In 2004, the American Association of Colleges of Nursing (AACN) endorsed a position statement on the practice doctorate in nursing. The Doctor of Nursing Practice (DNP) degree was created as a result of stakeholder discussions, consensus building, and research from the Institute of Medicine’s To Err is Human: Building a Safer Health System (1999), Crossing the Chiasm (2001), and Health Professions Education: A Bridge to Quality (2003). Despite the call for more doctorally prepared nurses, the AACN in 2017 estimated that only 1.2% of the workforce had a DNP, and only 0.6% had a Doctor of Philosophy (PhD). This number has marginally improved over time; however, there is still a dire need to increase the doctorally prepared nursing workforce for academia, research, leadership/management, and clinical practice. The DNP is considered 1 of 3 terminal degrees for nursing, the other being the PhD and Doctor of Education (EdD). Compared to other doctorates, it is relatively newer and it has received both positive and negative feedback from those within and outside the profession. In particular, it is probably one of the most polar degrees amongst certain groups of physicians. There are all sorts of misconceptions that run rampant on social media. You see it on Twitter, Facebook, Student Doctor Network (SDN), Reddit, and the like. Unfortunately, they find one DNP program they dislike and mistakenly misconstrue it to represent each and every program across the country. They sometimes take anecdotes and apply it to the entire degree and profession. The truth is that the DNP is too diverse of a degree to make broad sweeping generalizations. I’ll go through a few facts and myths about the degree that will help clarify a few issues:
1. The DNP is a mill degree that is pumping out tens of thousands of graduates each year.
Myth: There are a growing number of programs, with approximately 357 in the US. More programs are in the process of being created. The degree gets flack for being a mill, despite only 7944 graduates in 2018-2019 (Campaign for Action, 2021). The idea that tens of thousands of graduates are flooding the market is an exaggerated claim. Are DNP programs highly accessible across the US? Yes. Do I think admission requirements should be raised? Yes. Are graduates being pumped out at astronomical rates? Not so much. There are still plenty more students enrolling in master’s programs across the country. For comparison, there were approximately 26,000 medical students who graduated in 2019 (Statista, 2019). There were about 10,000 physical therapists who graduated in 2018 (PT Progress, 2018). Having said this, I do believe that academic programs need to exercise caution with the proliferation of programs, particularly because there are too many pathways/tracks for nursing. I would imagine that it is quite difficult for accrediting organizations to keep track of all the various programs and respective curriculums. Nursing makes accessibility for students a high priority, for better and worse for the profession. Accessibility is very important, but it must be coupled with standardization, quality, and consistency.
2. The DNP degree has many tracks that can make it confusing for the public and healthcare professionals.
Fact: Although the terminal degree was originally designed for clinical practice, it was changed to advanced nursing practice, which included specialties outside of clinical specialties (ie CNP, CNS, CNM, CRNA). This was clarified in the AACN current issues and clarifying recommendations paper. The AACN (2015) defines advanced nursing practice as “any form of nursing intervention that influences healthcare outcomes for individuals or populations, including the provision of direct care or management of care for individual patients or management of care populations, and the provision of indirect care such as nursing administration, executive leadership, health policy, informatics, and population health. Also, it is important to remember that the DNP is an academic degree, not a role…” (p. 1).
Rather than creating multiple different types of degrees, the DNP was selected as the umbrella degree with multiple sub-specialties to avoid public confusion (unfortunately, this can still be quite confusing to lots of different parties). Someone with a DNP can be a registered nurse or an advanced practice registered nurse. They can be a clinical or non-clinical specialist. DNP students can have a bachelor’s or master’s degree, with the length of the program varying depending on their previous training. This can make it difficult for faculty members to train both types of students with very different backgrounds (McClauley et al., 2020). Unlike an MD/DO, PA, DPT, PharmD, PsyD., etc., it would be difficult to know what type of skill set the person has without examining their specialty track. I think the nursing profession needs to do a better job outlining these various specialties and its respective curriculum. Programs do use the core competencies as outlined by the AACN (2006) as a guide, but it still leaves room for curriculum variation.
