Professional Issues in Nursing: the Pros and Cons of the DNP

There has been much debate about higher education for nurses, specifically Advanced Practice Nurses (ANPs). The issue at hand relates to making the Doctor of Nursing Practice (DNP) the standard entry level for ANPs. There has also been a mutual consensus between the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation (RWJF) supporting the DNP. (Terhaar, Taylor, Sylvia 2016)

Understanding the DNP

So what exactly is the 'DNP'? The Doctor of Nursing Practice is the highest degree that an APN can obtain.

"It is the pinnacle of practice-focused nursing degrees, building upon master's programs by providing an educational foundation in quality improvement, evidence-based practice, and systems leadership, among others.", Compared to a Master of Nursing (MSN)Degree, the DNP is highly focused on applying clinical research and evaluating outcomes. It also enhances the nurse's knowledge about the business and management elements of healthcare while still staying clinically focused.

Pros of the DNP

Now, let's go over some of the pros of the DNP. A lot of time, effort, and money is invested for researchers to conduct and document research to improve the quality of healthcare and enhance patient outcomes. That same credible research is not worthwhile if it is not applied in clinical practice. The DNP prepares advanced practice nurses to apply evidence-based research in the clinical setting and to be able to accurately evaluate outcomes based on implemented changes. "DNP programs focus heavily on practice that is innovative and evidenced-based, reflecting the application of credible research findings."

Systems Level Advocacy

The systems level of advocacy aims to influence legislators and public policymakers. (Joel, L. A. 2018, P219). For healthcare to improve across the board, the focus of improvement cannot be localized; strategies for improvement must be extendable to practice settings in a wide range of communities. To get this done, the system as a whole must be challenged; thus, APNs must be proficient in their ability to reach out to those in positions of authority, such as legislators, and be able to articulate clearly the benefits of changing policies as it relates to patients everywhere. According to Trautman et al., "DNP-prepared APRNs also often serve a dual role, concurrently practicing at the systems level to have a broader impact on patient systems outcomes." The DNP-prepared nurse is then able to influence changes for the better.

Interdisciplinary Teamwork

Healthcare consists of many different professions, and for facilities to function smoothly, all professionals, regardless of the field in healthcare they work under, must be able to collaborate and work together as a team. If there is an issue with interdisciplinary teamwork or lack of communication among professionals, then this can adversely affect patient satisfaction and outcomes. APNs must be able to apply strategies to dissolve conflicts when they arise so as to maintain a professional and comfortable work environment for all individuals. As stated by Rodriguez, 2016, "DNP Programs aim to grow visionary leaders who can apply situation-based strategies and work productively with inter-professional team members."

Addressing Nurse Shortages

Lastly, the DNP can help to address the problem of nurse shortages currently posing an issue in healthcare. It is no secret that many nursing programs decline the acceptance of many qualified potential nursing student applicants because of a lack of faculty to teach and train new nurses. As more and more nurses seek to attain the DNP, they can be able to fill the gap in faculty shortages and thus directly help the issue of nurse shortages everywhere. According to Bednash et al. 2014; Chism, 2009; Patzek, 2010 (as cited by Rodriguez, 2016), "…the increase in doctorally prepared nurses can help meet this need." that is the need for nurse faculty.
Now that we have reviewed some pros let's get started on the cons.

Cons of the DNP

Currently, most APNs possess an MSN, and most Nurse Practitioners (NPs) hold a master's degree and, in addition, may be board-certified. APNs with an MSN have been providing care, helping to fill the gaps of primary care shortages and contributing to higher standards of care and improved patient safety, and better outcomes. APNs, specifically NPs, have pushed for the rights of being independent care providers to patients; current laws have been put in place to allow NPs to become independent practitioners and relieve the need for the NP to have to be supervised by a physician. The push for DNP as the entry-level standard implies that MSN-prepared nurses are not adequately trained and may be unsafe for the roles that they are currently filling. "By suggesting that practice doctorates will improve safety, AACN appears to be implying that master's prepared advanced practice nurses are unsafe."

