Pursuing Nursing’s Terminal Clinical Degree, the DNP: The Practical Benefits

TON May 2016 Vol 9 No 3 - Perspective
Gary Shelton, DNP, NP, ANP-BC, AOCNP

The doctoral degree in nursing is earned as either a professional or a practice degree. Nurses with professional doctorates test and validate new knowledge, whereas nurses with practice doctorates apply knowledge in a practice setting to solve problems or inform practice.1 Stated differently, our PhD colleagues generate new information and the doctor of nursing practice (DNP) degree prepares advanced practice nurses (APNs) to translate those concepts into best practice using their expert assessment and analysis skills.2,3

The DNP-prepared APN can also assume a leading role in true research. As we investigate the knowledge and evidence to support practice change, we may determine there is limited or inconclusive evidence and therefore need to produce new knowledge. The DNP can collaborate with those holding nursing science doctorates to coinvestigate gaps in the literature.4

Evidence-Based Medicine

Both original research and evidence-based practice (EBP) change can result in new knowledge, but generally the EBP interventions result in better outcomes by translating knowledge into practice. Sigma Theta Tau International Honor Society of Nursing defined EBP as integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are served.5 EBP change is seen as the completion of the research process, creating improved outcomes for patient care.

“EBP has been recognized by the healthcare community as well as by regulatory agencies as the gold standard for the provision of safe and compassionate health care,” according to Toole and colleagues.6 In addition, organizations are being reimbursed on clinical care and patient experience measures.6

Polit and Beck point out that “strong leadership in healthcare organizations is essential to making evidence-based practice happen.”7 Problem-focused or knowledge-focused triggers that identify the call for change are the beginning of the organization’s evaluative process. “Evidence-based practice is imperative in clinical settings because it bridges the gap between research findings and clinical practice; promoting nursing interest and enthusiasm for research is crucial,” note Liou and colleagues.8 DNPs understand the need to investigate systems issues, nursing knowledge or interest, and organizational buy-in, as well as patient or client satisfaction, to develop a climate that embraces EBP.

Striving to Be Leaders

The need to increase our education to that of a DNP is reflective of the times. We wish to increase our own legitimacy. Although the proposed educational paradigm shift that by 2015 all nurses would be prepared either at the baccalaureate level or the doctoral level did not happen universally, scholars and leaders in nursing indicate that such distinction is near.9 Eldridge espouses this belief: “The advanced practice nurse begins with the human being, not with the disease, and with the individual human’s unique values and goals. The person and the nurse embark on an experiential journey together...guiding the person along a path that belongs only to the person within his or her special environment.”10 As Eldridge reminds us, “Graduation with a DNP degree should be only one stage of an ongoing, lifelong quest for knowledge and growth.”10

Petersen cited the 2006 American Association of Colleges of Nursing publication that noted “advanced nursing practice includes an organizational and systems leadership component that emphasizes practice, ongoing improvement of health outcomes, and ensuring patient safety.”11 Petersen also describes strategic facets of “systems thinking.” The accountabilities and interactions of all stakeholders within the healthcare system should be emphasized, and DNPs are well-suited to lead the process. As Nelson and colleagues point out, “patients and their families are active agents and indeed partners in the creation, preservation, and restoration of their own health.”12 The DNP leader and scholar will assure that EBP is provided to patients.

A wealth of experiences follows APNs into DNP programs, expanding knowledge, and enabling them to appraise the level and quality of research analyzed. Citing Linda Pearson’s definition, Scott and McSherry share that “EBP is the process of making clinical decisions based on the most valid and relevant information currently available.”13

The 2 Facets of Healthcare

Batalden and colleagues explain that “everyone in health care really has two jobs: to do the work and to improve the value of that work...all microsystem members must endeavor to learn continually, so that both clinical care and its system-based improvement are performed with ever-increasing effectiveness and creativity.”14 DNPs’ strengths come from increasing knowledge, years of observational experience, and confidence in their abilities to lead. Morrisey and DeBourgh mirror the DNP philosophy: “nurses assume responsibility and accountability for their practice...nurses are challenged to find efficient and effective methods to stay current in their knowledge and practice.”15

As the DNP assesses the clinical microsystem, help comes from the Institute of Medicine (IOM). The IOM describes 6 foci for improving healthcare systems, in Crossing the Quality Chasm.16 As discussed by Suresh and colleagues, patient safety is a primary aim, as well as effectiveness, patient centeredness, timeliness, efficiency, and equity.17 They continue, “To create the precondition of safety it is necessary to assess and improve processes at the microsystem, mesosystem, and macrosystem levels….”17

