includes skills in change management, finance, quality improvement, data management, and technology innovation. Other healthcare disciplines also recognize the need to incorporate these skills into professional practice degrees. In 2013, the Association of American Medical Colleges published recommendations for integrating quality improvement into medical education.17 Likewise, physical therapy (PT) education recognizes the need for quality indicators to guide clinical decision making and evaluate patient quality of life.18
The nursing profession was an early adopter, recommending specific competencies within the DNP Essentials to ensure that advanced practice nurses can meet the challenges of an evolving healthcare system and act as proactive change agents.7 The question remaining is: Has the vision for the DNP graduate come to fruition?
Approval for participation of human subjects was received from the Seattle University internal review board. This cross-sectional study, using conventional content analysis,19 explored DNP graduates' narratives regarding the manner and extent to which doctoral education impacted their daily work life. Interviews with supervisors of the DNP graduates were explored for evidence that confirmed, refuted, or added to the graduate interviews.
The 10 graduates were from 7 different schools across the United States and held a variety of positions from educator to assistant chief nurse. The number of years the new graduates had practiced as an RN ranged from 6 to 37. Seven of the graduates held positions in acute care settings, 2 in academic settings, and 1 in primary care. Nine had attended post–master's degree DNP programs (7 were nurse practitioners and 2 held an MSN in nursing administration), and 1 was from a BSN-to-DNP (family nurse practitioner) program. All self-identified as female. Of the 9 supervisors, 7 were nurses, 1 was a PT, and 1 was an MD. Eight supervisors identified as female. Of the 7 nurse supervisors, 3 held a DNP, 3 a PhD, and 1 was master's degree prepared. Time supervising the DNPs ranged from 1 to 6 years. Each had supervised the DNP graduate during a portion of the graduate's doctoral studies as well as postgraduation.
Participants were recruited through professional networking and ARNP Listservs. Ten DNP graduates and 9 supervisors were interviewed either in person or over the phone (1 supervisor did not return emails). When DNP graduates expressed interest, an email was sent to describe the study, invite participation, and set up an appointment. Written informed consent was obtained prior to interviews (30-60 minutes). DNP graduates were asked to contact their supervisor to ascertain agreement to be interviewed. When the supervisor agreed to participate, a similar email was sent. Recruitment and data collection continued until it was agreed that no new codes or themes were found in the newly gathered transcripts and that there was strong convergence across graduates and supervisors around emerging themes.
Graduates were invited to think about how and if their performance had changed since completing their DNP and to provide specific examples. Supervisors were asked if they perceived the graduates' performance had changed since obtaining the DNP. Interview questions started out broadly (eg, In what ways does your current practice/job differ from your predoctoral practice?). Questions became more focused to guide participants toward discussion of the 8 DNP Essentials.7 Probes were focused on the following topics:
- Translating evidence into clinical practice (Essentials I, III, and VIII)
- Leading interprofessional teams toward a common goal (Essentials II, VI, and VIII)
- Designing, implementing, and evaluating programs for a specific patient population (Essentials V, VII, and VIII)
- Leading change across a complex system (Essentials II, IV, VI, and VIII)
- Improving patient outcomes (Essentials VII and VIII)
At the end of each interview, we asked, “What has been the biggest change in your (or the graduate's) approach to work since completing the DNP?” and “What do you (or the graduate) bring to the table now that you didn't bring before?” Interviews were recorded and transcribed verbatim.
To answer research questions 1 and 2, we used conventional content analysis. Hsieh and Shannon19 claim that this inductive method “is usually appropriate when existing theory or research literature on a phenomenon is limited.”19(p1279) The authors further elaborate that while theory does not drive inductive content analysis, it is appropriate to refer to extant theories and research to make sense of study findings. Each team member initially read and reread the text to “grasp” the narratives/stories being told. Team members then separately coded passages where the text provided evidence that the graduate's current work and effectiveness were influenced by having completed DNP education. The team met several times comparing and converging on which codes best captured which portion of the texts. This common coding schema was then applied individually to each transcript. We collectively grouped similar codes into thematic categories wherein coded texts became evidence of the existence of common themes. Supervisors' coded transcripts were analyzed for evidence that confirmed, amplified, or refuted the DNP-prepared employees claims about how having earned a DNP influenced their current practice. Themes were identified across the sample rather than by dyad.
