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Under new American Association of Colleges of Nursing (AACN) guidelines adopted October 25, 2004, advanced practice nurses and other RNs seeking top clinical roles will be educated at the doctorate level. By 2015, all programs that prepare APNs — nurse practitioners, midwives, anesthetists, and clinical nurse specialists — will be established to grant the Doctor of Nursing Practice (DNP). Doctorates will not be required for APNs currently in practice. They will maintain authority to practice, as occurred when APN education transitioned to the master’s level.

“This is a patient care issue,” says AACN Executive Director Geraldine (Polly) Bednash, RN, PhD, FAAN. “APNs will be better prepared for the complex health care system and will have the authority to intervene, which will help patients get better care.”

Though many schools of nursing are moving in this direction, the transition from master’s to DNP is not without controversy.

A matter of degree

DNP advocates say it’s time to commit to the development of clinical practice knowledge at the highest level possible. Of the two types of nursing doctorates — research- and practice-based — educational programs for terminal degrees in nursing tend to focus on research. McEwen and Bechtel’s 1999 Survey of Doctoral Programs in Nursing reports that 88% of the 70 existing doctoral programs in the U.S. award PhDs.¹

“The DNP is a practice degree that prepares graduates to assume full leadership roles in clinical practice, clinical teaching, and action research,” says Ann O’Sullivan, RN, PhD, CRNP, CPNP, FAAN, president of the National Organization of Nurse Practitioner Faculties (NONPF). Here, nursing practice refers to direct patient care by clinicians and direct care policies, programs, and protocols that expert nurse clinicians organize and improve on, says AACN’s Position Statement on the Practice Doctorate in Nursing .

In addition to acknowledging their expertise, the DNP provides APNs and nurse leaders parity with medical doctors, pharmacists, and dentists. “If other health science disciplines award doctoral degrees for their highest level of practice, why would nursing do less?” says Phyllis Zimmer, RN, ARNP, MN, FNP, FAAN, faculty, FNP Program, School of Nursing, University of Washington, Seattle.

The DNP is different from — but not less than — the research doctorate. Faculty who hold the DNP will have the best preparation for clinical teaching, says Joyce Fitzpatrick, RN, MBA, PhD, FAAN, professor, Frances Payne Bolton School of Nursing, Case Western Reserve Univer­sity, Cleveland. The clinical teacher should be the expert clinician who prepares nurses for basic and advanced clinical practice. According to Fitzpatrick, the majority of PhD graduates don’t assume positions in which their primary responsibility is research. They teach in the clinical arena when often they are no longer expert clinicians.²

Though proponents say the practice degree more adequately speaks to the educational and professional needs of APNs, others support the better-known PhD.

“The PhD prepares nurse scientists, but its research component is driven by the fundamental knowledge needed for practice; and this knowledge is translated into practice,” says Afaf Meleis, RN, PhD, DrPS (hon), FAAN, dean, School of Nursing, University of Pennsylvania, Philadelphia.

Science will answer important practice questions as evidenced by the research programs across the country relating to patient care and clinically important questions — pain management, sleep issues, coping, and living with chronicity.

“We need to be translating these programs instead of developing another degree that will create another tier in academic life,” says Meleis.

The PhD is a respected, rigorous academic degree, says Kathleen Dracup, RN, DNSc, FAAN, dean, School of Nursing, University of California, San Francisco. In the 1990s, the few opportunities for PhD nurses included teaching or conducting research. Now hospitals hire them as chief nursing officers; directors of education, research, and quality improvement departments; and in other clinical roles. “Why add a new professional degree when you can practice with the PhD as other disciplines do?” she asks.

A matter of curriculum

Current APN programs are credit-dense — some near twice the length of master’s programs in other disciplines.

“The DNP program is expanded with appropriate doctoral content, and the degree recognizes the amount of work that goes into the APN program,” says Margaret Fitzgerald, APRN, MS, BC, NP-C, FNP, FAAN, president of Fitzgerald Health Education Associates and family nurse practitioner at the Greater Lawrence (Mass.) Family Health Center, Inc.

Zimmer describes the proposed DNP curriculum for the School of Nursing at the University of Washington, Seattle, as an enhancement of an already strong master’s program. It will include a residency component that supports the integration of knowledge into practice and focuses on practice management skills. What’s more, health policy coursework with a focus on leadership development will enable graduates to become change agents in the health care system.

“As scientific knowledge, practice opportunities, and technology have evolved, so too have the expectations of APN practice,” says Zimmer. There is growing complexity of patient care and service delivery with a strong emphasis on evidence-based care. APNs are not simply caring for well individuals: They are caring for those with complex health needs and concurrent psychosocial problems.

Those opposed to the DNP point to research indicating that the quality of care provided by nurse practitioners is equal to that of physicians.³