The DNP is instrumental in making sure problems are addressed and assessed in a systematic way, delving into the permutations of cause, so that a clearer focus for change is examined. Searching the literature for EBP provides the basis for healthcare interventions tailored to individual patient needs that are both personalized to patient values and integrated with the best research evidence.7 Citing Maurino’s observation that “humans can never outperform the system which bounds and constrains them,”18 Liang points out that the fundamental systems-based nature of error and its successful reduction clearly demonstrate that the individual-oriented shame-and-blame mechanisms are antithetical to, and ineffective in, reducing error.19

DNP leadership style includes a skill set that understands evaluation of process, has tools for evaluating evidence, and flows with communication and people skills to achieve improved outcomes due to behavior change.20 The DNP knows to ask the “why” questions that lead us to review and evaluate the evidence. Understanding how to prioritize gives us more credibility and clout.21 There are challenges, however, in arriving at better practice. We understand that fostering teamwork and collaboration with our nursing peers rewards and inspires their buy-in, thus improving outcomes.22

Conclusion

The defining concept of DNP coursework is that of creating the transformational leader. The nurse leader has a variety of attributes, complete with a vision for developing an interdisciplinary team able to be collaborative and autonomous. The DNP assures a viable healthcare setting for organizational growth and improved patient outcomes.23 DNPs’ actions matter and influence the working environment.24 We will create the future. I feel more confident, and insightful, to share a dream and create change.

A new concept for me was that of emotional intelligence—how well do we know ourselves and how can we propel ourselves from a feeling of self-actualization? As healthcare settings become more complex and we become more technologically savvy, we may be emotionally underdeveloped. Chism states that emotional intelligence is more important in promoting excellence than IQ.25 I hope to improve both.

As DNPs, we reflect on a wealth of experience. We know that a good leader is aware of potential conflict and ethical dilemmas that are inevitable in complex working environments. We know the importance of having strategies to prevent disruptive behaviors. Our ethic-of-care framework promotes a working environment where patient-centered and peer-centered foci facilitate a harmonious healthcare team.26,27 Boyer’s Criteria for Evaluation of Scholarship (as cited in White) states that there must be “evidence of self-reflection and learning.”9 From this, I can share comfortably that while becoming a DNP and throughout my scholarly coursework, both my learning and self-reflection have been immense. While a student DNP, I allowed myself time to read 31 nonhealthcare books for my own enjoyment. Frustration and fatigue plagued my full-time work and family life, however, and finding a balance in performing all of life’s duties was difficult. Inner strength, focusing on my educational goals, and accepting the support of others allowed me to take care of myself. Visualizing myself as a DNP helped in maintaining some normalcy.

Transformational leaders engage patients and families, thus providing for patient-centered care and improved outcomes. I definitely identify myself as a transformational leader. I have gained the confidence to allow my charisma to be contagious and to use my leadership as a beacon to light the environment fostering interdisciplinary collaboration.28,29 Although it is important to identify the DNP as a terminal degree, education should never be seen as being completed. The pursuit of higher education opens doors that reveal more possibilities and opportunities.

