In 2011, The Future of Nursing report made the bold recommendation to increase bachelor's-prepared nurses to 80% by 2020.1 To achieve this impressive goal, the number of doctorally prepared nurses needs to increase to provide the infrastructure in both academia and the clinical setting to educate baccalaureate nursing students. In the same report, the recommendation was made to double the number of doctorally prepared nurses by 2020.
Nursing doctorates are available through two different educational programs. The PhD in nursing, which typically takes 4 to 5 full-time years to complete, is research-focused.2 The doctor of nursing practice (DNP) degree is clinically focused and takes 2 to 3 full-time years to complete. PhD-prepared nurses are leaders and scholars who generate external evidence and excel in the roles of researcher, faculty member, and administrator in both academic and healthcare organizations. DNP-prepared nurses are clinician leaders who generate internal evidence through quality improvement and evidence-based practice (EBP) and can likewise be faculty members and administrators, as well as direct care providers with advanced practice certification.2 DNP programs require students to produce a capstone or final project as an academic product reflecting their knowledge, expertise, and immersion experience, whereas PhD programs require students to produce a dissertation that demonstrates thorough and rigorous research.3
Obtaining a nursing doctorate is an ambitious undertaking that requires nurses to overcome several obstacles. Healthcare organizations and nurse managers can provide valuable support to nursing doctoral students and graduates to reap the benefits of this rich partnership. In this article, we explore barriers to doctoral nursing education, associated nurse manager and organizational supports, and the benefits of a positive practice environment for nurses working to advance their education. We also share the experiences of one health system that's supporting nurses during their doctoral studies.
Benefits of employing nurses with advanced degrees
To appreciate why a greater supply of doctorally prepared nurses is needed to educate, mentor, and precept nursing students at the master's and baccalaureate level, it's important to understand the impact of a more educated nursing workforce. Studies have shown that hospitals with higher proportions of RNs with baccalaureate degrees have better patient outcomes, which contribute to organizational cost savings.4-7 Economic simulations from one longitudinal study estimated that an academic medical center employing 1,500 nurses may save $5.6 million annually from the decrease in readmission rates associated with having 80% bachelor's-prepared nurses.7
Hospital-based PhD-prepared nurse researchers can contribute to the development and implementation of EBP processes that decrease costs. A study using average rates of reported adverse events for a 500-bed hospital to project the cost reductions that may be realized from nurse researcher-led EBP implementations addressing falls with injury, severe pressure injuries, uncomplicated pressure injuries, catheter-associated urinary tract infections (CAUTIs), and CAUTIs with bacteremia estimated that the total annual savings related to these hospital-acquired conditions exceeded $9 million.8 Nurses with PhD and DNP degrees can have a positive financial impact and improve patient outcomes at the same time as they contribute to growing the numbers of bachelor's-prepared nurses in the RN workforce.
Barriers and motivators
Entering a nursing doctoral program is a serious decision that entails facing barriers and challenges. Nurses enrolled in doctoral programs must be able to draw on internal and external motivation and know they'll be supported along the way. Primary barriers to pursuing doctoral studies include financial costs and the problem of balancing time for family, work, and studies.9 Difficulties finding preceptors and determining a final project are unique challenges reported by DNP degree students.10,11 The length of the program is a distinct issue for nurses pursuing PhD degrees.12
One study examining external strategies to motivate nurses to pursue advanced degrees found that organizational incentives and rewards, including scheduling flexibility, tuition reimbursement, forgivable service loans, worksite classes, and web-based classes, increased a nurse's likelihood to return to school.13 Internal motivators for nurses to pursue higher degrees include role modeling for their children, professional development and achievement, and personal and job satisfaction.9,14 As nurses consider doctoral studies, their employers and nurse managers can positively influence their decision-making process.
Nurse manager and organizational supports
Nurse managers play an essential role in creating an environment that's supportive to nurses pursuing higher education. Increasing nurse participation in hospital affairs has been associated with lower emotional exhaustion, work-family conflict, and burnout.15-17 Additionally, nurses who perceive more opportunities for development are less likely to leave the organization and report higher employee engagement.18,19 Support from nurse managers has been reported to decrease nurse intent to leave, job dissatisfaction, and emotional exhaustion.15,18,20-22 Nurse managers can facilitate flexible scheduling, which is consistent with lower intent to leave and higher job satisfaction.18,23-25
Supporting nursing doctoral students by providing opportunities to address issues within the organization can help promote their participation in hospital affairs while presenting developmental opportunities. Nurse managers' provision of flexible scheduling can foster work-life balance for nursing doctoral students. These concrete demonstrations of support may prove beneficial for nurses in doctoral programs, keeping them highly engaged and satisfied and helping the organization retain nurses who are doctoral students.
