A number of people have asked why I chose to pursue another doctorate degree (for as long as I’ve been in school, sometimes I ask myself the same question!). After finishing my master of science in nursing, I strongly considered obtaining a PhD in nursing science or the Doctor of Nursing Practice (DNP) degree. I wrestled with the decision daily because there were benefits and drawbacks to each one. Even though a PhD has the strongest reputation for being THE terminal academic degree, there were certain factors that ultimately drove me away from it. The DNP degree, while far from perfect, made the most sense for me. I was accepted into the top program of my choice and the rest is history. Listed below is a table from Vanderbilt (2020) that compares the differences between the two degrees:
| Comparison | DNP | PhD |
|---|---|---|
| Program Objective | Prepare the highest level nursing practice scholars for clinical, administrative and academic career; terminal degree in practice | Prepare scholars for research and academic careers in public or private sectors of health care; terminal degree in research |
| Applicant Evaluation | Evidence of scholarly ability; professional goals consistent with the advanced practice nursing role and past nursing and leadership experiences | Evidence of scholastic preparation and intellectual capability; research/career goals consistent with the School’s research foci/faculty expertise |
| Course of Study / Competencies | Practice integration experience and emphasis on knowledge and skills for applying and translating evidence-based research into practice | Two tracks of study: Clinical Research and Health Services Research; opportunities to work in interdisciplinary research teams |
| Degree Requirements | Successful completion of a scholarly project demonstrating the synthesis of the student’s coursework and practice application, culminating in a final manuscript and public presentation. | Successful completion of advanced coursework, a qualifying examination paper, an oral qualifying examination and dissertation (including oral defense of the proposal and findings) |
| Career Focus of Graduates | Leadership positions in nursing practice, management, information technology and academia. Developing practice innovations designed to improve health care outcomes. | Conduct/disseminate research that responds to regional, national and international priorities. Graduates advance the nursing discipline and practice through research, education and health policy. |
Examining the objectives, competencies and career focus helped me identify which degree was best for me. After researching the degrees, I had to self-reflect on some of these questions:
“What do I hope to accomplish with the degree?”
“Do I see myself in academia pursuing a tenure track?”
“Do I see myself primarily practicing as a clinician?”
“What am I most passionate about?”
“What is the endgame for my career?”
Asking these questions enabled me to list some pros and cons that ultimately steered me towards the DNP:
Pros:
-The DNP degree will almost entirely be paid for by the institution I work at. At this stage of my career, not having extra debt is a high priority for me. It was a relief knowing that I could continue my education without sacrificing income.
-The DNP program allows me to continue working while completing the program. Most PhD students receive a stipend that is substantially less than a full-time, working clinician. With a wife and two children, maintaining household income was very important to me. The return on investment (ROI) for a 4-year PhD program must be considered prior to attending. In total, when factoring in a PhD stipend versus an NP income, I would have lost approximately $300,000+ in revenue (and that’s the minimum). The lost income in those 4 years would be quite substantial. Some PhD students can work part-time in their program, but it is extremely difficult given the coursework.
-The DNP degree is still considered 1 of 2 terminal degrees in nursing. Unlike the Doctorate in Physical Therapy (DPT), the DNP is considered a terminal degree, whereas the DSc and PhD are considered the terminal degrees in physical therapy (PT). This may be due to the plethora of degree pathways for nursing (ADN, BSN, MSN, DNP, etc.). Unlike PT, the doctorate in nursing is not the entry-level degree to practice and may not be for the foreseeable future. There are so many master’s prepared nurses in the country and many have no interest in pursuing a doctorate. Moreover, they will all be grandfathered into any national guidelines that possibly mandate the DNP going forward. Nonetheless, having a terminal degree in nursing matters to me, as it is considered one of the highest degrees a nurse can obtain.
-The DNP degree is already halfway complete for me. Because I am a master’s prepared nurse practitioner, I have finished a large majority of the coursework already. It would take a BSN-prepared nurse approximately 3.5-4 years to complete. I will finish in 2 years, which makes a big difference when I factor in my family and life outside of work. Most PhD programs are 4 years long, and it can be even longer depending on your research and dissertation.