Potential Impact on Nurse Education

Current Nurse Faculty shortages pose an issue because inadequate faculty equals fewer new graduate nurses. It may seem advantageous that the DNP can help fill the gap in faculty shortages, but does the DNP adequately prepare nurse faculty to teach new student nurses? Nurses who may not have even considered venturing into teaching may take up the role because they have decided that they want a practice doctorate, and the same can be used to become faculty in schools of nursing with no prior teaching experience. This may become problematic because nurses may be able to attain a DNP without the proper clinical training or moving through the right clinical track. According to Mckenna 2005 "…that without an adequate background in the knowledge and skills necessary for teaching and scholarship, faculty holding practice doctorates may be set up for failure in a university setting." And according to Tanner 2005 (as cited by Fulton & Lyon, 2005), "… AACN's DNP proposal is directed toward preparing advanced practice clinicians. We wonder whether this focus will adequately prepare teachers of nursing. (Fulton & Lyon, 2005).

Altering the Focus of Nursing

Is the DNP a move away from the science/art of Nursing? Although Nursing is grounded in scientific evidence, it is considered an 'art" by many. Nursing was grounded in the nurse's ability to display compassion and nurture the sick back to health while maintaining the basics of ethical and moral care. The science of nursing came after this, "With time and gaining knowledge, nursing has transformed itself into a science, as well.". (Danford, 2018). APNs looking to obtain a DNP can imply a move away from nursing and put them more in the realm of medicine. The focus and art of nursing are diluted with this elevated degree. According to Fulton and Lyon, 2005, "When a premier doctorate of the practice of nursing program for nurse practitioners advertises that it prepares nurses in the practice of primary care medicine, to independently diagnose and treat disease for the purpose of filling the gap in primary care physician services, it's hard to argue this is not doing the work of medicine." (Fulton and Lyon, 2005).

Implications for Research and Evidenced-Based Practice

Although programs for DNPs state that the focus is on the application of Evidenced Based Practice (EBP) rather than creating new research, nurses on all levels, whether bachelor-prepared or master prepared, are knowledgeable about the importance and implementation of EBP. This is one of the foundations taught to all new nurses and is taken with them regardless of the level of education they pursue. Thus, the application of EBP occurs daily at all levels of nursing. Now, for evidence-based practice to occur, there must be credible evidenced-based research performed, and for this to occur, students need to pursue a Doctor of Philosophy (Ph.D.). Enrollment into Ph.D. programs may be lessened due to potential students enrolling in a Doctorate program instead, leaving the research field to suffer. According to Fulton & Lyon, 2005, "…there is expressed concern that the clinical doctorate is threatening the Ph.D. pool of sustained research capabilities." This poses a threat because fewer student enrollments mean less research being performed and, of course, less evidence to back up or make beneficial changes to the delivery of care.

Conclusion

Although there are many supporting factors for encouraging nurses to pursue a DNP, I personally think that with the current shortage of nurses and faculty nurses, the pursuit of a DNP presently seems somewhat out of reach. I think that the current system of healthcare works well, and the addition of the DNP will not enhance it without compromising or adding to the current problems at hand. As stated earlier, although the DNP is focused on the application of EBP, nurses already have the attribute of applying EBP in the delivery of care embedded in them from the get-go. The focus should be on what can be done to alleviate the present problems that contribute to patient safety and outcomes, such as unsafe nurse-to-patient ratio and nurse burnout, among others which are directly linked to nurse shortages. I also think encouraging nurses to pursue a DNP will foster competition among nurses, and rather than nurses working together as a team to enhance patient care, division among nurses may occur. In addition to these factors, I think that MSN programs can be tailored so that knowledge about the business and management elements of healthcare can be incorporated in a deeper concentration rather than pushing nurses to pursue a DNP.

References

1. Terhaar, M., Taylor, L., Sylvia, M. (2016). The evolution and influence of the DNP degree: Implications for advanced practice nursing. Journal of Advanced Nursing, 72(9), 2095-2108.
2. Joel, L. A. (2018). Advanced Practice Nursing: Essentials for Role Development (4th ed.). F.A. Davis Company.
3. Trautman, D. E., Idzik, S., Hayes, E., & DNP, R. (2018). Policy and advocacy for DNP-prepared nurses. Journal of Professional Nursing, 34(2), 110-114.
4. Rodriguez, A. (2016). Leadership and collaboration skills in the DNP curriculum: Preparing nurse leaders for inter-professional work. Nurse Education in Practice, 19, 98-102.
5. McKenna, H. (2005). The dangers of pushing the doctorate of nursing practice. Journal of Clinical Nursing, 14(8), 913-919.
6. Fulton, J. S., & Lyon, B. L. (2005). The need for some sense making: Doctor of Nursing Practice. Online Journal of Issues in Nursing, 10(3), 5.

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