3. The DNP degree can be finished completely online with no in-person clinical hours required.
Myth: Every clinical DNP degree has clinical hours that MUST be fulfilled. Non clinical practice DNP degrees still have project hours that are required for their implementation study, the large majority of which require you to be on site. The DNP degree does require more clinical hours compared to masters programs. Most DNP programs require a minimum of 1000 hours prior to completion, which is a step up from the master’s degree. Do I believe more clinical hours should be required? Absolutely. It’s not nearly enough. I’ve pushed for this for a very long time. I’ve personally obtained 2000 hours so far in my program and I finish in August 2022. The bare minimum needs to be higher, but there are plenty of individuals getting far more hours than required. “No clinical hours required” and “clinical hours need to be raised” are two very different things that get conflated online far too often. Critics will take the non-clinical DNP website ads and act as though the clinical DNP degree does not require practicums. This is incorrect. No such program exists. Moreover, contrary to popular belief, there are solid, quality programs that secure clinical sites for their students (as a DNP student at Rush, I have not had to look for one placement). I’ve been a staunch advocate for requiring NP programs to secure clinical placements for their students. I believe programs should not be allowed to exist without this basic requirement being met. I’ve written letters of concern to the American Association of Nurse Practitioners (AANP), National Organization of Nurse Practitioner Faculties (NONPF), and the Commission on Collegiate Nursing Education (CCNE). Believe me: there are plenty of us on the ground trying to make nursing education better.
4. The DNP degree being online makes it easier and less rigorous than other degrees.
Myth: This is probably one of the biggest criticisms of the degree, which doesn’t make much sense given the times we live in. I’ve had the opportunity to work with medical students from Rush, Loyola, Rosalind Franklin, Caribbean schools, etc., and all of them have online classes except for labs and OSCES. None of them attended class in person. Many nursing programs function the same way and have in-person labs, practicals, and OSCEs. My DPT was 3.5 years full-time and every single class was in person. My 2-year master of science program was all in person. Does that make it superior to other fields, including medicine? Not at all. As a matter of fact, some of my classes SHOULD have been online. Physically sitting in a lecture hall does not make the class superior. The difference between nursing and other professions is that they provide students opportunities to learn and work at the same time. The curriculum in many programs are specifically formatted and designed that way on purpose. I currently work full time, go to school full time, and have 2 children to take care of at home. There is nothing easy about managing all of these at once. It is quite challenging, in some ways more difficult. Students do not get less out of the program because they can work at the same time. There are actually positives to this beyond financial benefits, which is something that many healthcare professional students miss out on. Lastly, the credit load required from DNP programs are comparable to other doctorate degrees, including the PhD. There is some variation school to school, but that goes for other disciplines outside of nursing as well.
5. The DNP degree does not provide the same rigorous research methodology courses as the PhD.
Fact: Although there are research courses in the DNP curriculum, it does not go nearly as in depth with traditional research coursework (ex. qualitative and quantitative methods, grant writing, etc.). The degree was never intended to be identical or replace the PhD; rather, it was meant to fill in a missing gap that was sorely needed. DNP prepared nurses were meant to complement and work hand in hand with PhD colleagues in nursing research. The PhD clinician generates new knowledge and the DNP clinician translates/implements that science into clinical practice (Cygan & Reed, 2019). This is why implementation science, quality improvement, and program evaluation is heavily embedded in DNP programs. Contrary to popular belief, the DNP is not inferior to the PhD. They are both considered terminal degrees in the field of nursing. They were created for different purposes and have different goals, yet they uniquely complement one another. One is a research scientist and the other is a research translation/implementation science specialist (Olson, 2019). I do not think there are any other professions who combine implementation science and traditional research in this way. With increasing collaboration between PhD and DNP prepared clinicians, nursing has the opportunity to truly stand out from other fields. McNett et al. (2021) outline very nicely how these doctorally prepared nurses can work together to contribute to implementation science.
6. The DNP degree is filled with fluff classes that are useless for clinical practice.
Myth: The DNP fills in gaps that other degrees do not have training in, including implementation science, translational science research, quality improvement, etc. It also has core coursework in leadership, healthcare policy and economics, and administration (AACN, 2015). If you really look at the core competencies, the degree fills a nice niche in a variety of different settings. Very few degrees offer this type of training, as not all PhD and MPH programs focus on these areas of study. I do not know of any degrees that combine both clinical practice + implementation science curriculum. DPTs, PAs, MDs, and DOs certainly don’t have these classes in this detail. There are more programs even outside of nursing that are starting to value implementation science (ex. University of Washington, PhD in Implementation Science in Global Health; Northwestern University, PhD in Integrated in Health Sciences w/ emphasis on implementation science), but this field is still relatively new. My implementation study involved implementing the first comprehensive standardized smoking cessation protocol in our clinic. The results were rather remarkable, as there were increased rates of pharmacotherapy treatment, patient education, and referrals for smoking cessation counseling from nurse practitioners and physicians. The study led to improved clinical practice patterns and behaviors for the clinicians in the clinic. It was very much useful for clinical practice, not just for the clinicians, but for the patients as well. A DNP prepared clinician has the potential to reach a wider population and have an impact beyond just the patient sitting in front of them.