-The DNP degree with psychiatric specialization will improve my knowledge and sharpen my skill in psychiatric mental health. It was actually my collaborating physician, who is board certified in internal medicine and psychiatry, who encouraged me to pursue additional training. I have seen so many patients with psychiatric issues in outpatient orthopedics, the ED, and primary care. It is a huge passion of mine and it will allow me to take care of this population better. Having experience in orthopedics, family practice, emergency medicine, and mental health provides me a well-rounded skillset to holistically care for patients. The PhD does not expand my clinical knowledge in the same capacity.
-The DNP degree strongly emphasizes implementation and quality improvement science in the curriculum. It is a field that I am passionate about, as best practice clinical guidelines are simply not being implemented into practice. The DNP degree helps an individual systematically dissect why that is the case and what can be done to improve the problem.
-The DNP degree still provides an opportunity to teach in doctoral nursing programs. Although tenure is far less likely, the degree still opens doors into nursing academia. Even director and leadership positions in the college of nursing (CON) are obtainable with the DNP. It is nice to have the option of switching to full-time academia down the road.
-The DNP degree is more in alignment with my end-goals. I want clinical practice to be at the forefront of my career: I do not want to be a researcher and have my practice take a backseat. My goal has always been to be a multifaceted clinician and teach part-time. The DNP degree allows me to achieve both of these goals. Even though I love reading and applying research, I do not have as much passion to conduct research. This is a problem, as tenure is largely based on your ability to conduct research and obtain grants for your institution. Unfortunately, I know very few PhD-prepared professors who still consistently practice in the clinical setting. Every professor I’ve met has told me that clinical practice HAS to give at some point. You might be able to practice a few hours here or there per week in faculty clinic, but academic responsibilities will eventually preclude you from dedicating a significant amount of time. Do you want your career to be research focused or practice focused? My passion is the latter.
-The DNP degree, on average, has a higher income potential compared to the PhD. While tenured PhD nursing professors make a substantial amount of money, it is not the norm by any stretch of the imagination. Tenure opportunities are shrinking across all fields, and the statistical likelihood of getting tenure is daunting due to competition and saturation. I know some PhD prepared nurse practitioners who have left academia all together due to the stark differences in income. Academicians are not paid enough at all. No question about it. With that said, spending 4 additional years in school for less pay simply does not make any sense for me.
-The DNP will help me achieve my personal goal of having two doctoral degrees. It’s not a traditional pathway, which is why I’m excited to use these degrees in my own unique way. Some people have a DPT /PhD, DNP/PhD, MD/PhD, or even DPT + MD/DO! These are fantastic combos that provide all sorts of wonderful opportunities. Nonetheless, I truly believe the DNP compliments my DPT degree the best. This combination provides me the rare opportunity to pursue multiple interests AND tie them all together in one clinical practice setting. My hope is to use dual doctorates in two different fields to impact patients and the academic community.
Cons:
-The DNP degree makes it less likely to obtain academic tenure. This can be an issue for those who see themselves full-time in academia. A nurse with a PhD is much more likely to obtain a tenure track. If this is an end-goal for you, the PhD is the way to go.
-The DNP degree does not automatically garner an increased income. Some institutions will reward their employee with a raise, but some companies do not. Consequently, depending on the cost and specialty of the program, it may not be worthwhile to pursue.
-The DNP is still a relatively new degree. It’s in its infancy stages and would benefit from various curriculum updates. The degree is composed of core coursework that consists of public/population health, health administration, information technology, systems management, quality improvement, and clinical practice. After researching other degrees, I realized that there was overlapping curriculum with the PhD, EdD, MHA, MPH, and MBA. This can be good or bad depending on what your goals are. There are few clinical tracks that exist for the DNP, and that is a problem, considering that was the original intention of the degree. The clinical track programs that are offered need to be improved with more clinical hours and enhanced curriculum. No question. Conversely, the aforementioned curriculum is beneficial for those interested in applying and conducting research with other nurse scientists. The strength of each program varies and students have to do their diligence in researching which program to apply to.