References

1. Edwardson SR. Introduction: imagining the DNP role. In: Zaccagnini ME, White KW, eds. The Doctor of Nursing Practice Essentials: A New Model for Advanced Practice Nursing. 2nd ed. Sudbury, MA: Jones and Bartlett Publishers; 2014:xiii-xxiv.
2. Brown-Benedict D. The Doctor of Nursing Practice degree: lessons from the history of the professional doctorate in other health disciplines. J Nurs Educ. 2008;47(10):448-457.
3. Tymkow C. Clinical scholarship and evidence-based practice. In: Zaccagnini ME, White KW, eds. The Doctor of Nursing Practice Essentials: A New Model for Advanced Practice Nursing. 2nd ed. Sudbury, MA: Jones and Bartlett Publishers; 2014:61-132.
4. Webber PB. The Doctor of Nursing Practice degree and research: are we making an epistemological mistake? J Nurs Educ. 2008;47(10):466-472.
5. Evidence-based nursing position statement. Sigma Theta Tau International Honor Society of Nursing. www.nursingsociety.org/about-stti/position-statements-and-resource-papers/evidence-based-nursing-position-statement. Revised July 6, 2005. Accessed February 12, 2016.
6. Toole BM, Stichler JF, Ecoff L, Kath L. Promoting nurses’ knowledge in evidence-based practice. J Nurses Prof Dev. 2013;29(4):173-181.
7. Polit DF, Beck CT. Evidence-based nursing: translating research evidence into practice. In: Nursing Research: Generating and Assessing Evidence for Nursing Practice. 9th ed. Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins; 2012:25-47.
8. Liou SR, Cheng CY, Tsai HM, Chang CH. Innovative strategies for teaching nursing research in Taiwan. Nurs Res. 2013;62(5):335-343.
9. White KW, Zaccagnini ME. A template for the DNP scholarly project. In: The Doctor of Nursing Practice Essentials: A New Model for Advanced Practice Nursing. 2nd ed. Sudbury, MA: Jones and Bartlett Publishers; 2014: 417-466.
10. Eldridge CR. Nursing science and theory: scientific underpinnings for practice. In: Zaccagnini ME, White KW, eds. The Doctor of Nursing Practice Essentials: A New Model for Advanced Practice Nursing. 2nd ed. Sudbury, MA: Jones and Bartlett Publishers; 2014:3-36.
11. Petersen SW. Systems thinking, healthcare organizations, and the advanced practice nurse leader. In: Zaccagnini ME, White KW, eds. The Doctor of Nursing Practice Essentials: A New Model for Advanced Practice Nursing. 2nd ed. Sudbury, MA: Jones and Bartlett Publishers; 2014:37-60.
12. Nelson EC, Lazar JS, Godfrey MM, Batalden PB. Partnering with patients to design and improve care. In: Nelson EC, Batalden PB, Godfrey MM, Lazar JS, eds. Value by Design: Developing Clinical Microsystems to Achieve Organizational Excellence. San Francisco, CA: Jossey-Bass; 2011:47-85.
13. Scott K, McSherry R. Evidence-based nursing: clarifying the concepts for nurses in practice. J Clin Nurs. 2009;18(8):1085-1095.
14. Batalden PB, Nelson EC, Godfrey MM, Lazar JS. Introducing clinical microsystems. In: Nelson EC, Batalden PB, Godfrey MM, Lazar JS, eds. Value by Design: Developing Clinical Microsystems to Achieve Organizational Excellence. San Francisco, CA: Jossey-Bass; 2011:1-29.
15. Morrisey LJ, DeBourgh GA. Finding evidence: refining literature searching skills for the advanced practice nurse. AACN Clin Issues. 2001;12(4):560-577.
16. Executive Summary. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001. www.nap.edu/read/10027/chapter/1. Accessed February 12, 2016.
17. Suresh GK, Godfrey MM, Nelson EC, Batalden PB. Improving safety and anticipating hazards in clinical microsystems. In: Nelson EC, Batalden PB, Godfrey MM, Lazar JS, eds. Value by Design: Developing Clinical Microsystems to Achieve Organizational Excellence. San Francisco, CA: Jossey-Bass; 2011:87-130.
18. Maurino D, Reason J, Lee R. Beyond Aviation Human Factors: Safety in High Technology Systems. Aldershot, UK: Avery Press; 1995:83.
19. Liang BA. The adverse event of unaddressed medical error: identifying and filling the holes in the health-care and legal systems. J Law Med Ethics. 2001;29(3-4):346-368.
20. Shirey MR. Lewin’s theory of planned change as a strategic resource. J Nurs Adm. 2013;43(2):69-72.
21. Leape LL, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine meets patient safety. JAMA. 2002;288(4):501-507.
22. Irwin MM, Bergman RM, Richards R. The experience of implementing evidence-based practice change: a qualitative analysis. Clin J Oncol Nurs. 2013;17(5):544-549.
23. Dreher HM. The historical and political path of doctoral nursing education to the doctor of nursing practice degree. In: Dreher HM, Smith Glasgow ME, eds. Role Development for Doctoral Advanced Nursing Practice. New York, NY: Springer Publishing Company; 2011:7-46.
24. Weinstock B, Smith Glasgow ME. Executive coaching to support doctoral role transitions and promote leadership consciousness. In: Dreher HM, Smith Glasgow ME, eds. Role Development for Doctoral Advanced Nursing Practice. New York, NY: Springer Publishing Company; 2011:261-280.
25. Chism LA. Leadership, collaboration, and the DNP graduate. In: Chism LA, ed. The Doctor of Nursing Practice: A Guidebook for Role Development and Professional Issues. 2nd ed. Sudbury, MA: Jones & Bartlett Publishers; 2013:35-58.
26. Botes A. A comparison between the ethics of justice and the ethics of care. J Adv Nurs. 2000;32(5):1071-1075.
27. Sorbello B. The nurse administrator as caring person: a synoptic analysis applying caring philosophy, Ray’s Ethical Theory of Existential Authenticity, the ethic of justice, and the ethic of care. Int J Human Caring. 2008;12(1):44-49.
28. Davidson JU, Davidson JC. Fundamentals of restructuring: how to accomplish transformational change via transformational leadership. Kansas Nurse. 2000; 75(4):1-3.
29. Marshall ES. Characteristics of a transformational leader. In: Marshall ES. Transformational Leadership in Nursing: From Expert Clinician to Influential Leader. New York, NY: Springer Publishing Company; 2011:27-50.

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Last modified: May 24, 2016