Doctor of nursing practice (DNP) programs are now available in all 50 states plus the District of Columbia.1,2 As of April 2018, there were 303 DNP programs enrolling students at schools of nursing nationwide, and an additional 124 new DNP programs were in the planning stages (58 post–baccalaureate degree and 66 post–master's degree programs). As the number of both DNP programs and students increases annually across the United States, the potential for program and outcomes variation increases.3
An area that seems to be particularly prone to variability is the degree to which Quality and Safety Education for Nurses (QSEN) graduate-level competencies and quality improvement (QI) processes are incorporated into DNP curricula and applied in the DNP project. The content of DNP education influences how DNP-prepared nurses are perceived and function within the US health care system. Therefore, it is critical that there is consistency across DNP programs as they relate to graduates' outcomes and ability to meet the needs of the health care systems and patients they serve.
Since 2005, the QSEN initiative has provided guidance for faculty to facilitate the education of nurses to ensure they are gaining the knowledge and skills needed to provide high-quality and safe patient care at all levels of practice. In January 2016, the QSEN Institute formed a National QSEN Doctor of Nursing Practice Task Force to foster collaboration with key organizations to advance quality and safety education in DNP programs and measure the impact of DNP graduates in transforming quality and safety in health care systems. As the QSEN DNP task force set goals for 2016-2017, the following issues were identified as areas to be addressed: wide variation in DNP scholarly project expectations and output, inconsistency in DNP program curricula related to QSEN competencies, inconsistent integration of QI and QSEN in DNP curricula, and lack of data to describe graduates' impact on the health care system. This study was a beginning step to address these issues and attempt to gain greater insight into the current state of DNP project characteristics as well as faculty knowledge, skills, and attitudes (KSAs) related to QI processes as this will influence how QI and QSEN principles are integrated into curricula.
The DNP project may take several forms, but at minimum the American Association of Colleges of Nursing (AACN) recommends that the project elements of system change, planning, implementation, evaluation, and sustainability should be required for all students.3 These elements are inherent in QI processes, and attention to safe, quality health care is threaded throughout the DNP Essentials document2 and Graduate-Level QSEN Competencies.4 Integration of QSEN competencies in DNP curricula is an effective strategy to facilitate the acquisition of the KSAs important for providing high-quality and safe care for patients at all levels of practice and for system transformation.5
While there is general agreement that the DNP project should demonstrate evidence of the application of the Essentials, there is wide variability in how projects are conducted.6 Quality improvement projects comprise the majority of DNP projects6 and are an essential component to the system change strategies needed to improve the quality and safety of US health care. However, the majority of faculty are dissatisfied with the end product of most DNP projects, which is due largely to a reported lack of knowledge in QI and evidence-based practice among the faculty.6 This lack of knowledge is expected given that faculty in DNP programs are often PhD-prepared faculty whose expertise tends to be with research methodology rather than the practice of QI and evidence-based application in clinical settings.6,7 Although the faculty makeup is shifting as growing numbers of DNP graduates seek faculty roles, there is a current need to ensure that faculty are prepared to educate tomorrow's DNP-prepared providers to meet future system, employer, and patient needs and expectations.
Although a topic of discussion among many DNP faculty, a literature search yielded minimal information regarding the use of QSEN competencies and QI processes in DNP curricula, extent to which DNP faculty feel prepared to teach or skilled to implement QI, and degree to which graduates feel prepared to apply these skills in practice. There is a need for baseline data to identify needs and opportunities for improvement related to quality and safety curricular integration and faculty knowledge of QI and QSEN principles. Further, to determine the current impact of the DNP role in health care transformation, it is important to know the extent to which DNP graduates are applying quality and safety in their practice and to identify factors that influence the application of quality and safety principles. Therefore, the purposes of this national survey were to (1) describe DNP program scholarly project characteristics, (2) compare KSAs of QI processes between faculty teaching in DNP programs and DNP graduates, and (3) compare KSAs of QI processes between faculty types (faculty with DNP degrees vs faculty with PhD, EdD, DNSc [hereafter designated as PhD] degrees).
This project was a cross-sectional, descriptive study that used a national convenience sample from 2 different groups: faculty who currently teach in and graduates from a US DNP program. Faculty were recruited by an email that included a link to the survey. Simultaneously, DNP graduates were recruited by posting the study invitation with a cover letter on the website of Doctors of Nursing Practice, Inc.8 Data collection occurred in the spring of 2017 using an online survey software program.9 This study received approval from the university institutional review board.
The DNP scholarly project characteristics were assessed using an 8-item structured survey. Items included project requirement, defense requirement, number of semesters devoted to the project, type of project (4 types), number of faculty on the DNP team, group versus solo project, and interdisciplinary involvement. Response options for the type of project included a mini dissertation, QI/practice improvement project, needs assessment, literature review, or other.