-The DNP does not currently have as strong a reputation in some medical communities. It simply does not have the same standing as the PhD. You can go to Twitter and find quite a few threads of physicians and other folks bashing the degree. The degree gets bombarded with negative comments because of the issues I listed above. Honestly, some of the criticism is warranted. It needs to be revamped similar to the DPT or PharmD. More diagnostic imaging, differential diagnosis, pathophysiology, pharmacology, etc. would go a long way to help the degree. To be fair, critiques about online, part-time DNP programs are a bit over the top. Online programs allow an applicant to be more selective of superior programs. Why choose a brick and mortar program that is possibly more expensive and mediocre? Your path to graduate school should not entirely be dictated based on where you live. Additionally, all clinical DNP programs require clinical rotations and practical exams in person: none of them are 100% online. Most of the programs that get critiqued about being 100% online are ones that don’t even pertain to clinical practice (ex. systems leadership, healthcare management, etc.). Many of my friends who went to medical school had lectures that were entirely online. They never attended any in-person lectures. My DPT program was full-time and all in person. Does this mean my program and curriculum was superior? Of course not. Frankly, I would have greatly appreciated online lectures for certain classes. Some classes simply do not require my physical presence to be effective. Lastly, a graduate program that is completed part-time does not automatically guarantee that it is easy. I work in primary care full-time, have two small children, and teach in DPT programs. Balancing my time and energy is extremely challenging, and in some ways, more difficult than when I was in DPT school full time. No matter how good a degree is, all programs should work to strengthen its curriculum. I do believe the DNP could use some improvement, but it is not as bad as naysayers make it out to be. There are diploma mill programs that exist and they need be addressed by our profession. I have been vocal about these issues with every relevant organization stakeholder in the profession. Nonetheless, it is a unique degree that attempts to blend clinical practice with research application, which is no easy feat. Nurses with DNPs, regardless of the specialty, are well equipped to assess structures, processes, and outcomes that influence patient care. It cannot be all things to all people even with continued refinement.
Upon further reflection, I realized that the reputation of the PhD was the primary driver for originally wanting to pursue the degree. Quite frankly, that reason alone wasn’t sufficient enough for me to spend another 4-6 years in school. Even the PhD does not protect someone from ridicule, disrespect, or criticism. The Doctor of Osteopathy (DO) in the U.S., one of the best degrees in the country, still gets disrespect from ignorant and naïve colleagues and the public. The Doctor of Medicine (MD) may be the most bulletproof from criticism, but people still critique that degree depending on the institution you attend. Tribalism and identity politics permeate into every profession and discipline. Don’t bother looking for a degree that doesn’t have these issues: the perfect degree doesn’t exist. Some degrees have a stronger reputation in the public eye, but the degree after your name will not stop cynical critics. The DNP degree likely gets the most flack, but its not alone in that regard.
In summary, you have to choose a degree that makes the most sense for you. I know of DNP folks who wish they obtained their PhD because of prestige and a change of heart towards research. I also know of PhD folks who wish they obtained their DNP because of reduced income and lack of continued interest in academia. Is your end game clinical practice? Or is it traditional research? Sometimes the roles are reversed depending on the situation. In either case, it is impossible to maintain clinical practice AND research with equal time and energy. One passion will supersede the other.
Respect is earned. A degree alone will not grant you any respect: competence will earn you respect. Reputation goes far beyond titles, degrees or accomplishments. There are plenty of bad nurses, nurse practitioners, physician assistants, physical therapists, pharmacists, and physicians, regardless of their degree/title. I could care less about the credentials behind a person’s name. Your compassion, determination, humility, and drive for knowledge will undoubtedly be the deciding factors that make you a respected clinician. Arrogance and complacency will almost certainly cause you to bite the dust. My hope is to complete the DNP and make the most out of it. I have already infused nursing knowledge into the DPT curriculum. Upon finishing the DNP, I will incorporate everything I’ve learned in PT into nursing. I believe this is one of the best ways to bring different professions together, strengthen inter-professional collaboration, and tear down silos. Pursue the degree that makes the most sense for you. Do not go chasing after dreams that aren’t yours. Go after what you want and make the most out of it!