7. Those with a DNP degree should be allowed to use the term ‘doctor’ in practice.
Fact: Anyone with a doctorate has earned the right to use the term ‘doctor’. Full-disclosure: I do not call myself a doctor in the primary care clinic. Although I do not use it in the clinic, I still use the term on my website and biography. Interestingly, my physician colleagues do call me that to patients (ex. “I’m going to refer you to Dr. Lee, he’s a physical therapist and nurse practitioner who has expertise in orthopedics. I’d like you to see him“). They highly respect my expertise and what I bring to the table. To this day, there has never been any confusion by patients who are referred to me. If I were to use the term doctor, I’d say something like “Hi, my name is Dr. Lee, I am an orthopedic physical therapist and a family nurse practitioner, and I will be working with you today. You can just call me Jamie though. How can I help you today?” All doctors who are not physicians should use a qualifier. Plain and simple. It is deceitful (and even illegal in certain states) to not qualify what type of doctor you are. There is no deceit when someone says “My name is Dr. Smith, I am a family nurse practitioner who will be working with you“. Having said that, Mundinger and Carter (2019) report that only 15% of the total DNP programs are clinical focused. Consequently, it might make more sense for clinically focused DNPs to use the term in the clinical setting. The reality is that ‘doctor’ is not a term owned by physicians. Many optometrists, pharmacists, physical therapists, psychologists, dentists, chiropractors, etc. use the term in some capacity in various settings. A previous past president of the American Academy of Family Physicians, Dr. Wanda Filer, agreed that others should be allowed to call themselves doctors, as long as they clearly outline what type they are (Collier, 2016). While some physician colleagues may not share her opinion, I have met plenty who support her perspective. This is always going to be a hot topic of discussion; however, the reality is that PhD graduates were the first ones to use this term, not physicians. It will continue to be used by other clinicians, regardless if physicians are on board with it or not.
In summary, I believe the DNP fills an important niche in healthcare. It has unique aspects that make it different from other degrees. Rather than making generalizations and jumping to conclusions, it is prudent for critics to examine competence the old fashioned way. You will read and hear all sorts of negative anecdotes related to nurses, physicians, and other healthcare professionals. Anecdotes are often not without some level of truth, but it says nothing about your DNP colleague sitting next to you. See it with your own eyes. Ask them about their training and respective practice pathway. You have the opportunity to leverage their skillset, which can profoundly impact clinicians and patients, both directly and indirectly. They bring more to the table than you think.
Resources:
American Association of Colleges of Nursing. (2017). Creating a more highly qualified nursing workforce. https://www.aacnnursing.org/news-information/fact-sheets/nursing-workforce
American Association of Colleges of Nursing. (2015). The doctor of nursing practice: current issues and clarifying recommendations. https://www.aacnnursing.org/
Portals/42/DNP/DNP-Implementation.pdf
American Association of Colleges of Nursing. (2006). The essentials of doctoral education in advanced nursing practice. https://www.aacnnursing.org/Portals/42/
Publications/DNPEssentials.pdf
Collier, R. (2016). Who is entitled to the title of ‘doctor’? Canadian Medical Association Journal, 188(13), E305.
Cygan, H.R. & Reed, Monique. (2019). DNP and PhD scholarship: Making the case for collaboration. Journal of Professional Nursing, 35, 353-357.
Olson, A.C. (2019). Research translation and the evolving PhD and DNP practice roles: a collaborative call for nurse practitioners. Journal of the American Association of Nurse Practitioners, 31(8), 447-453.
McClauley, L.A., Broome, M.E., Frazier, L., Hayes, R., Kurth, A., Musil, C.M., Norman, L.D., Rideout, K.H., & Villarruel, A.M. (2020). Doctor of nursing practice (DNP) degree in the United States: Reflecting, readjusting, and getting back on track. Nursing Outlook, 68, 494-503.
McNett, M., Masciola, R., Sievert, D., & Tucker, S. (2021). Advancing evidence-based practice through implementation science: critical contributions of doctor of nursing practice – and doctor of philosophy-prepared nurses. Worldviews on Evidence-Based Nursing, 18(2), 93-101.
Mundinger, M.O. & Carter, M.A. (2019). Potential crisis in nurse practitioner preparation in the United States. Policy, Politics, & Nursing Practice, 20(2), 57-63.