To answer research question 3, we audited each transcript to determine if, according to graduates and supervisors, there was any evidence that recent graduates exhibit the DNP Essentials in practice. The audit consisted of counting the number of graduates who provided at least 1 exemplar of enactment of an essential. Likewise, we counted the number of supervisors who provided at least 1 exemplar of the recent graduate enacting the Essentials.7
The overarching theme emerging from narratives was “becoming more: re-envisioning self as an agent of change.” Overall, graduates expressed that they felt equipped and empowered to lead change within their organization. Moreover, for each of the 8 DNP Essentials, at least 80% of graduates provided exemplars from their current practice. As one stated,
I think of self-confidence, a professional self-confidence in who I am… I think it's more of a holistic systematic purview. Even if I went to another organization, I would still bring foundational elements of understanding systems, processes, and the importance of all the different dimensions that come along with a DNP. I think it's completeness.
An example of a supervisor quote that substantiated this theme is:
The fact that she had her DNP gave her that additional learning to be able to manage a wider variety or core of people versus just 1 hospital.
In addition, 3 subthemes emerged: “Belonging at the table,” “An engaged sense of agency,” and “Leading with and through others.” Supervisors' comments, embedded within the identified themes, provide substantiating evidence. Each subtheme is described below.
Belonging at the Table
Graduates conveyed that through the process of obtaining a DNP degree they felt they were now equal to other healthcare professionals within their organizations. Most expressed feeling a sense of equality with other leaders and a renewed sense of confidence. One graduate stated:
I felt I could sit at the table and I belonged at the table. I had the same level of professionalism and education that the team around me had.
Another graduate said:
I bring my voice… I have a level of confidence and belief in myself… being bold and not afraid to go against the grain.
The renewed sense of confidence provided graduates with the self-assurance to speak up at interdisciplinary meetings, initiate evidence-based practice changes, or lead organizational project teams. As one graduate stated:
It helped me with that process (leading interprofessional teams); I felt empowered to be able to move forward and felt empowered with knowledge.
This theme was substantiated by supervisor comments:
…one of the components that the DNP has done for her is provided her with framework and confidence in how she goes into those discussions. She is able to maneuver those dialogues a little more differently than what she had been doing. One of the things that I think the DNP did for her and for many others is to pull it up into a more equalized dialogue, with especially our physician partners, our physician leaders where we've had historically in nursing that educational gap, or the differential between different provider groups.
Engaged Sense of Agency
The 2nd theme was 1 of acquiring a new lens, or the ability to observe and interpret more complex patterns across an organization. The realization that they needed to consider patients as a population rather than simply their own panel of patients was evident across the interviews. Graduates stated that they felt they had acquired new knowledge and skills that helped them navigate complex systems and interpret data.
It makes me ever cognizant that things that appear on the surface certainly have more complexity underneath.
Another graduate stated:
It definitely gave me a different perspective on things. I think I started thinking more systems wide.
Graduates also expressed an appreciation for what constitutes evidence-based practice and how to apply evidence to practice. Prior to pursuing a DNP, most of the graduates stated that they had a basic knowledge of research, but felt they did not have the skills to translate evidence into practice. As 1 graduate stated:
By truly evaluating the evidence and delving into the literature, I came to understand more deeply what strong evidence directs you to do.
And, one of the supervisors stated:
She has become more adept at using educational evidence and applying that to her practice as an educator and administrator. Recently she was able to identify several evidence-based practices to improve the performance of site visits by clinical faculty.
Leading With and Through Others
Lastly, graduates overwhelmingly expressed that they felt empowered to lead change within and across organizations. The graduates acquired leadership strategies through both course work and the implementation of their DNP projects. Graduates realized that they could draw on these newly acquired skills and be impactful with regard to both the organization and patient outcomes. As 1 graduate stated:
Before I completed my DNP, I didn't have the tools that I needed to move forward in leadership, in a kind of system wide clinical practice.
Another graduate stated:
I learned concepts from the business sector and how to apply them through quality improvement processes to make change, such as Sigma Lean Six.