KSAs of QI processes were assessed using a modified version of the Quality Improvement Knowledge, Skills, and Attitudes (QuIKSA) tool,10 selected items from the Institute for Health Care Improvement's Improvement Advisor Professional Development Program Self-Assessment Tool,11 and from other surveys assessing QI KSAs. The original QuIKSA survey consisted of 73 items with 3 dimensions: QI knowledge, QI skills, and QI attitudes. Members of the QSEN DNP task force conducted a pilot study (N = 17) using the QuIKSA for length and feasibility at 1 college of nursing. Subsequently, the original QuIKSA survey was reduced to 63 items by deleting items inappropriate for this study. Of the 63 items, 6 questions evaluated QI knowledge with true-false or multiple-choice questions. Thirty-three questions assessed QI skills and used a 6-point Likert scale (1 = novice, not familiar with, never used, to 6 = understand the process/term, use >9 times in my work, able to teach). Attitudes toward QI processes were assessed in 24 items using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). The QuIKSA interitem correlation was 0.89 (P = .001).10 For the revised survey, internal consistency ranged from 0.88 to 0.96 for the skills and attitude questions.
Three open-ended questions were added to gather participants' comments or concerns with QI education in the academic setting (faculty) or use of QI processes in the clinical setting (graduates), curricular integration of QSEN competencies, and faculty development needs related to QI and QSEN competencies. To enable sample description, demographic characteristics of the DNP faculty and graduates were collected. These items included age, gender, years as a licensed RN, years teaching in a DNP program if applicable, highest earned degree, and area of practice.
Descriptive statistics, including means and SDs or frequency distributions, as appropriate, were used to summarize study variables. Individual items as well as total mean scores from the QI skills and attitudes measures were compared between groups (DNP-prepared faculty vs faculty with other doctorates [PhD], faculty vs graduates) using the 2-sample t test. All data analyses were conducted using Statistical Analysis System (SAS), version 9.4 (SAS Institute, Cary, NC), with an α level of .05 throughout.
Of the 232 DNP programs, a total of 117 faculty who teach in a US DNP program completed the demographic and project characteristics survey items; only 73 of these faculty completed the KSA items in the survey. Thirty DNP graduates who are not faculty also completed the demographic and project characteristics items, but only 18 of these DNP graduates completed the KSA survey items. Most of the participants were female (91%), were older than 51 years (77.3%), and had more than 30 years of experience as a nurse. Among the faculty, the majority had more than 3 years of experience teaching in a DNP program, were PhD prepared, and worked in an academic setting (Table 1, Supplemental Digital Content, http://links.lww.com/NE/A623).
DNP Scholarly Projects
Of the 117 DNP faculty, 98% reported that the DNP scholarly project was a requirement of their program. The predominant type of project was QI or practice improvement (n = 100 [85.5%]). Thirteen faculty (12%) listed other types of scholarly projects including evidence-based practice project, policy analysis, or program evaluation. Most of the DNP programs devoted 3 or 4 semesters to the project development (62.9%), included 2 to 3 faculty on the project team (n = 50 [69.5%]), and required a formal defense process (n = 95 [82.2%]). Half of the DNP faculty (55%) responded that their DNP program required implementation of a practice change, and 65% of DNP faculty reported that their program required an evaluation of a practice change. About one-quarter (22.8% [n = 27]) of the DNP faculty reported that their program allowed students to work in groups during the DNP project. Sixty-five percent (n = 76) of faculty reported that scholarly projects involved interprofessional teams.
KSAs Between DNP Faculty and Graduates
Sixty-six percent of DNP faculty had completed a formal QI course. For QI knowledge, 86% (n = 73) of DNP faculty correctly answered all questions except 1 item regarding the purpose of a control chart where only 47% (n = 35) chose the correct answer. All DNP graduates (n = 18) correctly answered all knowledge questions except for 1 question in which 1 participant answered incorrectly (Table 2, Supplemental Digital Content, http://links.lww.com/NE/A624).
The faculty rated themselves as skilled but not proficient in the majority of the QI skills. Mean scores for the items in which the faculty rated themselves as the most skilled ranged from 4 to 4.9 on a 6-point scale (from 1 = novice to 6 = expert). Examples of most proficient skills included facilitating focus groups, making changes in a system, and developing changes. The areas in which faculty rated themselves as less proficient (mean scores ≤4) were failure modes and effects analysis, run charts, control charts, and Pareto charts. The DNP graduates also rated themselves as skilled but not proficient in QI skills with mean scores of 4.1 to 4.9 on a 6-point scale. The graduates rated themselves as most proficient in developing changes and assuming the role as team leader, with mean scores of 4.8 and 4.9, respectively. There were no significant differences between the faculty and graduates on QI skills (Table 3, Supplemental Digital Content, http://links.lww.com/NE/A625).