Recognizing healthcare organizations for establishing positive practice environments, the Pathway to Excellence® Program has multiple components that relate to the support of nurses pursuing doctoral studies.26 The six Pathway standards contributing to the positive practice environment are shared decision-making, leadership, safety, quality, well-being, and professional development. Elements linked to nursing doctoral education within the professional development standard include providing support for lifelong learning and higher education, guiding professional development through mentoring experiences, increasing competence after orientation, and empowering nurses as emerging leaders. The well-being standard specifies that organizations must support flexible scheduling for nurses, a practice that can help nursing doctoral students overcome scheduling challenges. Additionally, both nursing doctoral students and graduates serving as formal and informal leaders on shared governance committees, as described in the shared decision-making standard, can contribute to improvement initiatives consistent with the safety and quality standards.
At the BayCare Health System throughout the Tampa Bay and central Florida regions, all acute care hospitals have achieved Pathway to Excellence designation. BayCare's nursing research and EBP council mentors nurses and nursing students with their research and quality improvement/EBP inquiries. In addition to mentorship, the council holds an annual nursing research and EBP conference and provides doctorally prepared preceptors. The council supports all nursing research and EBP projects that align with the BayCare quality outcome indicators. BayCare has relationships with local colleges and universities, and the council has college and university representation.
When a doctoral student requests student placement within BayCare, student liaisons diligently work to pair the student with a doctorally prepared nurse in the student's specialty area. This pairing provides the student with the support needed to assist in development of a project that's mutually beneficial to the student and organization. In conjunction with the academic program, students are mentored to align BayCare's goals with academic requirements. During the initial project or study development, BayCare requires written manager and director support from the unit in which the project or study will be implemented. For current BayCare team members, the student project or study can't be completed on their unit of employment.
During development of the EBP project or dissertation study, students are required to first obtain the school's Institutional Review Board (IRB) approval before seeking BayCare's IRB approval. Each doctoral student is encouraged to utilize internal resources to develop and organize their dissertation defense. Various BayCare resources include submission guidelines, IRB information, and links for IRB researcher training—all in a central online location. Once the school's IRB approval is obtained, the student presents his or her proposal to the nursing research and EBP council for support to proceed to IRB. Members of the council, including the college or university council members, provide feedback and have the opportunity to ask questions to enhance the project. Once fully supported by the council, the project or dissertation can then be submitted to BayCare's IRB for approval.
BayCare promotes educational development and training through a tuition assistance program that provides financial assistance to help team members improve, advance, or transfer to another position within the organization. In addition to tuition assistance, the use of flexible scheduling empowers nurses to balance work and personal life. For example, one nurse currently enrolled in a DNP degree program who was required to attend classes 1 day a week was able to schedule around her school commitments through self-scheduling. She's also an active member of the nursing research and EBP council. This supports her engagement and increases her level of job satisfaction. She can leverage her work-life balance and passion for EBP to advance nursing excellence at the unit level.
Throughout BayCare, doctorally prepared nurses work in a variety of roles from clinical nurse, nurse educator, and nurse manager to the vice president of systems and resources. Doctorally prepared nurses are encouraged to use their educational preparation in their current roles and mentor doctoral students through participation in the nursing research and EPB council. The advantage of doctorally prepared nurses in any role is their ability to use their educational background to critically identify and evaluate problems through an EBP lens, removing barriers to enhancing patient care outcomes. At one BayCare hospital, a PhD nurse researcher overseeing an EBP project reduced indwelling catheter device days and CAUTIs. In another example, a PhD nurse researcher working with a DNP-prepared nurse streamlined the initial competency for nurses to be driven at the division level rather than using one initial competency for every nurse in the organization.
Student IRB-approved research and EBP or quality projects at BayCare have addressed topics such as CAUTI prevention, hand hygiene practices on the CCU, using all patient refined diagnosis-related groups to reduce hospital readmissions, and post cardiac arrest outcomes among patients eligible for targeted temperature management to name a few. Doctoral students' success has been beneficial to BayCare because these projects have all had a positive impact on patient care. Results of each project are presented to project site leaders, with recommendations for change evaluated individually. Additionally, results are disseminated at the annual nursing research and EBP conference.
The Pathway to Excellence philosophy of a positive practice environment where nurses can excel is embedded throughout patient services within the BayCare Health System. Through encouraging the pursuit of lifelong learning, tuition assistance, and employee engagement, BayCare supports its nurses to pursue doctoral education.
Supporting doctoral students, whether PhD or DNP, positively impacts the organization through promotion of EBP to improve patient care outcomes. Nurse leaders play a critical role in creating open and supportive environments for nurses to pursue doctoral degrees. Through robust tuition reimbursement programs and accommodating work schedules, organizations also play a pivotal role. By implementing a structured process to support doctoral students, earning an advanced degree doesn't have to be as challenging as it may seem.
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