Graduates also expressed confidence in their skills to lead through others, igniting sparks for change in both their colleagues and interdisciplinary partners. As one graduate stated:
What I did to prepare this organization for change (for DNP project) was to start to pull everybody (dental, MAs, MDs, front desk, pharmacy, coding team) together to sit down and ask them for common goals.
A supervisor summarized the graduate's newly acquired leadership skills in this way:
She is more confident in her leadership capability. She has a level of emotional maturity that we all hope our colleagues will have.
Enactment of the DNP Essentials
Supplemental Digital Content 1, http://links.lww.com/JONA/A694, summarizes the number of graduates and supervisors who provided at least 1 exemplar of the occurrence of each essential in the practice of the recent graduate. Also displayed are exemplary quotes of essential enactment. There was evidence provided by 100% of the graduates that their practice was based on each of the 8 Essentials.7 Supervisor support for recent graduate essential enactment ranged from 78.8% to 100%.
Results support the claim that doctoral education prepares advanced practice nurses for effective leadership across complex healthcare systems. Enactment of the DNP Essentials is realized when graduates perceive themselves as equal to other leaders and capable of driving change using evidence and effective collaboration.
An enhanced sense of agency and empowerment were consistent themes across interviews with the graduates. These attributes reflect new ways of viewing self in relationship to others and greater confidence in self as an agent of change at a system level. From where and what did this transformation in self-understanding arise? Markus and Nurius20 provide a framework for examining transformations in self-understanding that occur through development and experience. They propose the concept of “possible selves” as cognitive maps or schema that bridge an individual's past and present with possibilities for self in the future. While individuals entertain many “possible selves,” not every possibility is realized. When an envisioned possibility for self is aligned with relevant models, plans, and strategies, these previously vague possibilities become more firmly linked to the present sense of self. The ability to envision oneself enacting a future self-ideal gains form and direction through knowledge, experience, and practice. As DNP students engage in goal-directed learning and modeling of system leaders, their vision of themselves as future system leaders becomes more strongly elaborated as possibilities for self in the future.21-23
To utilize DNP graduates to their fullest potential, nurse administrators must also be knowledgeable about the skills and expertise DNP-educated nurses bring to an organization. As 1 supervisor stated, "In that sense I think that leading change across continuums, across complex systems, is truly more successful at the DNP level. The receptiveness and the readiness of an entire system to benefit from a DNP graduate are beyond the graduate's control.” DNP graduates' newly discovered vision of themselves as agents of change will be magnified when mirrored back by administrators who affirm the DNP's capacity to transform healthcare across complex systems.
As with all descriptive qualitative research, human behavior and responses may be influenced by the researcher, process, and setting. Two of the 3 authors conducted all the interviews. A script of questions was used to maintain consistency across the interviews, and both researchers conducted the interview of the 1st dyad to ensure a uniform approach. However, as the authors developed the post–master's degree curriculum at their own university, it is possible that bias toward the DNP degree may have affected subject answers. Interviewers did not disclose to subjects their roles within the university unless asked by subjects. In addition, 9 of the 10 subjects completed a post–master's degree, which may or may not be representative of BSN-to-DNP students. And, although saturation across the sample was reached, the sample size was small and may not be universally applicable.
Conclusion and Recommendations for Future Research
Findings support the claim that through the process of obtaining a DNP degree advanced practice nurses acquire the skills and confidence to lead change across complex healthcare systems.2,24 An important finding is that for those advanced practice nurses who chose to return to school to obtain a DNP (9 of the 10 nurses interviewed), they acquired the ability to envision themselves as competent leaders who can work across multidisciplinary teams and leadership roles to implement measures to improve patient outcomes. Future research should focus on quantifying the impact on healthcare by DNP graduates, that is, money saved through the implementation of best practices or decreased patient morbidity and mortality. Similar to research on the positive impact of BSN-prepared nurses at the bedside,25 nurses need to continue to study the impact of DNP advanced practice nurses on healthcare outcomes. If employers receive evidence that the DNP degree can positively impact patient outcomes and cost-effectiveness, the value of DNP-prepared advanced practice nurses may be realized and recognized.
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