The attitude item both DNP faculty and DNP graduates most strongly agreed with were “Nurses play an important role in a hospital's QI efforts,” although the difference between the groups was significant at (4.8, 4.9; P = .026). An additional significant finding occurred for the item “Employers expect DNP graduates to be well prepared to help facilitate health care transformation in their clinical setting.” Both faculty and the graduates were neutral or agreed (4.2, 3.7; P = .022). Although not statistically significant, an interesting finding was that faculty and graduates both disagreed with the statement “Employers expect DNP graduates to be prepared to participate in, but not lead, QI initiatives in their clinical setting” (3.2, 3.5; P = .29; Table 4, Supplemental Digital Content, http://links.lww.com/NE/A626) and had stronger agreement that “Employers expect DNP graduates to be prepared to lead QI initiatives in their clinical setting” (4.2, 3.7; P = .11).
Items that assessed confidence in one's KSAs to participate in QI revealed significant differences between the faculty and graduates. The DNP faculty reported significantly less confidence in their knowledge (P = .002) and skills (P = .007) to participate in QI than the DNP graduates (Table).
KSAs Between DNP and PhD-Prepared Faculty
Comparing QI KSAs between DNP- and PhD-prepared faculty was the third study aim. No differences were found between groups for QI knowledge or skills, but were found for QI attitudes. The DNP-prepared faculty had more favorable attitudes on all attitudes items with significant differences between 4: (1) they felt significantly more positive that physicians (DNP 3.6, PhD 3.1; P = .038) and (2) hospital management/managers (DNP 4.5, PhD 3.9; P = .011) highly value QI initiatives/projects, and QI initiatives/projects are important for improving (3) patient satisfaction (DNP 4.9, PhD 4.5; P = <.001) and (4) hospital reimbursement (DNP 4.8, PhD 4.5; P = .035).
The Table illustrates the differences between DNP- and PhD-prepared faculty concerning confidence in KSAs to participate in QI in nursing practice. The PhD-prepared faculty had significantly less confidence in knowledge (PhD 3.8, DNP 4.4; P = .026) and less confidence in their skills (PhD 3.8, DNP 4.4; P = .025) than DNP-prepared faculty.
Twenty-five faculty participants responded to the open-ended questions. The majority of those responding had no concerns with QI or QSEN in the academic and practice settings. The focus of the DNP faculty concerns included the need for a QI and QSEN faculty refresher, more in-depth QI content in the DNP program, faculty development in both QI and QSEN, and the need to apply QSEN to a practice setting. DNP graduate concerns involved implementing QI in the practice setting and the ability to be “at the table” when QI is discussed.
This study describes the current state of DNP projects and differences in QI KSAs between DNP program faculty and graduates, and between faculty with varying doctoral degrees (DNP and PhD and all other doctoral degrees). The main findings indicate that nearly all DNP programs represented in this study (98%) require a DNP project, and 85% of these projects are classified as QI. Quality improvement knowledge deficits were identified for the DNP program faculty. The faculty reported a lack of confidence in knowledge and skills related to QI yet high confidence in having the necessary attitudes for participating in QI. In the narrative comments, strong themes emerged related to the need for faculty development in the area of QI and QSEN competencies.
Despite the efforts of the 2015 AACN white paper to provide guidance on the characteristics of the DNP project,3 many challenges remain. As expected, the majority of programs (98%) reported the requirement of a DNP project, most of which are classified as QI/practice improvement (85%). This is similar to a recent study by Dols et al6 that described project characteristics of 90 DNP programs in the United States and found that 97% of the DNP projects consisted of QI activities.
KSAs Between Faculty and Graduates
In this study, the majority of participants reported having some type of formal training in QI, with DNP graduates reporting more training than DNP program faculty. Participants answered correctly all but 1 of the knowledge questions. Knowledge about the purpose of a control chart was a differentiating item. All the DNP graduates knew this answer, with more than half of the PhD-prepared faculty (52%) and only 20% of the DNP-prepared faculty answering this question correctly. This finding was unexpected because a control chart is a basic QI tool that one would expect to find in a DNP curriculum and is not typically taught in a PhD curriculum; thus, further investigation is warranted.
Faculty and graduates had favorable attitudes related to employers' expectations that DNP graduates lead QI in their clinical setting and are prepared to facilitate health care transformation. Interestingly, the DNP graduates' attitudes were less favorable than the faculty. This finding is consistent with Melnyk7 and may suggest that DNP graduates are not experiencing the expectation or opportunity to lead health care change in their practice environments. One revealing open-ended response from a DNP graduate illustrates this sentiment, “Employers need to get nurses and advanced nursing practice at the table when developing and implementing QI for sustainability.” Employers may not fully recognize the potential contribution the DNP graduate can have.12 Evaluation of the impact of the role of the DNP graduate in health care transformation is an important next step to facilitate employers' recognition and actualization of the value of the DNP-prepared clinician.
KSAs Between Faculty by Degree Preparation
The fact that there were no statistically significant differences in QI knowledge between the DNP- and PhD-prepared faculty is an important finding to highlight in this study. Both faculty groups rated themselves as most proficient in leading teams and facilitating groups, developing and making changes, and using a QI methodology such as PDSA (Plan-Do-Study-Act). Both groups rated themselves as least proficient in the skills related to data display and use of QI tools (run charts, control charts, Pareto charts), as well as processes to help prevent a quality problem (failure modes and effects analysis). Similarly, Dols and colleagues6 reported faculty knowledge about QI methods was the most frequently reported challenge (33%) to successful completion of the final DNP project. These findings are consistent with the Altmiller and Armstrong's13 study that found QI was one of the least likely QSEN competencies to be taught. These findings provide direction for faculty development efforts.
Another important finding was that PhD-prepared faculty had significantly less confidence in QI knowledge (PhD 3.8, DNP 4.4; P = .026) and less confidence in QI skills (PhD 3.8, DNP 4.4; P = .025) than DNP-prepared faculty. The lack of confidence reported by PhD-prepared faculty in both QI knowledge and skills offers further support for faculty development. In contrast, the DNP-prepared faculty may have a more accurate sense of the expectation for and impact of QI in the clinical setting by nature of their more recent education and focus on clinical practice.
DNP program faculty are acutely aware of the challenges of project quality, QI in DNP education, and quality and safety in clinical settings and are prepared to act. By using the modified QuIKSA survey from this study, individual DNP programs could benefit from a self-assessment to identify priority needs in their programs. This evaluation could provide information regarding the degree to which didactic learning and experiential learning address QSEN competencies and application of QI knowledge. Previously published articles expand on learning activities designed to enhance curricular integration of QSEN graduate competencies.14
Faculty also need to seek out opportunities in experiential learning in quality and safety through simulation or real-life application with clinical partners for DNP students to augment their clinical practice experience. Such collaborative partnerships can provide an exceptionally rich learning experience for students, faculty, and clinicians and facilitate achievement of educational and patient care outcomes.15
The need for QI faculty development was a clear finding from this study. While basic knowledge and skills were adequate, confidence in both knowledge and skills was lacking. Narrative comments from both DNP program faculty and graduates reinforced the need for repeated application of QI processes. Consequently, DNP faculty require further QI competency education and practice to fully engage students in learning.
Limitations to the study included issues with obtaining the best email addresses for the target audience as well as some minor technical challenges with survey administration. These 2 limitations may have resulted in a smaller total sample size. Another limitation was a relatively small sample, particularly in DNP-prepared faculty, which limits generalizability. Finally, there was an unexplained drop in responses on the KSA items (which came after the demographic and program characteristic items) in both the faculty (from n = 117 to n = 73) and the DNP graduate (from n = 30 to n = 18) groups, which needs to be explored further for possible causes. Despite these limitations, important similarities and differences were identified among groups, and QI and QSEN competencies were identified as key areas for faculty development.
This study found that DNP scholarly projects across the United States contained many of the common characteristics of being QI focused and requiring planning, implementation, and evaluation of a practice change. The faculty reported having basic knowledge, basic proficiency, and positive attitudes about their ability to apply QI skills. For QI knowledge and QI skills, no differences were found between faculty groups (PhD vs DNP). Several statistically significant differences were found with QI attitudes. PhD-prepared faculty had significantly less confidence in their knowledge and skills than DNP-prepared faculty. This finding suggests a need for DNP faculty development.
In addition, this study identified the need for further clarification of the role and impact of the DNP graduate in health care. DNP curricula that are solidly aligned with the QSEN graduate competencies should provide graduates with the QI KSAs to maximize health care transformation. Ensuring a predictable DNP graduate from programs across the country will enhance employers' perceptions of the contribution and value of the DNP graduate. The skill set of the DNP graduate has the potential to provide significant leadership in addressing the challenges inherent in the US health care system. Robust DNP program curricula along with ample opportunities to learn and apply QI skills while in the DNP programs will maximize this potential.
This work was completed on behalf of the QSEN DNP Task Force, of which all authors are members. The authors acknowledge Dr Amanda Thaxton-Wiggins for assistance with data analysis.
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